Table Of ContentCyberKnife
NeuroRadiosurgery
A practical Guide
Alfredo Conti
Pantaleo Romanelli
Evangelos Pantelis
Scott G. Soltys
Young Hyun Cho
Michael Lim
Editors
CyberKnife NeuroRadiosurgery
Alfredo Conti • Pantaleo Romanelli
Evangelos Pantelis • Scott G. Soltys
Young Hyun Cho • Michael Lim
Editors
CyberKnife
NeuroRadiosurgery
A practical Guide
Editors
Alfredo Conti Pantaleo Romanelli
Associate Professor of Neurosurgery Scientific Director
Alma Mater Studiorum University AB Medica
of Bologna Milano, Italy
Bologna, Italy
Consultant and Scientific Director
IRCCS ISNB Istituto delle Scienze Neurosurgery and Brain Radiosurgery
Neurologiche di Bologna CyberKnife Center, CDI
Bologna, Italy Milano, Italy
Resident Research Scientist Visiting Scientist
Charité University European Synchrotron Radiation
Berlin, Germany Facility (ESRF)
Grenoble, France
Evangelos Pantelis
CyberKnife Center, CDI
Assistant Professor, Medical Physics
Via Saint Bon 20
Laboratory, Medical School
Milano, Italy
National and Kapodistrian
University of Athens
Scott G. Soltys
Mikras Asias 75
Associate Professor, Department
Athens, Greece
of Radiation Oncology
Stanford University Cancer Center
Young Hyun Cho
875 Blake Wilbur Drive
Associate Professor, Department of
Stanford, CA
Neurosurgery and Radiosurgery Center
USA
Asan Medical Center, University of
Ulsan, College of Medicine
Michael Lim
Seoul, Republic of Korea
Department of Neurosurgery
The Johns Hopkins University School
of Medicine
Baltimore, MD
USA
ISBN 978-3-030-50667-4 ISBN 978-3-030-50668-1 (eBook)
https://doi.org/10.1007/978-3-030-50668-1
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“Beautiful things have dents and scratches too”
This book is dedicated to Nathalie Chadeau for her immense
passion.
Foreword 1
I am very delighted to write a foreword for this comprehensive book on
image-guided robotic (CyberKnife) neuro-radiosurgery for at least three
important reasons.
The first reason is that single and hypofractionated stereotactic radiation
therapy represents, nowadays, a well-established adjunct to our armamentar-
ium for the treatment of several neurosurgical diseases. I am sure that the
neurosurgical community will find a thorough assessment of appropriate
indications, clinical benefits, risks, and pitfalls related to this technology
useful.
The second reason is related to the fact that I was proud to introduce the
CyberKnife at the University Hospital of Messina, Italy, in 2006. At that time,
I realized how important it was to make this novel technology available and
to evaluate its role and limits in the neurosurgical practice. Since the begin-
ning, Dr. Alfredo Conti, a gifted investigator and neurosurgeon working at
that time with me in Messina, was able to bridge his knowledge and experi-
ence of image-guided surgery of brain and spine lesions to a new robotic
radiosurgical facility.
The third reason is that I consider it extremely important to have a bal-
anced view of the potential and limits of this technology. Sometimes, radio-
surgery is proposed as primary option for neurosurgical diseases which could
be definitively cured by microsurgical procedures. Thus, it is extremely
important to neurosurgeons and radiation oncologists to cooperate in the
patient selection and decision-making process and share common experi-
ences and cultural background. Only this factual collaboration will result in
the best treatment option for each individual patient.
The occasional overindication for Stereotactic Radiosurgery (SRS) is due,
on the one hand, to an understandable enthusiasm and familiarity of radiation
oncologists with this technique. On the other hand, neurosurgeons with direct
responsibility in SRS should reconsider the definition of SRS as a minimally
invasive treatment that can be, to some extent, misleading to patients. As a
matter of fact, although radiation is image-guided on targets with a sufficient
safety, we cannot underestimate the fact that long-term adverse effects, poten-
tially threatening the quality of life of patients, may occur. Nonetheless, SRS
remains a strategic tool for the treatment of hazardous lesions, remnants, and
recurrences for fragile patients.
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viii Foreword 1
These are all good reasons to welcome this book reporting the perspec-
tives of clinicians and physicists with a large experience in the field of SRS
gained through years spent in outstanding international institutions.
The rationale for the use of radiosurgery is highlighted by each contributor
in a very systematic discussion of personal data, an extensive literature review
with special reference to safety-effectiveness, and a final summary of indica-
tions and contraindications. The chapters cover different issues, an historical
review, physics, imaging, and a thorough essay of brain and spine tumors,
cerebral vascular lesions, and functional disorders. The structure of each
chapter is perfectly organized in order to provide a practical guide and to
make this book an excellent resource for residents, fellows, and practicing
neurosurgeons.
Definitely, I am impressed by the broad and deep insight into applications
of this novel robotic tool with different radiation doses and modalities. I am
confident that the invaluable scientific information delivered by this book will
benefit the international neurosurgical community. The editors and contribu-
tors are to be commended for their effort in making us aware of the current
possibilities and limitations of radiosurgery for the treatment of neurosurgical
disorders.
