Professional Documents
Culture Documents
John R. Adler, Jr., MD
Professor of Neurosurgery
& Radiation Oncology
Stanford University
BangkokSpine
C-3 Spinal Metastasis Treated by SRS:
1991
Hamilton Rigid Stereotactic Spine
Frame
Hamilton Rigid Stereotactic Spine
Frame
Less painful, especially for children
Ability to fractionate
Potential to treat tumors
below the skull base
Image-guidance Using Real-time X-
ray
VHL: T-1 Hemangioblastoma
1997
Stainless Steel Spine
Fiducial
Fiducial Placement @ L-3: Recurrent
Ependymoma
Image-guided Spine
Tracking
C-Spine w/ Deformable
Correction
Fiducialess Spine Targeting
Accuracy
Table 14. Clinical V&V Test Results
RMS (mm)
Tracking accuracy is about 0.5 mm: Ho et al
“Dose Painting” Inverse
Planning
Schweikard & Stanford CS
Previously Irradiated T-Spine Met:
Breast CA
>2 dozen publications in 2007 alone
Stanford CK Papers
2000
n=16 2001
n=6 2001
Stanford CK Papers
n=59 2006
n=102 2007
n=15 2006
Stanford:CK Spine SRS
Pathology
Schwan
Neurofibr
>400 Patients
Ependym
Chordoma
AVM
Cav Mal
Hemangiobl
Metastasis
Meningioma
Misc
Stanford Intra- & Extra-
Cranial SRS 1994-2007
Stanford Cyberknife 1994-2007
1000
2004:
900 1st X-Sight
800 SRS
700
600
# lesions 500
1995: Extracranial
400
1st Spine SRS
300 Intracranial
200
100
0
1994- 2000 2001 2002 2003 2004 2005 2006 2007
1999
Year
L-1 Vertebral Metastasis: Esophageal CA
primary
April, 1999
T-6 Renal Cell Metastasis
3
mo
25 Gy in 2 Stages
C-4 Thyroid Cancer Metastasis
3 x 8 Gy
PreSRS
PostSRS
C-4 Thyroid Metastasis Presenting with
Pain
PreSRS
PostSRS
Recurrent C-2 Sarcoma Metastasis s/p
XRT
24 Gy in 4 sessions, Dmax: 32 Gy
Cervical-occipital fusion @ 3 mo
C-2 Sarcoma: 36 months s/p CK
12 yo ♂ w/ Recurrent Chordoma
s/p Resection x2
& 70 Gy XRT
Recurrent Chordoma: C2
Lesion
Vol: 17.368 cc
TX: 30 Gy (75%)
in 5 sessions
Dmax: 40 Gy
Recurrent Chordoma: C5 Lesion
Vol: 16.150 cc
TX: 30 Gy (76%)
In 5 sessions
Dmax: 39.47Gy
Recurrent Chordoma: 6 Month Follow-
up
Recurrent Clival Chordoma with C5
Metastasis: 6 mo post Palliative SRS
52 yo T-5 Spine Metastasis: Breast
Cancer
Recurrent
S/P Prior Novalis SRT: 5 x 5 Gy
Not enough dose!!!!!
Recurrent T-5 Metastatic Breast
CA
3 X 8 Gy
Irradiated Renal Cell CA Sacral
Metastasis
How large? 70 yo ♀ Rx’ed
2 x 10 Gy
total =20 Gy
Vol. >130 cc
Pain free w/ intact bowel & bladder @ 2 yr
Complications of Spinal SRS
C7-T2 Meningioma
(post-op residual)
3 x 8 Gy= 24 Gy
C7-T2 Meningioma @ 1 yr
Spinal SRS for Mets
Citation Site Number Median Prior Local Pain
of F/U XRT (%) Control (%) Relief (%)
targets (months)
Ryu Henry 230 6 0% NR 84%
2008 Ford
Degen Gtown 58 12 53% 88% 97%
2005
Gibbs SUH 102 9 74% NR 84%
2007
Gerszten UPMC 500 21 87% 92% 86%
2007
Chang MDACC 74 21 56% 84% NR
2007
Yamada MSKCC 103 15 0% 90% NR
2008
30Gy in >1300 ~90% 73%
10 days
8Gy in >1300 ~75% 73%
1 day
Spinal Mets: Importance of Surgical
Resection
Does localized
tumor ablation
achieve equivalent
outcome?
SRS for Spinal Metastases
Surgical Resection vs. SRS
In many patients there
is only one good option
or a tandem procedure
is warranted
Painful T-6 Renal Cell Carcinoma: No
XRT
Normal
neurol exam
Karnofsy 90
Post-Kyphoplasty CyberKnife SRS
SRS dose: 22.5 Gy in 1 session
Excellent
pain relief
Metastatic Breast Cancer (C2-3)
20 Gy in 2 stages
Metastatic Breast Cancer (C2-3)
@ 6 mo
20 Gy in 2 sessions:
But only modest
neurologic improvement
spine 2: inf/sup
Typical Pt.
d x (m m )
5
movement during
0
0 20 40 60
-5
CK spinal SRS
nod e
spine 2: left/right
d y (m m )
5
0
0 20 40 60
-5
nod e
spine 2: ant/post
However
d z (m m )
5
movement
0
0 20 40 60
-5
>5 mm
nod e
occurs in
some Pts.
In “Immobilized” Spines: How
Accurate?
Rotterdam CyberKnife
Novalis
Treatment of Spinal Metastases:
Goals
Cure? Occasionally possible in
setting of oligometastatic disease
Palliation
Function
Pain
Cost/Convenience
Virtues of SRS for Spinal
Metastases
Outpatient requiring at most 5 days
By most relevant measures, very effective:
Axial pain
Neurologic symptoms
Much more cost effective than resection
No need for postop radiotherapy
0.5% risk of significant myelopathy
Gibbs et al (2008)
CyberKnife SRS
C7-T1 Schwannoma: 3 yr post
SRS
T1-2 Meningioma: 20 Gy in 2
sessions
36 mo f/u
Recurrent Spinal Schwannoma at T-
7
Pre SRS 2 yrs Post SRS
Multi-session SRS for Spinal Cord AVM
First 15
patients
Another Satisfied
Customer
ขอบคุณ
L4-5 Facet Rhizotomy
Rhizotomy may not be just for cranial nerves
SRS Atrial Ablation
for AFib (a leading
cause of stroke)
Atrial Fibrillation
Posterior Views of Atria
Catheter RF Ablation
CyberKnife?
Cardiac Ablation in Porcine Animal
Model
3D Reconstruction of Treatment
Plan
RV
SVC
RA
IVC
subject 3659_5/22/06-8/19/06
CARTO: 3D-Electroanatomical
Mapping
Right Atrium, RAO
subject 3659_5/22/06-8/19/06
3D Overlays
RV
SVC
RA
IVC
subject 3659_5/22/06-8/19/06
3D Overlays
RV
SVC
RA
IVC
subject 3659_5/22/06-8/19/06
3D Overlays
control
RV
SVC
RA
IVC
subject 3659_5/22/06-8/19/06
Conclusion
Experience demonstrates that the contemporary
surgical management of spinal disorders requires
access to spine radiosurgery