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Goc B, Roch-Zniszczoł A, Larysz D, Zarudzki Ł, Stąpór-Fudzińska M, Rożek A, Woźniak G, Boczarska-Jedynak M, Miszczyk L, Napieralska A. The Effectiveness and Toxicity of Frameless CyberKnife Based Radiosurgery for Parkinson's Disease-Phase II Study. Biomedicines 2023; 11:288. [PMID: 36830825 PMCID: PMC9952894 DOI: 10.3390/biomedicines11020288] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/15/2022] [Revised: 01/15/2023] [Accepted: 01/17/2023] [Indexed: 01/21/2023] Open
Abstract
Frame-based stereotactic radiosurgery (SRS) has an established role in the treatment of tremor in patients with Parkinson's disease (PD). The low numbers of studies of frameless approaches led to our prospective phase 2 open-label single-arm clinical trial (NCT02406105), which aimed to evaluate the safety and efficacy of CyberKnife frameless SRS. Twenty-three PD patients were irradiated on the area of the thalamic ventral nuclei complex with gradually increasing doses of 70 to 105 Gy delivered in a single fraction. After SRS, patients were monitored for tremor severity and the toxicity of the treatment. Both subjective improvement and dose-dependent efficacy were analysed using standard statistical tests. The median follow-up was 23 months, and one patient died after COVID-19 infection. Another two patients were lost from follow-up. Hyper-response resulting in vascular toxicity and neurologic complications was observed in two patients irradiated with doses of 95 and 100 Gy, respectively. A reduction in tremor severity was observed in fifteen patients, and six experienced stagnation. A constant response during the whole follow-up was observed in 67% patients. A longer median response time was achieved in patients irradiated with doses equal to or less than 85 Gy. Only two patients declared no improvement after SRS. The efficacy of frameless SRS is high and could improve tremor control in a majority of patients. The complication rate is low, especially when doses below 90 Gy are applied. Frameless SRS could be offered as an alternative for patients ineligible for deep brain stimulation; however, studies regarding optimal dose are required.
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Affiliation(s)
- Bartłomiej Goc
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Agata Roch-Zniszczoł
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Dawid Larysz
- Department of Head and Neck Surgery for Children and Adolescents, University of Warmia and Mazury in Olsztyn, 10-561 Olsztyn, Poland
| | - Łukasz Zarudzki
- Department of Radiology and Diagnostic Imaging, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Małgorzata Stąpór-Fudzińska
- Department of Radiotherapy Planning, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Agnieszka Rożek
- “Kangur” Centre for Treatment of CNS Disorders and Child Development Support in Katowice, 40-594 Katowice, Poland
| | - Grzegorz Woźniak
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Magdalena Boczarska-Jedynak
- Neurology and Restorative Medicine Department, Health Institute dr Boczarska-Jedynak, 32-600 Oświęcim, Poland
| | - Leszek Miszczyk
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
| | - Aleksandra Napieralska
- Radiotherapy Department, MSC National Research Institute of Oncology Gliwice Branch, 44-102 Gliwice, Poland
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Ito H, Fukutake S, Yamamoto K, Yamaguchi T, Taira T, Kamei T. Magnetic Resonance Imaging-guided Focused Ultrasound Thalamotomy for Parkinson's Disease. Intern Med 2018; 57:1027-1031. [PMID: 29269662 PMCID: PMC5919866 DOI: 10.2169/internalmedicine.9586-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Thalamotomy is effective in treating refractory tremor in Parkinson's disease (PD). We herein report a PD patient who underwent left ventral intermediate nucleus and ventro oralis posterior nucleus thalamotomy using magnetic resonance imaging-guided focused ultrasound (MRgFUS). Right-side resting tremor and rigidity were abolished immediately following the ultrasound energy delivery. In addition, left-side resting tremor and rigidity also improved. No adverse events occurred during the procedure. We observed the exacerbation of bradykinesia, which might have been caused by edema around the target. This is the first report of thalamotomy using MRgFUS for PD patient from Japan. Further investigations concerning the efficacy and safety of this procedure are necessary.
