Stanford

CyberKnife

LONG-TERM RESULTS OF RADIOSURGERY IN THE TREATMENT OF PARAGANGLIOMAS

STANFORD CYBERKNIFE CENTERDEPARTMENTS OF NEUROSURGERY

AND RADIATION ONCOLOGY

ROBERT LIEBERSON, JOHN ADLER, GRIFF HARSH, MARCO LEE,

CLARA CHOI, SCOTT SOLTYS, IRIS GIBBS, ROB LOBER,

AND STEVEN CHANG

Stanford

CyberKnifeParagangliomas

Indolent, locally invasive, tumors of sympathetic and parasympathetic ganglia cells

Difficult to resect, especially when intracranial

1941, Guild coined the term “glomus jugulare”

Stacy Rufus Guild

Stanford

CyberKnifePatient Characteristics35 patients with 39 tumors, age 54 (21 to 86)

7 previously treated (7 surgery, 1 embolization)4 with multiple tumors3 syndromic (2 NF2, 1 inherited)

Location31 Cranial

6 Carotid

2 Spinal

Sex13 Men

22 Women

Stanford

CyberKnifeSmall Lesions

0 - 8 cm3

1905 cGy (1600-2000) One fraction 79% Isodose 1.43 Conformality Index

8 - 16 cm3

2000 cGy (1800-2200) Two fractions 80% Isodose 1.39 Conformality Index

Stanford

CyberKnifeMedium Lesions

16 - 32 cm3

2250 cGy (1800-2400) Three fractions 76% Isodose 1.34 C.I.

Stanford

CyberKnifeLarge Lesions (1)

42 cm3

(8.4 x 3.1 x 2.8) 2400 in three for

each of two sections

Isodose 76%/79% C.I. 1.27/1.18

12/2006

3/2007

Stanford

CyberKnifeLarge Lesions (2)

69 cm3

(8.6 x 3.5 x 2.8) 2500 in five Isodose 80% C.I. 1.32

Stanford

CyberKnifeFollow-Up

Clinical 56 months

MRI 47 months

≥ 5 years 10 patients≥ 10 years 4 patients

Stanford

CyberKnifeLocal Control

Feigl and Horstmann Radiosurgery Response ClassificationRRC Grade Definition

I Tumor shrinks at least 10%

II Tumor unchanged

III Tumor grows

21 of 39 tumors smaller (grade I) 16 of 39 tumors stable (grade II) None enlarged (grade III)

Stanford

CyberKnife

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1.0

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l Con

trol

0 2 4 6 8 10 12 14 16 18Years

Open Surgery

CyberKnife

Local Control

Stanford

CyberKnifeComplications Two patients with transient cranial neuropathies One patient with permanently increased vertigo

One patient, severely cachexic before SRS, died 1.3 months after treatment (malnutrition)

One with spinal tumors and radiculopathies did not improve and required open surgery

Stanford

CyberKnifeOther SRS Series

18 centers, 345 patients, 1994-2009 86 patients previously operated 56.2 mean age, 9.38 cm3 mean size 1622 cGy mean, 39 mo. mean f/u 97.7 % local control 4.3 % complication rate

(CN deficits, vertigo, serous otitis, headache)

Stanford

CyberKnifeSurgical Series 21 series, 769 patients, 1988-2005

*

82.9 % (568/685) local control ~48 % (~261/539) complications

(at least 40% CN palsies but also 3 deaths, > 10 CVA’s, > 30 wound infection/meningitis, cholesteotomas, aspiration pneumonias, tracheostomies, dysphagia) * Reviewed by Hinerman RW, Amdur RJ, Morris CG, Kirwan MA, MendenhALL WM.

Definitive Radiotherapy in the Management of Paragangliomas Arising in the Head and Neck: A 35-Year Experience. Head and Neck, 30:1431 (2008).

Stanford

CyberKnifeConclusions SRS near 100% local control SRS complications rare, less

severe than from surgery SRS should be the primary

treatment for new or recurrent paragangliomas

Stanford

CyberKnifeThank you

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Numbe

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atients

Year

NEUROSURGERYSteven ChangJohn AdlerMike EdwardsGriff HarshJon ParkJaimie HendersonStefan MindeaRob LiebersonMarco Lee

RADIATION ONCOLOGYIris GibbsScott SoltysQuynh Le Don Goffinet Chris King Albert Koong Billy LooSarah DonaldsonSteve HancockDan ChangPhuoc TranDan Kapp

RADIOLOGYMary MarcellusNancy Fischbein

ENT, GENERALTHORACIC, AND UROLOGIC SURGERYRobert JacklerNick BlevinsRichard WhyteGeorge YangRalph GrecoJoe PrestiHarash Gill

PHYSICS AND RTSonja DeiterichTony Lo Tony HoLei WangLaurence JangJackei LoSandra Kuerth

NURSINGElizabeth LeeAmi LombardiChristine Rico ErbLaurie TupperMichelle Klesczewski

SUPPORTKai KoScarlett WhiteLucy TovarMerna GodoyBarbara PedrickAisha Ali

Treatments by Year