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CyberKnife Spinal Radiosurgery

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

Hamilton et al Neurosurgery 36(2):311-19, 1995


Hamilton et al Stereo Functional NS, 1995
Targeting Challenges of Non-rigid Unfixed
Spine
Frameless Radiosurgery:
Advantages
Improved Accuracy?

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)

Patient # Spine Type Target #1 Target #2 Target #3 Target #4 Mean

1 Cervical 0.55 0.96 0.36 0.5 0.59

2 Cervical 0.61 0.34 0.77 0.21 0.48

3 Cervical 0.45 0.47 0.58 0.29 0.45

4 Cervical 0.79 0.83 0.33 0.44 0.6

5 Thoracic 0.49 0.32 0.42 0.39 0.41

6 Thoracic 0.62 0.41 0.27 0.21 0.38

7 Thoracic 0.68 0.6 0.92 0.7 0.73

8 Lumbar 0.5 0.31 0.14 0.16 0.28

9 Lumbar 0.24 0.24 0.6 0.63 0.43

10 Lumbar 0.46 0.24 0.37 0.48 0.39

11 Lumbar 0.25 0.76 0.61 1 0.66

RMS = ( dx − dx0 ) 2 + ( dy − dy0 ) 2 + ( dz − dz0 ) 2

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

Max spinal cord dose 9 Gy: vol. >8 Gy=0.15 cc

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 6 mo post SRS @ 3 yrs


C4-5 SCAVM: 2 Yrs Post 2 x 10 Gy
Cervical Spinal Cord
AVM

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

pulmonary veins pulmonary veins


cavotriscupid cavotriscupid

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

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