CyberKnife Center

Milano, Italy

CyberKnife Center

Milano, Italy
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Barbarisi M.,The Second University of Naples | Romanelli P.,CyberKnife Center
Current Radiopharmaceuticals | Year: 2012

Stereotactic radiosurgery is an emerging treatment option offered to patients with Glioblastoma multiforme (GBM). Radiosurgery is performed as an outpatient procedure and provides a safe and effective non invasive treatment for focal GBM. High energy beams originating from cobalt sources placed into an helmet (Gamma-Knife) or generated by a linear accelerator (LINAC) rotating on a gantry (X-Knife, Novalis) or maneuvered by a robotic arm (CyberKnife) are delivered with submillimetric accuracy to a selected intracranial target. Treatment accuracy is provided by image-guided volumetric CT and MR studies complemented with advanced metabolic neuroimaging techniques such as CT-PET. Radiosurgery is typically used as a salvage treatment in patients with recurrent GBM to avoid further surgical procedures or as a complement to conventional fractionated radiotherapy. This paper reviews the emerging role of stereotactic radiosurgery in the treatment of GBM. © 2012 Bentham Science Publishers.


Marchetti M.,Fondazione Irccs Instituto Neurologico C Besta | Marchetti M.,University of Milan | Marchetti M.,Fondazione IRCCS Instituto Neurologico Carlo Besta | Bianchi S.,University of Milan | And 5 more authors.
Neurosurgery | Year: 2011

Background: Traditional treatment options for optic nerve sheath meningiomas (ONSMs) include observation, surgery, and radiotherapy, but to date none of these has become the clear treatment of choice. Objective: To evaluate the effectiveness and safety of multisession radiosurgery for ONSMs. Methods: From May 2004 to June 2008, 21 patients with ONSMs were treated by radiosurgery using the frameless CyberKnife system. Patient age ranged from 36 to 73 years (mean, 54 years). All patients were treated using multisession radiosurgery, with 5 fractions of 5 Gy each to a total dose of 25 Gy prescribed to the 75% to 85% isodose line. Patients were evaluated for tumor growth control and visual function. Results: The median pretreatment tumor volume was 2.8 mL (range, 0.3-23 mL). The mean follow-up was 30 months (range, 11-68 months). All patients tolerated treatment well, with only 1 patient in whom a mild optic neuropathy developed (which remitted after systemic steroid therapy). No other acute or late radiation-induced toxicities were observed. No patients showed ONSM progression on follow-up magnetic resonance imaging. Two patients (10%) had a partial response. No patients had worsening of visual function; visual function was stable in 65% and improved in 35% of patients. Conclusion: Multisession radiosurgery for ONSMs was found to be safe and effective. The preliminary results from this study, in terms of growth control, visual function improvement, and toxicity, are quite promising. Further investigations are warranted. Copyright © 2011 by the Congress of Neurological Surgeons.


Striano S.,University of Naples Federico II | Santulli L.,University of Naples Federico II | Ianniciello M.,University of Naples Federico II | Ferretti M.,University of Genoa | And 2 more authors.
Epilepsy and Behavior | Year: 2012

Hypothalamic hamartoma (HH) can be associated with a wide spectrum of epileptic conditions, ranging from a mild form with seizures characterized by urge to laugh and no cognitive involvement up to a catastrophic encephalopathy with early onset gelastic seizures (GS), precocious puberty, and mental retardation. Moreover, a refractory, either focal or generalized, epilepsy develops during the clinical course in nearly all the cases. Neurophysiologic and neuroimaging studies have demonstrated that HH itself generates GS and starts a process of secondary epileptogenesis responsible for refractory focal or generalized epilepsy. The intrinsic epileptogenicity of HH may be explained by the neurophysiological properties of small GABAergic, spontaneously firing HH neurons. Surgical ablation of HH can reverse epilepsy and encephalopathy. Gamma-knife radiosurgery and image-guided robotic radiosurgery seem to be useful and safe approaches for treatment, in particular of small HH. Here, we review this topic, based on literature reports and our personal observations. In addition, we discuss pathogenetic hypotheses and suggest new approaches to this intriguing issue. © 2012 Elsevier Inc.


