Cyberknife Centre performance since the opening
Stereotactic radiosurgery centre Sigulda was opened last December. 12 patients have already received treatment by CyberKnife M6, the most modern radiosurgery equipment, since the opening of the first CyberKnife center in Baltics.
Five patients with auditory nerve neurinoma (schwannoma), three patients with meningioma in the sites unfavourable for surgical treatment, one patient with uveal melanoma, and two patients with recurrent glial cell tumour underwent treatment in the Cyberknife center. One of the patients underwent irradiation of spinal metastases; another patient was treated after repeated bleeding from the brain vascular malformations in the brain sistem – cavernous sinus malformation.
Stereotactic radiosurgery equipment CyberKnife M6 is designed to ensure the highest quality of radiosurgery and stereotactic radiation therapy procedure. To protect the surrounding tissues and direct destructive radiation dose to the tumour cells, a specially designed linear accelerator (source of the radiation) in combination with a precise robot allows directing the beam of rays to the tumour from almost any angle. During these few months patients with auditory nerve neurinomas or schwannoma underwent radiosurgery, which means that the entire treatment dose was delivered during one session of irradiation.
Dr. Dace Saukuma, attending physician, about the patients:
“Over the last year the patient Lorena from Lithuania (50 years old) started to complain about hearing impairment in the right ear and balance disorder in the last three months. Magnetic resonance imaging (MRI) of the head performed this January revealed neurinoma of the right auditory nerve (a benign tumour from nerve sheaths) ~1.8*1.5 cm in diameter. The decision to choose CyberKnife therapy was made after the consultation of the neurosurgeon. The patient underwent one radiation procedure; the patient has no complaints during the procedure.”
The patient Artis (62 years old) observed impairment of hearing in the right ear in recent months. MRI performed in December 2015 revealed a neurinoma of the right auditory nerve ~1.5 cm in diameter. After the neurosurgeon’s consultation the patient was offered surgical treatment which entailed high complication risk, therefore the patient chose CyberKnife. Arturs underwent one radiation session during which he had no complaints or complications, and he can continue his everyday activities.
The third patient Jānis (43 years old), whose hobby is listening to music with high sound quality, over several months stated that he was unable to hear certain sound frequencies and therefore consulted an ENT specialist. During the visit the specialist recommended to undergo an enhanced MRI of the head which revealed neurinoma of the right auditory nerve, which is also called schwannoma. Considering the small size of the tumour, radiation therapy required one session only.
In all aforementioned cases radiosurgery procedure was performed with “CyberKnife M6” equipment of the new generation which is the most modern equipment in the Baltic States. High resolution MRI images from Siemens Magnetron 3 Tesla magnetic resonance imaging equipment located in Riga in Orto Clinic are used for the procedure planning.
Cyberknife therapy ensures significant advantages in case of small tumours:
- a tumour can be suppressed when it is still small and does not cause undesirable symptoms;
- sensitivity of the adjacent nerves can be preserved in a favourable situation during and after the procedure, i.e. the activity of the facial muscles and hearing can be maintained at the current level;
- avoid relatively major surgery, postoperative complications and long-term rehabilitation period;
- patients normally don’t have any complaints during or after the procedure;
- admission to hospital is not required; and there is no need to suspend daily activities;
Preparation for the procedure (immobilisation, computed tomography and MRI) in Riga takes no more than two hours, but the procedure itself takes about 35-45 minutes. The total time a patient needs to spend in the Radiosurgery center in Sigulda is up to two hours. The second most commontype of benign tumours that can be efficiently treated using Cyberknife robot-assisted stereotactic surgery are meningiomas. They are usually slowly growing benign tumours developing from the meninges.
Dr. Dace Saukuma, attending physician, about the patients:
The patient Leonids (63 years old) suffering from the tumour of the posterior cranial fossa (a benign tumour growing from the dura mater – figure 1). Since the tumour was found, it slowly grows during one-two years; the patient also had subjective complaints about his memory impairment and headache. The patient had been offered operative treatment, but he wanted more sparing therapy because of long postoperative period. After having looked for alternative therapy options abroad, the patient found out that the cost of the offered therapy was too high, and came to SRC Sigulda. During the procedure the patient underwent four stereotactic radiation therapy sessions. The patient was very satisfied with the therapy process and returned to his daily activities after the therapy. He observes decrease in subjective complaints one week after the therapy was completed.
