Radiosurgery

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Radiosurgery
Intraoperative photograph showing a radiosurgery system.png
Intraoperative photograph showing a radiosurgery system being positioned. The patient in the photo is being treated for rectal cancer.
Specialty Oncology / Neurosurgery
MedlinePlus 007577
eMedicine 1423298

Radiosurgery is surgery using radiation, [1] that is, the destruction of precisely selected areas of tissue using ionizing radiation rather than excision with a blade. Like other forms of radiation therapy (also called radiotherapy), it is usually used to treat cancer. Radiosurgery was originally defined by the Swedish neurosurgeon Lars Leksell as "a single high dose fraction of radiation, stereotactically directed to an intracranial region of interest". [2]

Contents

In stereotactic radiosurgery (SRS), the word "stereotactic" refers to a three-dimensional coordinate system that enables accurate correlation of a virtual target seen in the patient's diagnostic images with the actual target position in the patient. Stereotactic radiosurgery may also be called stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR) when used outside the central nervous system (CNS). [3]

History

Stereotactic radiosurgery was first developed in 1949 by the Swedish neurosurgeon Lars Leksell to treat small targets in the brain that were not amenable to conventional surgery. The initial stereotactic instrument he conceived used probes and electrodes. [4] The first attempt to supplant the electrodes with radiation was made in the early fifties, with x-rays. [5] The principle of this instrument was to hit the intra-cranial target with narrow beams of radiation from multiple directions. The beam paths converge in the target volume, delivering a lethal cumulative dose of radiation there, while limiting the dose to the adjacent healthy tissue. Ten years later significant progress had been made, due in considerable measure to the contribution of the physicists Kurt Liden and Börje Larsson. [6] At this time, stereotactic proton beams had replaced the x-rays. [7] The heavy particle beam presented as an excellent replacement for the surgical knife, but the synchrocyclotron was too clumsy. Leksell proceeded to develop a practical, compact, precise and simple tool which could be handled by the surgeon himself. In 1968 this resulted in the Gamma Knife, which was installed at the Karolinska Institute and consisted of several cobalt-60 radioactive sources placed in a kind of helmet with central channels for irradiation with gamma rays. [8] This prototype was designed to produce slit-like radiation lesions for functional neurosurgical procedures to treat pain, movement disorders, or behavioral disorders that did not respond to conventional treatment. The success of this first unit led to the construction of a second device, containing 179 cobalt-60 sources. This second Gamma Knife unit was designed to produce spherical lesions to treat brain tumors and intracranial arteriovenous malformations (AVMs). [9] Additional units were installed in the 1980s all with 201 cobalt-60 sources. [10]

In parallel to these developments, a similar approach was designed for a linear particle accelerator or Linac. Installation of the first 4  MeV clinical linear accelerator began in June 1952 in the Medical Research Council (MRC) Radiotherapeutic Research Unit at the Hammersmith Hospital, London. [11] The system was handed over for physics and other testing in February 1953 and began to treat patients on 7 September that year. Meanwhile, work at the Stanford Microwave Laboratory led to the development of a 6 MeV accelerator, which was installed at Stanford University Hospital, California, in 1956. [12] Linac units quickly became favored devices for conventional fractionated radiotherapy but it lasted until the 1980s before dedicated Linac radiosurgery became a reality. In 1982, the Spanish neurosurgeon J. Barcia-Salorio began to evaluate the role of cobalt-generated and then Linac-based photon radiosurgery for the treatment of AVMs and epilepsy. [13] In 1984, Betti and Derechinsky described a Linac-based radiosurgical system. [14] Winston and Lutz further advanced Linac-based radiosurgical prototype technologies by incorporating an improved stereotactic positioning device and a method to measure the accuracy of various components. [15] Using a modified Linac, the first patient in the United States was treated in Boston Brigham and Women's Hospital in February 1986.[ citation needed ]

21st century

Technological improvements in medical imaging and computing have led to increased clinical adoption of stereotactic radiosurgery and have broadened its scope in the 21st century. [16] [17] The localization accuracy and precision that are implicit in the word "stereotactic" remain of utmost importance for radiosurgical interventions and are significantly improved via image-guidance technologies such as the N-localizer [18] and Sturm-Pastyr localizer [19] that were originally developed for stereotactic surgery.