Nikolajek K.,Ludwig Maximilians University of Munich | Kufeld M.,Cyberknife Center | Muacevic A.,Cyberknife Center | Wowra B.,Cyberknife Center | And 2 more authors.
Radiation Oncology | Year: 2011

Background: Conventional external beam radiotherapy is a standard procedure for treatment of spinal metastases. In case of progression spinal cord tolerance limits further radiotherapy in pre-irradiated areas. Spinal stereotactic radiotherapy is a non-invasive option to re-treat pre-irradiated patients. Nevertheless, spinal radiosurgery results in relevant dose deposition within the myelon with potential toxicity. Aim of the study was to retrospectively analyse the efficacy and feasibility for salvage radiosurgery of spinal metastases.Methods: During a period of 4 years (2005-2009) 70 lesions in 54 patients were treated in 60 radiosurgery sessions and retrospectively analysed. Clinical (pain, sensory and motor deficit) and radiological (CT/MRI) follow-up data were collected prospectively after radiosurgery. Pain - as main symptom - was classified by the Visual Analogue Scale (VAS) score. Every patient received single session radiosurgery after having been treated first-line with conventionally fractionated radiotherapy. Kaplan-Meier method and life tables were used to analyse freedom from local failure and overall survival.Results: At a median follow-up of 14.5 months the actuarial rates of freedom from local failure at 6/12/18 months were 93%, 88% and 85%, respectively. The median radiosurgery dose was 1 × 18 Gy (range 10-28 Gy) to the median 70% isodose. The VAS score of patients with pain (median 6) dropped significantly (median 4, p = 0.002). In 6 out of 7 patients worse sensory or motor deficit after SRS was caused by local or distant failures (diagnosed by CT/MRI). One patient with metastatic renal cell carcinoma developed a progressive complete paraparesis one year after the last treatment at lumbar level L3. Due to multiple surgery and radiosurgery treatments at the lumbar region and further local progression, the exact reason remained unclear. Apart from that, no CTC grade III or higher toxicity has been observed.Conclusions: By applying spinal radiosurgery relevant radiation doses can be limited to small parts of the myelon. This prevents myelopathic side effects and makes it an effective and safe treatment option for well-suited patients. Especially for previously irradiated patients with local failure or pain salvage SRS represents a valuable treatment option with high local control rates, low toxicity and significant pain reduction. © 2011 Nikolajek et al; licensee BioMed Central Ltd.


Bijlani A.,Accuray Incorporated | Aguzzi G.,CyberKnife Center | Schaal D.W.,Accuray Incorporated | Romanelli P.,CyberKnife Center | Romanelli P.,European Synchrotron Radiation Facility
Frontiers in Oncology | Year: 2013

Objective: To describe and synthesize the current stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT) cost-effectiveness research to date across several common SRS and SBRT applications. Methods: This review was limited to comparative economic evaluations of SRS, SBRT, and alternative treatments (e.g., other radiotherapy techniques or surgery). Based on PubMed searches using the terms, "stereotactic," "SRS," "stereotactic radiotherapy," "stereotactic body radiotherapy," "SBRT," "stereotactic ablative radiotherapy," "economic evaluation," "quality adjusted life year (QALY)," "cost," "cost-effectiveness," "cost-utility," and "cost analysis," published studies of cost-effectiveness and health economics were obtained. Included were articles in peer-reviewed journals that presented a comparison of costs between treatment alternatives from January 1997 to November 2012. Papers were excluded if they did not present cost calculations, therapeutic cost comparisons, or health economic endpoints. Results: Clinical outcomes and costs of SRS and SBRT were compared to other therapies for treatment of cancer in the brain, spine, lung, prostate, and pancreas. Treatment outcomes for SRS and SBRT are usually superior or comparable, and cost-effective, relative to alternative techniques. Conclusion: Based on the review of current SRS and SBRT clinical and health economic literature, from a patient perspective, SRS and SBRT provide patients a clinically effective treatment option, while from the payer and provider perspective, SRS and SBRT demonstrate cost savings. © 2013 Bijlani, Aguzzi, Schaal and Romanelli.


Pantelis E.,National and Kapodistrian University of Athens | Moutsatsos A.,National and Kapodistrian University of Athens | Zourari K.,National and Kapodistrian University of Athens | Kilby W.,Accuray | And 6 more authors.
Medical Physics | Year: 2010

