Stintzing S.,Comprehensive Cancer Center |
Grothe A.,Ludwig Maximilians University of Munich |
Hendrich S.,Comprehensive Cancer Center |
Hoffmann R.-T.,Universitatsklinikum Carl Gustav Carus Dresden |
And 5 more authors.
Acta Oncologica | Year: 2013
Background. Stereotactic radiation therapy is an evolving modality to treat otherwise unresectable liver metastases. In this analysis, two local therapies: 1) single session robotic radiosurgery (RRS) and 2) percutaneous radiofrequency ablation (RFA) were compared in a total of 60 heavily pretreated colorectal cancer patients. Methods. Thirty patients with a total of 35 colorectal liver metastases not qualifying for surgery that were treated in curative intent with RRS were prospectively followed. To compare efficacy of both treatment modalities, patients treated with RFA during the same period of time were matched according to number and size of the treated lesions. Local tumor control, local disease free survival (DFS), and freedom from distant recurrence (FFDR) were analyzed for efficacy. Treatment-related side effects were recorded for comparison. Results. The median diameter of the treated lesions was 33 mm (7-53 mm). Baseline characteristics did not differ significantly between the groups. One- and two-year local control rates showed no significant difference but favored RRS (85% vs. 65% and 80% vs. 61%, respectively). A significantly longer local DFS of patients treated with RRS compared to RFA (34.4 months vs. 6.0 months; p < 0.001) was found. Both, median FFDR (11.4 months for RRS vs. 7.1 months for RFA p = 0.25) and the recurrence rate (67% for RRS and 63% for RFA, p > 0.99) were comparable. Conclusion. Single session RRS is a safe and effective method to treat colorectal liver metastases. In this analysis, a trend towards longer DFS was seen in patients treated with RRS when compared to RFA. © 2013 Informa Healthcare.
Staehler M.,Ludwig Maximilians University of Munich |
Bader M.,Ludwig Maximilians University of Munich |
Schlenker B.,Ludwig Maximilians University of Munich |
Casuscelli J.,Ludwig Maximilians University of Munich |
And 6 more authors.
Journal of Urology | Year: 2015
Purpose: High dose local stereotactic radiosurgery was performed in select patients to improve local tumor control and overall survival. We report on patients with renal tumors treated with single fraction robotic stereotactic radiosurgery. Materials and Methods: A total of 40 patients with a median age of 64 years who had an indication for nephrectomy and subsequent hemodialysis were entered in a prospective case-control study of single fraction stereotactic radiosurgery. Of the patients 11 had transitional cell cancer and 29 had renal cell cancer. Tumor response, renal function, survival and adverse events were estimated every 3 months. Followup was at least 6 months. Results: A total of 45 renal tumors were treated. Median followup was 28.1 months (range 6.0 to 78.3). The local tumor control rate 9 months after stereotactic radiosurgery was 98% (95% CI 89-99). There was a measurable size reduction in 38 lesions, including complete remission in 19. Renal function remained stable. Using the CKD-EPI (Chronic Kidney Disease Epidemiology Collaboration) equation median creatinine clearance was 76.8 (range 25.3 to 126.3) and 70.3 ml/minute/1.73 m2 (range 18.6 to 127.3) at baseline and followup, respectively (p = 0.89). Grade I erythrodermia developed in 1 patient, 3 reported grade I fatigue and 2 reported grade I nausea. Nephrectomy was avoided in all cases. Conclusions: Single fraction stereotactic radiosurgery as an outpatient procedure is a treatment modality with short-term safety and efficacy. It avoids treatment related loss of renal function and hemodialysis in select patients with transitional or renal cell cancer. At short followup oncologic results were similar to those of other ablative techniques for renal tumors. To date functional results have been excellent. Further studies are needed to determine the long-term results and limits of stereotactic radiosurgery in this setting. © 2015 American Urological Association Education and Research, Inc.