In the 21st century the original concept of radiosurgery expanded to include treatments comprising up to five fractions, and stereotactic radiosurgery has been redefined as a distinct neurosurgical discipline that utilizes externally generated ionizing radiation to inactivate or eradicate defined targets, typically in the head or spine, without the need for a surgical incision. [20] Irrespective of the similarities between the concepts of stereotactic radiosurgery and fractionated radiotherapy the mechanism to achieve treatment is subtly different, although both treatment modalities are reported to have identical outcomes for certain indications. [21] Stereotactic radiosurgery has a greater emphasis on delivering precise, high doses to small areas, to destroy target tissue while preserving adjacent normal tissue. The same principle is followed in conventional radiotherapy although lower dose rates spread over larger areas are more likely to be used (for example as in VMAT treatments). Fractionated radiotherapy relies more heavily on the different radiosensitivity of the target and the surrounding normal tissue to the total accumulated radiation dose. [20] Historically, the field of fractionated radiotherapy evolved from the original concept of stereotactic radiosurgery following discovery of the principles of radiobiology: repair, reassortment, repopulation, and reoxygenation. [22] Today, both treatment techniques are complementary, as tumors that may be resistant to fractionated radiotherapy may respond well to radiosurgery, and tumors that are too large or too close to critical organs for safe radiosurgery may be suitable candidates for fractionated radiotherapy. [21]

Today, both Gamma Knife and Linac radiosurgery programs are commercially available worldwide. While the Gamma Knife is dedicated to radiosurgery, many Linacs are built for conventional fractionated radiotherapy and require additional technology and expertise to become dedicated radiosurgery tools. There is not a clear difference in efficacy between these different approaches. [23] [24] The major manufacturers, Varian and Elekta offer dedicated radiosurgery Linacs as well as machines designed for conventional treatment with radiosurgery capabilities. Systems designed to complement conventional Linacs with beam-shaping technology, treatment planning, and image-guidance tools to provide. [25] An example of a dedicated radiosurgery Linac is the CyberKnife, a compact Linac mounted onto a robotic arm that moves around the patient and irradiates the tumor from a large set of fixed positions, thereby mimicking the Gamma Knife concept.

Mechanism of action

Planning CT scan with IV contrast in a patient with left cerebellopontine angle vestibular schwannoma Acoustic schwannoma gamma knife.jpg
Planning CT scan with IV contrast in a patient with left cerebellopontine angle vestibular schwannoma

The fundamental principle of radiosurgery is that of selective ionization of tissue, by means of high-energy beams of radiation. Ionization is the production of ions and free radicals which are damaging to the cells. These ions and radicals, which may be formed from the water in the cell or biological materials, can produce irreparable damage to DNA, proteins, and lipids, resulting in the cell's death. Thus, biological inactivation is carried out in a volume of tissue to be treated, with a precise destructive effect. The radiation dose is usually measured in grays (one gray (Gy) is the absorption of one joule of energy per kilogram of mass). A unit that attempts to take into account both the different organs that are irradiated and the type of radiation is the sievert, a unit that describes both the amount of energy deposited and the biological effectiveness.[ citation needed ]

Clinical applications

When used outside the CNS it may be called stereotactic body radiation therapy (SBRT) or stereotactic ablative radiotherapy (SABR). [3]

Brain and spine

Radiosurgery is performed by a multidisciplinary team of neurosurgeons, radiation oncologists and medical physicists to operate and maintain highly sophisticated, highly precise and complex instruments, including medical linear accelerators, the Gamma Knife unit and the Cyberknife unit. The highly precise irradiation of targets within the brain and spine is planned using information from medical images that are obtained via computed tomography, magnetic resonance imaging, and angiography.[ citation needed ]

Radiosurgery is indicated primarily for the therapy of tumors, vascular lesions and functional disorders. Significant clinical judgment must be used with this technique and considerations must include lesion type, pathology if available, size, location and age and general health of the patient. General contraindications to radiosurgery include excessively large size of the target lesion, or lesions too numerous for practical treatment. Patients can be treated within one to five days as outpatients. By comparison, the average hospital stay for a craniotomy (conventional neurosurgery, requiring the opening of the skull) is about 15 days. The radiosurgery outcome may not be evident until months after the treatment. Since radiosurgery does not remove the tumor but inactivates it biologically, lack of growth of the lesion is normally considered to be treatment success. General indications for radiosurgery include many kinds of brain tumors, such as acoustic neuromas, germinomas, meningiomas, metastases, trigeminal neuralgia, arteriovenous malformations, and skull base tumors, among others.