Purpose: The aim of this work is to implement a recently proposed dosimetric formalism for nonstandard fields to the calibration and small field output factor measurement of a robotic stereotactic radiosurgery system. Methods: Reference dosimetry measurements were performed in the nonstandard, 60 mm diameter machine specific reference (msr) field using a Farmer ion chamber, five other cylindrical chambers with cavity lengths ranging from 16.25 down to 2.7 mm, and alanine dosimeters. Output factor measurements were performed for the 5, 7.5, 10, and 15 mm field sizes using microchambers, diode detectors, alanine dosimeters, TLD microcubes, and EBT Gafchromic films. Measurement correction factors as described in the proposed formalism were calculated for the ion chamber and diode detector output factor measurements based on published Monte Carlo data. Corresponding volume averaging correction factors were calculated for the alanine output factor measurements using 3D dose distributions, measured with polymer gel dosimeters. Results: Farmer chamber and alanine reference dosimetry results were found in close agreement, yielding a correction factor of k Qmsr,Qfmsr,fref =0.999±0.016 for the chamber readings. These results were also found to be in agreement within experimental uncertainties with corresponding results obtained using the shorter cavity length ionization chambers. The mean measured dose values of the latter, however, were found to be consistently greater than that of the Farmer chamber. This finding, combined with an observed inverse relationship between the mean measured dose and chamber cavity length that follows the trend predicted by theoretical volume averaging calculations in the msr field, implies that the Farmer k Qmsr,Qfmsr,fref correction is greater than unity. Regarding the output factor results, deviations as large as 33% were observed between the different dosimeters used. These deviations were substantially decreased when appropriate correction factors were applied to the measured microchamber, diode, and alanine values. After correction, all diode and microchamber measured output factors agreed within 1.6% with the corresponding alanine measurements, and within 3.1% with the TLD measurements. The weighted mean output factors were 0.681±0.001, 0.824±0.001, 0.875±0.001, and 0.954±0.001 for the 5, 7.5, 10, and 15 mm beams, respectively. Conclusions: The comparison of Farmer chamber measurements versus alanine reference dosimetry validates the use of the former for dosimetry in the msr field of this treatment delivery system. The corresponding results of this work obtained using chambers with different cavity lengths, combined with previous literature findings, suggest that a Qmsr,Qfmsr,fref Farmer chamber dose response correction factor of 1.01 may improve calibration measurement accuracy when using the proposed dosimetric formalism. The k Qmsr,Qfmsr,fref correction factor is within 0.5% from unity for ion chambers with cavity lengths less than 10 mm. Substantial improvements in small field output factor measurement accuracy can be obtained when using microchambers and diodes by applying appropriately calculated correction factors to the detector measurements according to the proposed dosimetric formalism, and their routine use is therefore recommended. © 2010 American Association of Physicists in Medicine.


Pantelis E.,CyberKnife Center | Pantelis E.,National and Kapodistrian University of Athens | Papadakis N.,CyberKnife Center | Verigos K.,CyberKnife Center | And 7 more authors.
International Journal of Radiation Oncology Biology Physics | Year: 2010

Purpose: To study the efficacy of the integration of functional magnetic resonance imaging (fMRI) and diffusion tensor imaging tractography data into stereotactic radiosurgery clinical practice. Methods and Materials: fMRI and tractography data sets were acquired and fused with corresponding anatomical MR and computed tomography images of patients with arteriovenous malformation (AVM), astrocytoma, brain metastasis, or hemangioma and referred for stereotactic radiosurgery. The acquired data sets were imported into a CyberKnife stereotactic radiosurgery system and used to delineate the target, organs at risk, and nearby functional structures and fiber tracts. Treatment plans with and without the incorporation of the functional structures and the fiber tracts into the optimization process were developed and compared. Results: The nearby functional structures and fiber tracts could receive doses of >50% of the maximum dose if they were excluded from the planning process. In the AVM case, the doses received by the Broadmann-17 structure and the optic tract were reduced to 700 cGy from 1,400 cGy and to 1,200 cGy from 2,000 cGy, respectively, upon inclusion into the optimization process. In the metastasis case, the motor cortex received 850 cGy instead of 1,400 cGy; and in the hemangioma case, the pyramidal tracts received 780 cGy instead of 990 cGy. In the astrocytoma case, the dose to the motor cortex bordering the lesion was reduced to 1,900 cGy from 2,100 cGy, and therefore, the biologically equivalent dose in three fractions was delivered instead. Conclusions: Functional structures and fiber tracts could receive high doses if they were not considered during treatment planning. With the aid of fMRI and tractography images, they can be delineated and spared. © 2010 Elsevier Inc.