Schlaefer A.,University of Lübeck |
Schlaefer A.,TU Hamburg - Harburg |
Viulet T.,University of Lübeck |
Muacevic A.,European CyberKnife Center Munich |
Furweger C.,European CyberKnife Center Munich
Medical Physics | Year: 2013
Purpose: Treatment planning for radiation therapy involves trade-offs with respect to different clinical goals. Typically, the dose distribution is evaluated based on few statistics and dose-volume histograms. Particularly for stereotactic treatments, the spatial dose distribution represents further criteria, e.g., when considering the gradient between subregions of volumes of interest. The authors have studied how to consider the spatial dose distribution using a multicriteria optimization approach. Methods: The authors have extended a stepwise multicriteria optimization approach to include criteria with respect to the local dose distribution. Based on a three-dimensional visualization of the dose the authors use a software tool allowing interaction with the dose distribution to map objectives with respect to its shape to a constrained optimization problem. Similarly, conflicting criteria are highlighted and the planner decides if and where to relax the shape of the dose distribution. Results: To demonstrate the potential of spatial multicriteria optimization, the tool was applied to a prostate and meningioma case. For the prostate case, local sparing of the rectal wall and shaping of a boost volume are achieved through local relaxations and while maintaining the remaining dose distribution. For the meningioma, target coverage is improved by compromising low dose conformality toward noncritical structures. A comparison of dose-volume histograms illustrates the importance of spatial information for achieving the trade-offs. Conclusions: The results show that it is possible to consider the location of conflicting criteria during treatment planning. Particularly, it is possible to conserve already achieved goals with respect to the dose distribution, to visualize potential trade-offs, and to relax constraints locally. Hence, the proposed approach facilitates a systematic exploration of the optimal shape of the dose distribution. © 2013 American Association of Physicists in Medicine.
Stintzing S.,Ludwig Maximilians University of Munich |
Hoffmann R.T.,Ludwig Maximilians University of Munich |
Heinemann V.,Ludwig Maximilians University of Munich |
Kufeld M.,European Cyberknife Center Munich |
Muacevic A.,European Cyberknife Center Munich
European Journal of Cancer | Year: 2010
Introduction: Due to advanced chemotherapy regimens, patients presenting with residual liver metastases of colorectal cancer (CRC) has increased. Surgery of residual metastases enhances overall survival, but surgical resection is often limited. Less invasive techniques have been invented to enhance local disease control. We investigated in a selected patient cohort local control of liver metastasis from CRC using robotic radiosurgery. Methods and materials: In this study patients with colorectal liver metastases were prospectively followed after having been treated with single-session radiosurgery using a robotic image-guided device and real-time tumour tracking. The primary end-point was local control (LC); secondary end-points were toxicity, progression-free survival (PFS) and overall survival (OS). Extrahepatic metastases were excluded using a whole body (PET-CT: positron emission tomography computed tomography). Follow up was done by liver MRI every 3 months post-treatment. Results: Fourteen patients (median age 65 years), with a total of 19 colorectal liver metastases were treated with 24 Gy in one fraction. Median follow up was 16.8 months. A one-year LC rate of 87% and a median PFS of 9.2 months were reached. Discussion: Frameless robotic image-guided radiosurgery with real-time tumour tracking as an effective treatment for patients with colorectal liver metastases. This technique enhances the possibilities of multidisciplinary oncological concepts. © 2010 Elsevier Ltd. All rights reserved.
Stintzing S.,Ludwig Maximilians University of Munich |
Hoffmann R.-T.,Ludwig Maximilians University of Munich |
Heinemann V.,Ludwig Maximilians University of Munich |
Kufeld M.,European CyberKnife Center Munich |
And 2 more authors.
Annals of Surgical Oncology | Year: 2010
Background: The treatment of isolated liver metastases has become a rapidly developing field with many new, technically advanced methods. Here we present the therapeutic efficacy of a robotic radiosurgery for local control of liver metastases from solid tumors. Methods: Patients with tumorous lesions to the liver, not qualifying for surgery, were treated with single-session radiosurgery (24 Gy) that used robotic image-guided real-time tumor tracking. All detectable lesions had to be irradiated. In a prospective analysis, follow-up was performed by magnetic resonance imaging scanning 2 months after the treatment, and subsequently at 3-month intervals to evaluate local control. For inclusion into the radiosurgery treatment protocol, tumor volumes had to be <90 ml. Results: Thirty-six patients (median age, 65 years) with a total of 54 target lesions were evaluated. Single lesions were treated in 23 patients and multiple targets in 13 patients. Metastases originated from colon cancer (n = 19), ovarian cancer (n = 3), pancreatic cancer (n = 2), breast cancer (n = 2), and others (n = 6). Four lesions were of primary liver origin (hepatocellular carcinoma and cholangiocellular carcinoma). Median tumor volume was 18 ml (range, 2.2-90 ml). The median follow-up was 21.3 months. The disease of 25 patients (69.4%) showed complete or partial local response, 6 patients (16.7%) had stable lesions, and 5 patients (14%) experienced local recurrence. Grade 2-4 adverse events due to radiation treatment were not observed. Conclusions: Robotic radiosurgery with image-guided real-time tumor tracking of liver neoplasm is a new and promising approach for patients with disease that is not eligible for surgical resection and might enhance the possibilities of multidisciplinary oncological treatment concepts. © 2010 Society of Surgical Oncology.