Stereotatic radiosurgery of the spinal metastasis is efficient in controlling pain in up to 90% of the cases and ensures stability of the tumours on imaging evaluation in 95% of the cases, and is more efficient for spinal metastasis involving one or two segments. Meanwhile, conventional external beam radiotherapy is more suitable for multiple spinal involvement. [26]

Combination therapy

SRS may be administered alone or in combination with other therapies. For brain metastases, these treatment options include whole brain radiation therapy (WBRT), surgery, and systemic therapies. However, a recent systematic review found no difference in the affects on overall survival or deaths due to brain metastases when comparing SRS treatment alone to SRS plus WBRT treatment or WBRT alone. [27]

Other bodily organs

Expansion of stereotactic radiotherapy to other lesions is increasing, and includes liver cancer, lung cancer, pancreatic cancer, etc.[ citation needed ]

Risks

The New York Times reported in December 2010 that radiation overdoses had occurred with the linear accelerator method of radiosurgery, due in large part to inadequate safeguards in equipment retrofitted for stereotactic radiosurgery. [28] In the U.S. the Food and Drug Administration (FDA) regulates these devices, whereas the Gamma Knife is regulated by the Nuclear Regulatory Commission.

This is evidence that immunotherapy may be useful for treatment of radiation necrosis following stereotactic radiotherapy. [29]

Types of radiation source

The selection of the proper kind of radiation and device depends on many factors including lesion type, size, and location in relation to critical structures. Data suggest that similar clinical outcomes are possible with all of the various techniques. More important than the device used are issues regarding indications for treatment, total dose delivered, fractionation schedule and conformity of the treatment plan.[ citation needed ]

Gamma Knife

A doctor performing Gamma Knife Radiosurgery Dr. B. K. Misra performing Stereotactic Gamma Radiosurgery.jpg
A doctor performing Gamma Knife Radiosurgery
NRC graphic of the Leksell Gamma Knife Gamma Knife Graphic.jpg
NRC graphic of the Leksell Gamma Knife

A Gamma Knife (also known as the Leksell Gamma Knife) is used to treat brain tumors by administering high-intensity gamma radiation therapy in a manner that concentrates the radiation over a small volume. The device was invented in 1967 at the Karolinska Institute in Stockholm, Sweden, by Lars Leksell, Romanian-born neurosurgeon Ladislau Steiner, and radiobiologist Börje Larsson from Uppsala University, Sweden.

A Gamma Knife typically contains 201 cobalt-60 sources of approximately 30  curies each (1.1  TBq), placed in a hemispheric array in a heavily shielded assembly. The device aims gamma radiation through a target point in the patient's brain. The patient wears a specialized helmet that is surgically fixed to the skull, so that the brain tumor remains stationary at the target point of the gamma rays. An ablative dose of radiation is thereby sent through the tumor in one treatment session, while surrounding brain tissues are relatively spared.

Gamma Knife therapy, like all radiosurgery, uses doses of radiation to kill cancer cells and shrink tumors, delivered precisely to avoid damaging healthy brain tissue. Gamma Knife radiosurgery is able to accurately focus many beams of gamma radiation on one or more tumors. Each individual beam is of relatively low intensity, so the radiation has little effect on intervening brain tissue and is concentrated only at the tumor itself.

Gamma Knife radiosurgery has proven effective for patients with benign or malignant brain tumors up to 4 cm (1.6 in) in size, vascular malformations such as an arteriovenous malformation (AVM), pain, and other functional problems. [30] [31] [32] [33] For treatment of trigeminal neuralgia the procedure may be used repeatedly on patients.