Francesco Tomasello, MD
University of Messina
Messina, Italy
Foreword 2
The concept of radiosurgery is, and always has been, a genuine neurosurgical
concept. The ability to treat and control neurosurgical pathologies with an
(invisible) sharp knife, at low risk, has been a success story since its introduc-
tion by neurosurgical pioneers. In addition, the therapeutic approach,
decision-m aking, perception of perilesional surgical anatomy, and the pre-
interventional risk assessment strongly benefit from decades of lessons
learned from open neurosurgical operations. While radiosurgery was initially
reserved for benign intracranial tumors, the indications have been broadened
over the years into vascular, functional, pediatric, and spinal arenas. This is
the reason why skull base, stereotactic, functional, and so on hybrid neurosur-
geons, active in radiosurgical and open neurosurgical fields, seem to have an
easier career pathway than endovascular/open vascular neurosurgical hybrids,
for unknown reasons (although I have my ideas). Being a hybrid neurosur-
geon or working in an interdisciplinary setting allows us to better appreciate
the advantages and disadvantages of each therapeutic modality that we are
able to offer to our patients. This will finally eliminate therapeutic bias from
the decision-making process. The patients will benefit most from this devel-
opment, and this is what counts. I am also a strong supporter of hybrid neu-
rosurgeons since a thorough dual training is the most effective strategy to
prevent therapeutic extremism, as we have observed in the past, also in the
field of radiosurgery. By this, not everything will look like a nail since one has
not only a single hammer. One reason for this smooth and successful develop-
ment in radiosurgery is the trustful collaboration with our friends and col-
leagues from radiooncology, to whom we are, and always will be, grateful for
their support and friendship.
This view, however, as appealing as it may sound, is currently regarded as
“romantic,” “unrealistic,” or “useless” by critical neurosurgeons and radiation
oncologists, even among my friends. This just demonstrates that many still
need to be convinced by science- and evidence-based success and progress in
the field, and maybe also by overcoming classical borders when it comes to
neurointerventions. The single most important aspect that will consolidate
the hybrid neurosurgical concepts is the thrive for high-end clinical and aca-
demic training in both fields, in order to tackle the argument that one person
cannot be good at both therapies. Admittedly, there is still room for improve-
ment in this field for the next years or so.
Having said all this, it is a pleasure to hold this textbook that comprises all
aspects of radiosurgery, traditional and innovative ones in my hands. The
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x Foreword 2
leaders in the field are discussing these aspects in a very balanced and scien-
tific way to highlight areas of opportunities, challenges, controversy, and
common sense. The real value of this book, however, is that all authors
involved fulfill my introductory remarks about hybrid neurosurgeons or expe-
rienced interdisciplinary teams. They stand for high-quality concepts and bal-
anced views, always struggling for the best outcome in our patients.
It is a pleasure to see Alfredo Conti, a role model of an academic hybrid
neurosurgeon and to whom the Charité CyberKnife Program is grateful for
his collaboration and expertise, as the editor of this book. I applaud him for
this masterpiece. In addition, it is a pleasure to have Francesco Tomasello as
author of the second foreword. Francesco, as a very prominent representative
of the Italian Neurosurgical Society, has always been a mentor and close
friend for me over many years, for what I am truly grateful. However, in the
midst of the COVID-19 pandemic and all the associated suffering (when
these words are printed), I cannot resist to acknowledge and congratulate the
entire Italian Neurosurgical Society for their dedication to all the positive
aspects of our neurosurgical life: friendship, positivity, humbleness, elegance,
innovation, family, and strong shoulders that carry on and come up with
excellent books like this.
Peter Vajkoczy, MD
Department of Neurosurgery
Charité-Universitätsmedizin Berlin
Berlin, Germany
Preface
This book aims to represent a practical guide for image-guided stereotactic
radiosurgery and hypofractionated stereotactic radiotherapy of the brain and
spine. Leading physicians and scientists from four continents will provide the
readers with basic concepts, current evidence, and guidelines for the treat-
ment of neoplastic and non-neoplastic disease of the central nervous system.
Radiosurgery is one of the mainstreams of modern neurosurgery. Indeed,
it perfectly complies with the current requirements of a minimally invasive
neurosurgery and preservation of health-related quality of life.
Neurosurgery is a formidable challenge that, during its 100-year history,
has expanded the opportunities for healing many human diseases, previously
invariably mortal. Nonetheless, despite the amazing evolution of techniques
and technologies, it remains a substantially invasive and pervasive discipline
that often produces a negative impact on the cognitive performance of patients
and eventually dramatic effects on their quality of life.
Image-guided radiosurgery represents a refinement of a revolution initi-
ated almost 40 years ago through the introduction of frame-based radiosur-
gery. As a matter of fact, it has introduced several advantages for both the
patient and the physician.
Image-guided radiosurgery offers greater comfort for the patient who does
not need to be invasively attached to a stereotaxic frame. Treatment is usually
delivered as an outpatient procedure; imaging and treatment should not be
performed in a few hours, providing more time for physicians and physicists
to work out the best possible treatment for the patient.
Above all, image-guidance has introduced the concept of multisession
radiosurgery or hypofractionation, a term that indicates a radiotherapy treat-
ment with a shorter course than conventional radiotherapy with a dose distri-
bution that cannot be significantly different to that of single fraction
radiosurgery. This approach has significantly changed the horizon of radio-
surgery by expanding its boundaries of curative potential. Actually, by multi-
session radiosurgery it is now possible to treat larger brain tumors and tumors
close to the most critical structures of the brain and spine.
The great value of these features introduced through the first image-guided
radiosurgery device, the CyberKnife (Accuray Inc., Sunnyvale, CA), is testi-
fied by the adoption of image-guidance by other systems (i.e., Gamma Knife
Icon).
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