Furweger C.,European Cyberknife Center Munich
Journal of applied clinical medical physics / American College of Medical Physics | Year: 2011
The image-guided CyberKnife radiosurgery system is apable of tracking spinal targets without fiducial implants. Recently, a new version of this fiducial-free image guidance modality ("enhanced Xsight spine tracking") has been introduced. We assessed the accuracy of this novel technique versus its precursor in a comparative phantom study. The CyberKnife consists of a 6 MV linac on a six-axis robot and a stereoscopic kV image guidance system. An anthropomorphic head-and-neck phantom with a cervical spine section was mounted on the linac nozzle. The robotic manipulator was used to precisely move the phantom to defined positions in the CyberKnife workspace. Multiple stereoscopic images were acquired at different translational and rotational positions. The enhanced Xsight spine tracking readouts were recorded and compared to the nominal phantom position. These tests were repeated with the original Xsight spine tracking version to analyze potential differences. Enhanced Xsight spine tracking correctly reported translational offsets with an RMS error of less than 0.4 mm. Yaw and roll rotations were detected with an accuracy of 0.2°, 0.25°. Pitch offsets were slightly underestimated, with up to 0.3° for an offset of ± 2°. Nominal X (left-right) translational offsets were partially misinterpreted as roll (0.2° at a 10 mm offset). Apart from this, no correlation between rotational and translational directions was found. In comparison, the original Xsight spine tracking showed identical results for translations, but larger systematic and statistical errors for rotations. Enhanced Xsight spine tracking measurably improves precision in fiducial-free spinal radiosurgery with the CyberKnife.
Staehler M.,Ludwig Maximilians University of Munich |
Haseke N.,Ludwig Maximilians University of Munich |
Nuhn P.,Ludwig Maximilians University of Munich |
Tullmann C.,Ludwig Maximilians University of Munich |
And 5 more authors.
BJU International | Year: 2011
OBJECTIVE To analyse the safety and efficacy of simultaneous standard anti-angiogenic therapy and stereotactic radiosurgery (SRS) in patients with spinal and cerebral metastases from renal cell carcinoma. PATIENTS AND METHODS In all, 106 patients with spinal (n= 55) or cerebral (n= 51) metastatic lesions and an Eastern Cooperative Oncology Group status of 0 or 1 were treated with sorafenib or sunitinib and simultaneous SRS. The primary endpoint was local control. Secondary endpoints were toxicity and overall survival. RESULTS Median follow up was 14.7 months (range 1-42 months). Forty-five patients were treated with sunitinb and 61 patients with sorafenib. Two patients had asymptomatic tumour haemorrhage after SRS. No skin toxicity, neurotoxicity or myelopathy occurred after SRS, and SRS did not alter the adverse effects of anti-angiogenic therapy. Local tumour control 15 months after SRS was 98% (95% confidence interval 89-99%). The median pain score before SRS was 5 (range 1-8) and was lowered to 0 (range 0-2, P < 0.01) after SRS. There were no treatment-related deaths or late complications after SRS. Overall survival was 17.4 months in patients with spinal lesions and 11.1 month in patients with cerebral lesions (P= 0.038). CONCLUSIONS Simultaneous systemic anti-angiogenic therapy and SRS for selected patients with renal cell carcinoma who have spinal and cerebral metastases is safe and effective. Single-fraction delivery allows for efficacious integration of focal radiation treatment into oncological treatment concepts without additional toxicity. Further studies are needed to determine the limits of SRS for renal cell carcinoma metastases outside the brain and spine. © 2010 BJU INTERNATIONAL.