Acute complications following Gamma Knife radiosurgery are rare, [34] and complications are related to the condition being treated. [35] [36]

Linear accelerator-based therapies

A linear accelerator (linac) produces x-rays from the impact of accelerated electrons striking a high z target, usually tungsten. The process is also referred to as "x-ray therapy" or "photon therapy." The emission head, or "gantry", is mechanically rotated around the patient in a full or partial circle. The table where the patient is lying, the "couch", can also be moved in small linear or angular steps. The combination of the movements of the gantry and of the couch allow the computerized planning of the volume of tissue that is going to be irradiated. Devices with a high energy of 6 MeV are commonly used for the treatment of the brain, due to the depth of the target. The diameter of the energy beam leaving the emission head can be adjusted to the size of the lesion by means of collimators. They may be interchangeable orifices with different diameters, typically varying from 5 to 40 mm in 5 mm steps, or multileaf collimators, which consist of a number of metal leaflets that can be moved dynamically during treatment in order to shape the radiation beam to conform to the mass to be ablated. As of 2017 Linacs were capable of achieving extremely narrow beam geometries, such as 0.15 to 0.3 mm. Therefore, they can be used for several kinds of surgeries which hitherto had been carried out by open or endoscopic surgery, such as for trigeminal neuralgia. Long-term follow-up data has shown it to be as effective as radiofrequency ablation, but inferior to surgery in preventing the recurrence of pain.[ citation needed ]

The first such systems were developed by John R. Adler, a Stanford University professor of neurosurgery and radiation oncology, and Russell and Peter Schonberg at Schonberg Research, and commercialized under the brand name CyberKnife.

Proton beam therapy

Protons may also be used in radiosurgery in a procedure called Proton Beam Therapy (PBT) or proton therapy. Protons are extracted from proton donor materials by a medical synchrotron or cyclotron, and accelerated in successive transits through a circular, evacuated conduit or cavity, using powerful magnets to shape their path, until they reach the energy required to just traverse a human body, usually about 200 MeV. They are then released toward the region to be treated in the patient's body, the irradiation target. In some machines, which deliver protons of only a specific energy, a custom mask made of plastic is interposed between the beam source and the patient to adjust the beam energy to provide the appropriate degree of penetration. The phenomenon of the Bragg peak of ejected protons gives proton therapy advantages over other forms of radiation, since most of the proton's energy is deposited within a limited distance, so tissue beyond this range (and to some extent also tissue inside this range) is spared from the effects of radiation. This property of protons, which has been called the "depth charge effect" by analogy to the explosive weapons used in anti-submarine warfare, allows for conformal dose distributions to be created around even very irregularly shaped targets, and for higher doses to targets surrounded or backstopped by radiation-sensitive structures such as the optic chiasm or brainstem. The development of "intensity modulated" techniques allowed similar conformities to be attained using linear accelerator radiosurgery.[ citation needed ]

As of 2013 there was no evidence that proton beam therapy is better than any other types of treatment in most cases, except for a "handful of rare pediatric cancers". Critics, responding to the increasing number of very expensive PBT installations, spoke of a "medical arms race" and "crazy medicine and unsustainable public policy". [37]

Related Research Articles

<span class="mw-page-title-main">Radiation therapy</span> Therapy using ionizing radiation, usually to treat cancer

Radiation therapy or radiotherapy, often abbreviated RT, RTx, or XRT, is a treatment using ionizing radiation, generally provided as part of cancer therapy to either kill or control the growth of malignant cells. It is normally delivered by a linear particle accelerator. Radiation therapy may be curative in a number of types of cancer if they are localized to one area of the body, and have not spread to other parts. It may also be used as part of adjuvant therapy, to prevent tumor recurrence after surgery to remove a primary malignant tumor. Radiation therapy is synergistic with chemotherapy, and has been used before, during, and after chemotherapy in susceptible cancers. The subspecialty of oncology concerned with radiotherapy is called radiation oncology. A physician who practices in this subspecialty is a radiation oncologist.

<span class="mw-page-title-main">Brain tumor</span> Neoplasm in the brain

A brain tumor occurs when abnormal cells form within the brain. There are two main types of tumors: malignant tumors and benign (non-cancerous) tumors. These can be further classified as primary tumors, which start within the brain, and secondary tumors, which most commonly have spread from tumors located outside the brain, known as brain metastasis tumors. All types of brain tumors may produce symptoms that vary depending on the size of the tumor and the part of the brain that is involved. Where symptoms exist, they may include headaches, seizures, problems with vision, vomiting and mental changes. Other symptoms may include difficulty walking, speaking, with sensations, or unconsciousness.