The patient’s review about the treatment process using Cyberknife:
“Пока все по плану. Цена не безумно низкая, что успокаивает. Идеально корректный персонал. Ощутимые результаты возможны через полгода. Но это везде так, самое трудное не фантазировать и ждать. Нахожу положительным, что мы им очень нужны здоровенькие – интересы сходятся на 100%.”
(Translation: “So far everything is going as planned; the personnel is perfectly amiable. Tangible results will appear in six months, but it is like this everywhere. The hardest thing is not to dream and wait. The most important thing is that they need us to be healthy – our interests overlap by 100%”).
The daughter of Sofia, the first patient of the Stereotactic Radiosurgery Centre Sigulda, reviews about her mother’s experience during treatment of clivus tumor:
“Unique CyberKnife procedure, highly professional and competent team of SRC Sigulda – Dr. Dace Saukuma, Dr. Māris Skromanis, nurse Ginta and the others turned the negative meaning of the word “tumour” into a flash of hope that helped treat this frightening disease without any pain or various long-term complications. It has been three months after the procedure, and we have already forgotten our rueful feelings because of the diagnosis, as we live as if there was no disease. Huge thanks to all employees of SRC Sigulda for treating our mum Sofia and providing professional care during the treatment. And to everyone who is worried: there is no point, it will be fine!” CyberKnife procedure is an opportunity that should be used to continue living your life to the fullest.
The figure shows a magnetic resonance image with tumours in the skull base (violet) which slightly suppresses the brain stem. Coloured lines – zones of the planned radiation of different intensity.
According to Dr. Dace Saukuma, the patients have generally tolerated CyberKnife radiosurgical method well. The patients tolerated it particularly well – without any complaints or with minor complaints – in cases when the tumour was relatively small (up to 2.5 cm) and has not suppressed the surrounding brain structures.
Patients with larger brain tumours who before the therapy had such complaints as, for instance, headache, dizziness, nausea, numbness of the face, or other symptoms related to suppression of nerves or brain structures associated with oedema caused by tumour and suppression of the surrounding structures, usually require oral, or, in the most severe cases, intramuscular or intravenous antioedemic therapy before Cyberknife radiosurgical procedure. Antioedemic therapy is also required during the therapy and for a certain period of time after radiation therapy. When treating patients with relatively large tumours over 3 cm in diameter, the symptoms caused by the tumour may aggravate during and after Cyberknife therapy, however, it can be prevented by appropriate antioedemic therapy.
The figure (Neurinoma 1) shows the radiological picture in the patient who underwent operative treatment and was diagnosed with recurrent growth of the tumour. The tumour is dyed violet. The tumour has suppressed the brain stem in the figure. The figure shows distribution of doses with high dose (orange and red line) and sharp drop of dose in other lines.
Before the therapy the patient suffered from sensation disorders in the face, pressing feeling in the head which gradually reduced only after intensive antioedemic therapy. In this case antioedemic therapy was prescribed for a long time until regression of the tumour. Unfortunately, when radiation therapy is used for treatment, it is impossible to reduce symptoms immediately, as a result patients continue to have complaints until the moment when the tumour starts to shrink.
In cases when a tumour exceeds 5 cm or oedema of the tumour after radiosurgery can cause dangerous suppression of the adjacent brain structures, the patient is referred to a neurosurgeon for initial treatment of the tumour. A neurosurgeon can perform a radical surgery, thus significantly reducing the tumour size. If complete removal of a tumour cannot be performed because of its ingrowth, a surgery ensures immediate reduction of suppression of the adjacent brain structures. Radiosurgery can be applied after that for the residual tumour tissues.
Last September the Stereotactic radiosurgery centre Sigulda was contacted by the patient Aigars (64 years old); five years ago he had undergone a surgery of a neurinoma of the auditory nerve that exceeded three cm in diameter. At that time the patient was recommended to undergo tumour treatment in Germany, in Hamburg CyberKnife Centre by prof. M.H. Seegenschmiedt. In October it was found that the tumour is a mass with polycystic structure, as a result, it was recommended to remove it surgically. In November neurosurgeon Dr. Kaspars Auslands performed a repeated surgery and removed most of the tumour. In February the patient completed his treatment in Cyberknife Clinic in Hamburg.