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Affiliation(s)
- Hisashi Ito
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Shigeru Fukutake
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Japan
| | - Kazuaki Yamamoto
- Department of Neurosurgery, Shonan Kamakura General Hospital, Japan
| | - Toshio Yamaguchi
- Research Institute of Diagnostic Imaging, Shin-Yurigaoka General Hospital, Japan
| | - Takaomi Taira
- Department of Neurosurgery, Tokyo Women's Medical University, Japan
| | - Tetsumasa Kamei
- Department of Neurology, Shonan Fujisawa Tokushukai Hospital, Japan
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Niranjan A, Raju SS, Monaco EA, Flickinger JC, Lunsford LD. Is staged bilateral thalamic radiosurgery an option for otherwise surgically ineligible patients with medically refractory bilateral tremor? J Neurosurg 2018; 128:617-626. [DOI: 10.3171/2016.11.jns162044] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVEUnilateral Gamma Knife thalamotomy (GKT) is a well-established treatment for patients with medically refractory tremor who are not eligible for invasive procedures due to increased risk of compications. The purpose of this study was to evaluate whether staged bilateral GKT provides benefit with acceptable risk to patients suffering from disabling medically refractory bilateral tremor.METHODSEleven patients underwent staged bilateral GKT during a 17-year period (1999–2016). Eight patients had essential tremor (ET), 2 had Parkinson's disease (PD)–related tremor, and 1 had multiple-sclerosis (MS)–related tremor. For the first GKT, a median maximum dose of 140 Gy was delivered to the posterior-inferior region of the nucleus ventralis intermedius (VIM) through a single isocenter with 4-mm collimators. Patients who benefitted from unilateral GKT were eligible for a contralateral GKT 1–2 years later (median 22 months). For the second GKT, a median maximum dose of 130 Gy was delivered to the opposite VIM nucleus to a single 4-mm isocenter. The Fahn-Tolosa-Marin (FTM) clinical tremor rating scale was used to score tremor, drawing, and drinking before and after each GKT. The FTM writing score was assessed only for the dominant hand before and after the first GKT. The Karnofsky Performance Status (KPS) was used to assess quality of life and activities of daily living before and after the first and second GKT.RESULTSThe median time to last follow-up after the first GKT was 35 months (range 11–70 months). All patients had improvement in at least 1 FTM score after the first GKT. Three patients (27.3%) had tremor arrest and complete restoration of function (noted via FTM tremor, writing, drawing, and drinking scores equaling zero). No patient had tremor recurrence or diminished tremor relief after the first GKT. One patient experienced new temporary neurological deficit (contralateral lower-extremity hemiparesis) from the first GKT. The median time to last follow-up after the second GKT was 12 months (range 2–70 months). Nine patients had improvement in at least 1 FTM score after the second GKT. Two patients had tremor arrest and complete restoration of function. No patient experienced tremor recurrence or diminished tremor relief after the second GKT. No patient experienced new neurological or radiological adverse effect from the second GKT. Statistically significant improvements were noted in the KPS score following the first and second GKT.CONCLUSIONSStaged bilateral GKT provided effective relief for medically refractory, disabling, bilateral tremor without increased risk of neurological complications. It is an appropriate strategy for carefully selected patients with medically refractory bilateral tremor who are not eligible for deep brain stimulation.
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Affiliation(s)
| | - Sudesh S. Raju
- 2University of Pittsburgh School of Medicine, Pittsburgh, Pennsylvania
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Luo G, Neimat JS, Cmelak A, Kirschner AN, Attia A, Morales-Paliza M, Ding GX. Margin of error for a frameless image guided radiosurgery system: Direct confirmation based on posttreatment MRI scans. Pract Radiat Oncol 2016; 7:e223-e231. [PMID: 27720703 DOI: 10.1016/j.prro.2016.08.006] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2016] [Revised: 07/12/2016] [Accepted: 08/15/2016] [Indexed: 11/18/2022]
Abstract
PURPOSE To report on radiosurgery delivery positioning accuracy in the treatment of tremor patients with frameless image guided radiosurgery using the linear accelerator (LINAC) based ExacTrac system and to describe quality assurance (QA) procedures used. METHODS AND MATERIALS Between 2010 and 2015, 20 patients underwent radiosurgical thalamotomy targeting the ventral intermediate nucleus for the treatment of severe tremor. The median prescription dose was 140 Gy (range, 120-145 Gy) in a single fraction. The median maximum dose was 156 Gy (range, 136-162 Gy). All treatment planning was performed with the iPlan system using a 4-mm circular cone with multiple arcs. Before each treatment, QA procedures were performed, including the imaging system. As a result of the extremely high dose delivered in a single fraction, a well-defined circular mark developed on the posttreatment magnetic resonance imaging (MRI). Eight of these 20 patients were selected to evaluate treatment localization errors because their circular marks were available in posttreatment MRI. In this study, the localization error is defined as the distance between the center of the intended target and the center of the posttreatment mark. RESULTS The mean error of distance was found to be 1.1 mm (range, 0.4-1.5 mm). The mean errors for the left-right, anteroposterior, and superoinferior directions are 0.5 mm, 0.6 mm, and 0.7 mm, respectively. CONCLUSIONS The result reported in this study includes all tremor patients treated at our institution when their posttreatment MRI data were available for study. It represents a direct confirmation of target positioning accuracy in radiosurgery with a LINAC-based frameless system and its limitations. This level of accuracy is only achievable with an appropriate QA program in place for a LINAC-based frameless radiosurgery system.