<span class="mw-page-title-main">External beam radiotherapy</span> Treatment of cancer with ionized radiation

External beam radiation therapy (EBRT) is a form of radiotherapy that utilizes a high-energy collimated beam of ionizing radiation, from a source outside the body, to target and kill cancer cells. A radiotherapy beam is composed of particles which travel in a consistent direction; each radiotherapy beam consists of one type of particle intended for use in treatment, though most beams contain some contamination by other particle types.

<span class="mw-page-title-main">Vestibular schwannoma</span> Medical condition

A vestibular schwannoma (VS), also called acoustic neuroma, is a benign tumor that develops on the vestibulocochlear nerve that passes from the inner ear to the brain. The tumor originates when Schwann cells that form the insulating myelin sheath on the nerve malfunction. Normally, Schwann cells function beneficially to protect the nerves which transmit balance and sound information to the brain. However, sometimes a mutation in the tumor suppressor gene, NF2, located on chromosome 22, results in abnormal production of the cell protein named Merlin, and Schwann cells multiply to form a tumor. The tumor originates mostly on the vestibular division of the nerve rather than the cochlear division, but hearing as well as balance will be affected as the tumor enlarges.

<span class="mw-page-title-main">Proton therapy</span> Medical Procedure

In medicine, proton therapy, or proton radiotherapy, is a type of particle therapy that uses a beam of protons to irradiate diseased tissue, most often to treat cancer. The chief advantage of proton therapy over other types of external beam radiotherapy is that the dose of protons is deposited over a narrow range of depth; hence in minimal entry, exit, or scattered radiation dose to healthy nearby tissues.

Lars Leksell (1907–1986) was a Swedish physician and Professor of Neurosurgery at the Karolinska Institute in Stockholm, Sweden. He was the inventor of radiosurgery.

<span class="mw-page-title-main">Stereotactic surgery</span> Medical procedure

Stereotactic surgery is a minimally invasive form of surgical intervention that makes use of a three-dimensional coordinate system to locate small targets inside the body and to perform on them some action such as ablation, biopsy, lesion, injection, stimulation, implantation, radiosurgery (SRS), etc.

Elekta is a global Swedish company that develops and produces radiation therapy and radiosurgery-related equipment and clinical management for the treatment of cancer and brain disorders. Elekta has a global presence in more than 120 countries, with over 40 offices around the world and about 4,700 employees.

<span class="mw-page-title-main">Radiation treatment planning</span>

In radiotherapy, radiation treatment planning (RTP) is the process in which a team consisting of radiation oncologists, radiation therapist, medical physicists and medical dosimetrists plan the appropriate external beam radiotherapy or internal brachytherapy treatment technique for a patient with cancer.

Electron therapy or electron beam therapy (EBT) is a kind of external beam radiotherapy where electrons are directed to a tumor site for medical treatment of cancer.

<span class="mw-page-title-main">Tomotherapy</span> Type of radiation therapy

Tomotherapy is a type of radiation therapy treatment machine. In tomotherapy a thin radiation beam is modulated as it rotates around the patient, while they are moved through the bore of the machine. The name comes from the use of a strip-shaped beam, so that only one “slice” of the target is exposed at any one time by the radiation. The external appearance of the system and movement of the radiation source and patient can be considered analogous to a CT scanner, which uses lower doses of radiation for imaging. Like a conventional machine used for X-ray external beam radiotherapy, a linear accelerator generates the radiation beam, but the external appearance of the machine, the patient positioning, and treatment delivery is different. Conventional linacs do not work on a slice-by-slice basis but typically have a large area beam which can also be resized and modulated.

Intraoperative radiation therapy (IORT) is radiation therapy that is administered during surgery directly in the operating room.

Image-guided radiation therapy is the process of frequent imaging, during a course of radiation treatment, used to direct the treatment, position the patient, and compare to the pre-therapy imaging from the treatment plan. Immediately prior to, or during, a treatment fraction, the patient is localized in the treatment room in the same position as planned from the reference imaging dataset. An example of IGRT would include comparison of a cone beam computed tomography (CBCT) dataset, acquired on the treatment machine, with the computed tomography (CT) dataset from planning. IGRT would also include matching planar kilovoltage (kV) radiographs or megavoltage (MV) images with digital reconstructed radiographs (DRRs) from the planning CT.