Di Betta E.,Instituto Neurologico C Besta | Fariselli L.,Instituto Neurologico C Besta | Bergantin A.,CyberKnife Center | Locatelli F.,CyberKnife Center | And 3 more authors.
Medical Physics | Year: 2010

Purpose: The main purpose of this work was to compare peripheral doses absorbed during stereotactic treatment of a brain lesion delivered using different devices. These data were used to estimate the risk of stochastic effects. Methods: Treatment plans were created for an anthropomorphic phantom and delivered using a LINAC with stereotactic cones and a multileaf collimator, a CyberKnife® system (before and after a supplemental shielding was applied), a TomoTherapy® system, and a Gamma Knife® unit. For each treatment, 5 Gy were prescribed to the target. Measurements were performed with thermoluminescent dosimeters inserted roughly in the position of the thyroid, sternum, upper lung, lower lung, and gonads. Results: Mean doses ranged from of 4.1 (Gamma Knife) to 62.8 mGy (LINAC with cones) in the thyroid, from 2.3 (TomoTherapy) to 30 mGy (preshielding CyberKnife) in the sternum, from 1.7 (TomoTherapy) to 20 mGy (preshielding CyberKnife) in the upper part of the lungs, from 0.98 (Gamma Knife) to 15 mGy (preshielding CyberKnife) in the lower part of the lungs, and between 0.3 (Gamma Knife) and 10 mGy (preshielding CyberKnife) in the gonads. Conclusions: The peripheral dose absorbed in the sites of interest with a 5 Gy fraction is low. Although the risk of adverse side effects calculated for 20 Gy delivered in 5 Gy fractions is negligible, in the interest of optimum patient radioprotection, further studies are needed to determine the weight of each contributor to the peripheral dose. © 2010 American Association of Physicists in Medicine.


Romanelli P.,CyberKnife Center | Bianchi L.,CyberKnife Center | Muacevic A.,European CyberKnife Center | Beltramo G.,CyberKnife Center
Computer Aided Surgery | Year: 2011

Objective: Optic nerve sheath meningiomas (ONSMs) represent the most challenging lesions involving the optic pathways: Microsurgery is not indicated and classical single-stage radiosurgery appears to be too risky due to the expected destruction of the common blood supply with consequent loss of vision. Staged radiosurgery might be one treatment option because it exploits the ability of normal tissues to repair sub-lethal radiation-induced damage, offering a chance to control tumor growth while sparing function. Staged robotic radiosurgery was offered to 5 patients harboring ONSMs with the aim of sparing vision while achieving local growth control. Patients and Methods: Five patients with ONSM presenting with visual field deficits and loss of visual acuity were treated with staged CyberKnife radiosurgery, receiving 20Gy in 4 stages (5Gy per stage). Treatment planning was based on contrast-enhanced thin-slice CT (1.25mm thickness for the first three cases, 0.5mm for the last two) and volumetric MR imaging (1.5T for the first three cases, 3T for the last two). An interval of 24 hours was strictly observed between stages. Visual acuity and visual fields were assessed in all patients immediately prior to treatment and at intervals of 6 months thereafter. Follow-up MRIs were performed every 6 months for 2 years, then once per year. Results: The entire procedure, inclusive of imaging, treatment planning and treatment delivery, was performed in 5 days. Irradiation required approximately 45min per stage. Mean tumor volume was 2.94cc (range: 0.86.4cc). Treatment was well tolerated in all patients. Follow-up ranged from 36 to 74 months. Local growth control was achieved in all patients. Restoration of normal vision was experienced by 4 patients 6 to 12 months after the treatment. One patient, who was also affected by diabetic retinopathy, showed a modest improvement after 6 months, remaining stable thereafter. Conclusion: Staged CyberKnife radiosurgery provides a fast and well-tolerated non-invasive treatment with excellent visual outcomes. If these preliminary results are confirmed by larger series, staged radiosurgery could be proposed as a first-line treatment for ONSM. © 2011 Informa UK Ltd.


Colonnese C.,IRCCS Neuromed | Romanelli P.,CyberKnife Center
Current Radiopharmaceuticals | Year: 2012

Despite the extensive research efforts over the past century, glioblastoma multiforme (GBM) remains an ominous diagnosis leading fast to progressive disability and death despite the aggressive treatment including microsurgical resection, chemotherapy, radiotherapy and stereotactic radiosurgery. Advanced neuroimaging techniques, such as volumetric acquisitions, spectroscopy, diffusion and perfusion studies added to conventional imaging, provide in selected cases a non-invasive alternative to pathological diagnosis but they are also precious tools to define the boundaries of image-guided microsurgical resection and/or radiosurgical ablation. This paper reviews the role of advanced neuroimaging techniques in the diagnosis and treatment of GBM. © 2012 Bentham Science Publishers.

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