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Affiliation(s)
- Guozhen Luo
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Physics and Astronomy, Vanderbilt University, College of Art and sciences, Nashville, Tennessee
| | - Joseph S Neimat
- Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Anthony Cmelak
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Austin N Kirschner
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Albert Attia
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Manuel Morales-Paliza
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee
| | - George X Ding
- Department of Radiation Oncology, Vanderbilt University Medical Center, Nashville, Tennessee; Department of Physics and Astronomy, Vanderbilt University, College of Art and sciences, Nashville, Tennessee.
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Isaacs D, Cmelak A, Kirschner AN, Phibbs F. Radiotherapy-induced hemichorea. Neurology 2016; 86:1355-1357. [PMID: 26944270 DOI: 10.1212/wnl.0000000000002546] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2015] [Accepted: 12/02/2015] [Indexed: 11/15/2022] Open
Affiliation(s)
- David Isaacs
- From Vanderbilt University Medical Center, Nashville, TN.
| | - Anthony Cmelak
- From Vanderbilt University Medical Center, Nashville, TN
| | | | - Fenna Phibbs
- From Vanderbilt University Medical Center, Nashville, TN
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Dimitriadis A, Kirkby KJ, Nisbet A, Clark CH. Current status of cranial stereotactic radiosurgery in the UK. Br J Radiol 2015; 89:20150452. [PMID: 26689091 DOI: 10.1259/bjr.20150452] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
OBJECTIVE To investigate and benchmark the current clinical and dosimetric practices in stereotactic radiosurgery (SRS) in the UK. METHODS A detailed questionnaire was sent to 70 radiotherapy centres in the UK. 97% (68/70) of centres replied between June and December 2014. RESULTS 21 centres stated that they are practising SRS, and a further 12 centres plan to start SRS by the end of 2016. The most commonly treated indications are brain metastases and acoustic neuromas. A large range of prescription isodoses that range from 45% to 100% between different radiotherapy centres was seen. Ionization chambers and solid-water phantoms are used by the majority of centres for patient-specific quality assurance, and thermoplastic masks for patient immobilization are more commonly used than fixed stereotactic frames. The majority of centres perform orthogonal kilovoltage X-rays for localization before and during delivery. The acceptable setup accuracy reported ranges from 0.1 to 2 mm with a mean of 0.8 mm. CONCLUSION SRS has been increasing in use in the UK and will continue to increase in the next 2 years. There is no current consensus between SRS centres as a whole, or even between SRS centres with the same equipment, on the practices followed. This indicates the need for benchmarking and standardization in SRS practices within the UK. ADVANCES IN KNOWLEDGE This article outlines the current practices in SRS and provides a benchmark for reference and comparison with future research in this technique.
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Affiliation(s)
- Alexis Dimitriadis
- 1 Department of Physics, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, UK.,2 Department of Medical Physics, Royal County Hospital NHS Foundation Trust, Guildford, UK.,3 Radiation Dosimetry Group, National Physical Laboratory, Teddington, Middlesex, UK
| | - Karen J Kirkby
- 4 Manchester Academic Science, Institute of Cancer Sciences, University of Manchester, Manchester, UK.,5 The Christie NHS Foundation Trust, Manchester, UK
| | - Andrew Nisbet
- 1 Department of Physics, Faculty of Engineering and Physical Sciences, University of Surrey, Guildford, UK.,2 Department of Medical Physics, Royal County Hospital NHS Foundation Trust, Guildford, UK
| | - Catharine H Clark
- 2 Department of Medical Physics, Royal County Hospital NHS Foundation Trust, Guildford, UK.,3 Radiation Dosimetry Group, National Physical Laboratory, Teddington, Middlesex, UK
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