Particle therapy is a form of external beam radiotherapy using beams of energetic neutrons, protons, or other heavier positive ions for cancer treatment. The most common type of particle therapy as of August 2021 is proton therapy.

The CyberKnife System is a radiation therapy device manufactured by Accuray Incorporated. The system is used to deliver radiosurgery for the treatment of benign tumors, malignant tumors and other medical conditions.

Intraoperative electron radiation therapy is the application of electron radiation directly to the residual tumor or tumor bed during cancer surgery. Electron beams are useful for intraoperative radiation treatment because, depending on the electron energy, the dose falls off rapidly behind the target site, therefore sparing underlying healthy tissue.

Stereotactic radiation therapy (SRT), also called stereotactic external-beam radiation therapy and stereotaxic radiation therapy, is a type of external radiation therapy that uses special equipment to position the patient and precisely deliver radiation to a tumor. The total dose of radiation is divided into several smaller doses given over several days. Stereotactic radiation therapy is used to treat brain tumors and other brain disorders. It is also being studied in the treatment of other types of cancer, such as lung cancer. What differentiates Stereotactic from conventional radiotherapy is the precision with which it is delivered. There are multiple systems available, some of which use specially designed frames which physically attach to the patient's skull while newer more advanced techniques use thermoplastic masks and highly accurate imaging systems to locate the patient. The end result is the delivery of high doses of radiation with sub-millimetre accuracy.

<span class="mw-page-title-main">Neutron capture therapy of cancer</span> Nonsurgical therapeutic modality for treating locally invasive malignant tumors

Neutron capture therapy (NCT) is a type of radiotherapy for treating locally invasive malignant tumors such as primary brain tumors, recurrent cancers of the head and neck region, and cutaneous and extracutaneous melanomas. It is a two-step process: first, the patient is injected with a tumor-localizing drug containing the stable isotope boron-10 (10B), which has a high propensity to capture low energy "thermal" neutrons. The neutron cross section of 10B is 1,000 times more than that of other elements, such as nitrogen, hydrogen, or oxygen, that occur in tissue. In the second step, the patient is radiated with epithermal neutrons, the sources of which in the past have been nuclear reactors and now are accelerators that produce higher energy epithermal neutrons. After losing energy as they penetrate tissue, the resultant low energy "thermal" neutrons are captured by the 10B atoms. The resulting decay reaction yields high-energy alpha particles that kill the cancer cells that have taken up enough 10B.

<span class="mw-page-title-main">Central neurocytoma</span> Medical condition

Central neurocytoma (CNC) is an extremely rare, ordinarily benign intraventricular brain tumour that typically forms from the neuronal cells of the septum pellucidum. The majority of central neurocytomas grow inwards into the ventricular system forming interventricular neurocytomas. This leads to two primary symptoms of CNCs, blurred vision and increased intracranial pressure. Treatment for a central neurocytoma typically involves surgical removal, with an approximate 1 in 5 chance of recurrence. Central neurocytomas are classified as a grade II tumor under the World Health Organization's classification of tumors of the nervous system.

<span class="mw-page-title-main">Jefferson Hospital for Neuroscience</span> Hospital in Pennsylvania, U.S.

Jefferson Hospital for Neuroscience is a hospital in Center City Philadelphia, affiliated with Thomas Jefferson University and Thomas Jefferson University Hospital in Philadelphia. The hospital focuses on treating brain-related diseases and disorders. It is the only hospital of its kind in the Philadelphia area.

References

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  21. 1 2 Combs SE, Welzel T, Schulz-Ertner D, Huber PE, Debus J (January 2010). "Differences in clinical results after LINAC-based single-dose radiosurgery versus fractionated stereotactic radiotherapy for patients with vestibular schwannomas". International Journal of Radiation Oncology, Biology, Physics. 76 (1): 193–200. doi:10.1016/j.ijrobp.2009.01.064. PMID   19604653.
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  23. ↑ Mathis S, Eisner W (6 October 2010). Gamma Knife versus adapted linear accelerators: A comparison of two radiosurgical applications (Report). HTA-Projektbericht 47. eISSN   1993-0496. ISSN   1993-0488.
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