Although radiosurgery and stereotactic radiation therapy are generally applied as a radical treatment method in order to destroy completely the tumour cells, there are cases when it is applied in patients as a palliative treatment method. These cases include metastases of the tumour in the brain and spinal cord. In this case, if the growth of the original tumour tissues is limited (conventional radiosurgery or chemotherapy has been performed), radiation therapy of the tumour metastasis in the brain or spinal cord significantly improves the quality of patient’s life.
Dr. Māris Mežeckis’ patient Gabija (14 years old) from Lithuania suffering from metastasis of the anaplastic astrocytoma of the brain in the spinal cord underwent stereotactic radiation therapy for rapidly progressing metastasis in the spinal cord which threatened to cause complete cross-injury of the spinal cord, thus paralysing both legs and possibly causing dysfunctions of the pelvic organs. It could cause pressure injuries and considerably hinder the patient’s care during the remaining lifetime. Although most likely it had no impact on the prognosis of the disease, the radiation stopped metastasis progression, reduced pain and even slightly improved leg movements.
The patient Jola (49 years old) from Lithuania suffering from recurrent tumour of glial cells in the brain after operative treatment, radiation and chemotherapy had complained about headache and nausea for three months prior to radiosurgery, therefore she required intensive antioedemic therapy before the radiosurgery, after which the complaints virtually disappeared. Now when we call the patient, we can hear children’s voices in the background – the patient resumed her work as a teacher. She doesn’t complain about headache and nausea any more. However, she will have to continue follow-up and undergo magnetic resonance imaging every three months in order to detect repeated growth of the tumour in the same or another area of the brain in due time and undergo treatment again, if necessary.
Recurrent glial tumour.
Figure from the radiation therapy plan – light zone – glial cell tumour surrounded by the zone of the planned radiation of specific intensity (coloured lines).
Cyberknife robot-assisted stereotactic radiosurgery and radiation therapy can not only be used for radiation of benign and malignant tumours, but also for high-quality treatment of the patients suffering from various vascular disorders in the brain, such as arterial venous malformations, cavernomas, angiomas, and other non-oncological diseases – acromegaly, epilepsy or trigeminal nerve neuralgia.
In February the patient of our centre Krista (35 years old) from Lithuania underwent a significant, technically complicated and rare procedure – radiosurgery of a recurrent uveal melanoma. Uveal or intraocular melanoma is a tumour that is formed in the eye socket and grows from the structures of the eye tissues. Dr. Dace Saukuma about the patient: “In 2014 the patient underwent contact radiation therapy with ruthenium, in December 2015 MRI showed a recurrent mass in the posterior part of the left eye ~ 17mm*3.5 mm. The patient received a recommendation to undergo a radical surgery with the right eye removal. The patient so far refused the surgery and chose CyberKnife therapy. She underwent one radiation session. The aim of the therapy is to preserve the eye and the appearance for as long as possible. The procedure was carried out under retrobulbar anaesthesia to relax the eye muscle and reduce the eye mobility. The procedure was performed without any pain or complications.”
Intracranial robot-assisted radiosurgery was performed in three fractions to the patient suffering from the cavernous malformation of the brain stem (venous blood vessel node) in our centre in March. Dr. Māris Mežeckis’ comment about the treatment necessity for the patient Aina: “Considering the size of the vascular mass and its location in a vital part of the brain – in the brain stem – the therapy required three radiation sessions (see the figure X). In case of cavernous sinus malformation the treatment is indicated in order to reduce the risk of bleeding in the future.”
The patients suffering from tumours and metastases of the brain and spinal cord that have been treated by Cyberknife Sigulda specialists’ team have provided significant experience to continue treatment of tumours in other parts of the body using Cyberknife radiosurgery and stereotactic radiation therapy. In the nearest future we are planning to expand the range of offered services, start treating patients suffering from prostate tumours and offering hypofractioned radiation of prostate tumours.
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