PubMed | TU Hamburg - Harburg, University of Lübeck and European Cyberknife Center Munich
Type: Journal Article | Journal: Medical physics | Year: 2017
Ultrasound presents a fast, volumetric image modality for real-time tracking of abdominal organ motion. How-ever, ultrasound transducer placement during radiation therapy is challenging. Recently, approaches using robotic arms for intra-treatment ultrasound imaging have been proposed. Good and reliable imaging requires placing the transducer close to the PTV. We studied the effect of a seven degrees of freedom robot on the fea-sible beam directions.For five CyberKnife prostate treatment plans we established viewports for the transducer, i.e., points on the patient surface with a soft tissue view towards the PTV. Choosing a feasible transducer pose and using the kinematic redundancy of the KUKA LBR iiwa robot, we considered three robot poses. Poses 1 to 3 had the elbow point anterior, superior, and inferior, respectively. For each pose and each beam starting point, the pro-jections of robot and PTV were computed. We added a 20 mm margin accounting for organ / beam motion. The number of nodes for which the PTV was partially of fully blocked were established. Moreover, the cumula-tive overlap for each of the poses and the minimum overlap over all poses were computed.The fully and partially blocked nodes ranged from 12% to 20% and 13% to 27%, respectively. Typically, pose 3 caused the fewest blocked nodes. The cumulative overlap ranged from 19% to 29%. Taking the minimum overlap, i.e., considering moving the robots elbow while maintaining the transducer pose, the cumulative over-lap was reduced to 16% to 18% and was 3% to 6% lower than for the best individual pose.Our results indicate that it is possible to identify feasible ultrasound transducer poses and to use the kinematic redundancy of a 7 DOF robot to minimize the impact of the imaging subsystem on the feasible beam directions for ultrasound guided and motion compensated SBRT. Research partially funded by DFG grants ER 817/1-1 and SCHL 1844/3-1.
PubMed | Ludwig Maximilians University of Munich and European Cyberknife Center Munich
Type: Journal Article | Journal: Cureus | Year: 2016
CyberKnife radiosurgery (CK) is an effective tool for the treatment of malignancies. Its greatest potential is in high-dose radiosurgery delivered to targets in organs that move with respiration, e.g., liver tumors. For hepatocellular carcinoma (HCC), however, surgical treatment (resection, transplantation) is most likely to produce long-term survival; for non-resectable tumors, therapies other than radiosurgery are typically recommended. This study evaluated the long-lasting anti-tumor effects of CK combined with surgery in patients with HCC. MATERIALS AND METHODS: Eighteen patients (three women, 15 men) were included in this prospective observational study. They received 21 single-fraction CK treatments (26 Gy).Patient characteristics, treatment effects, tumor response (according to the Response Evaluation Criteria In Solid Tumors (RECIST) grading) and survival were measured for a median period of 29 months.Local tumor control was achieved in 15 patients, with complete and partial remission observed in 10 and five patients, respectively. One patient was treated for two separate lesions in one session, and one received three treatments each separated by two-year intervals; both patients are tumor-free.Two patients showed minimal response, and in one patient local tumor viability could not be excluded by MRI. Nine patients had HCC recurrence, all distant to the treated site.Nine patients died during follow-up, including two with clear relation to tumor progress. Tumor-free survival was 79.4% after one year and 29.8% after three years, and the corresponding overall survival was 84.8% and 66%. CONCLUSION: This study shows the high effectiveness of single-session frameless CyberKnife radiosurgery for treatment of hepatocellular carcinoma and reconfirms previous results of fractioned radiotherapy of HCC. It also demonstrates the potential of radiosurgery to be combined with surgical concepts.
PubMed | Ludwig Maximilians University of Munich and European CyberKnife Center Munich
Type: Journal Article | Journal: Radiation oncology (London, England) | Year: 2016
After focused high dose radiotherapy of brain metastases, differentiation between tumor recurrence and radiation-induced lesions by conventional MRI is challenging. This study investigates the usefulness of dynamic O-(2-Twenty-two patients with 34 brain metastases (median age 61.9years) were included. Due to follow-up scan evaluations after repeated treatment in a subset of patients, a total of 50 lesions with MRI-based suspicion of tumor recurrence after focused high dose radiotherapy could be evaluated. Tumor recurrence was found in 21/50 cases (15/21 verified by histology, 6/21 by radiological-clinical follow-up) and radiation-induced changes in 29/50 cases (5/29 verified by histology, 24/29 by radiological-clinical follow-up). Median clinical-radiological follow-up was 28.3months (range 4.2-99.1months). In patients with MRI-suspected tumor recurrence after focused high dose radiotherapy,