8.3 Adler, A Vision for Radiosurgery - Varian
8.3 Adler, A Vision for Radiosurgery - Varian
8.3 Adler, A Vision for Radiosurgery - Varian
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Berlin’11<br />
A <strong>Vision</strong> <strong>for</strong> <strong>Radiosurgery</strong><br />
John R. <strong>Adler</strong>, Jr., MD<br />
References may be made in this presentation to devices and their potential use that have not yet obtained regulatory clearance and are hereby presented with the aim<br />
of promoting a meaningful scientific in<strong>for</strong>mation exchange. <strong>Varian</strong> is in no way advocating <strong>for</strong> or recommending off label uses of its medical devices.
John R. <strong>Adler</strong>, Disclosure:<br />
� Chief of New Clinical Applications<br />
at <strong>Varian</strong> Medical Systems, Inc.<br />
� Founder of Accuray, Inc<br />
� Founder & CEO of peerEmed.com
Fractionated Radiation Therapy is Born<br />
S'il vous<br />
plaît le faire<br />
lentement
Fractionated Radiation Therapy<br />
Theoretical Basis: The “4 Rs”<br />
� Reassortment of cells w/ cell cycle<br />
� Repopulation<br />
� Reoxygenation<br />
� Repair of sublethal damage<br />
Note: No Volume Effect!
“Ablative” SRS: Parallel Universe<br />
�Highly accurate<br />
stereotactic localization<br />
�Large number of cross-<br />
fired beams providing <strong>for</strong><br />
steep gradient<br />
& BIG dose….<br />
up to 160 Gy<br />
Leksell GammaKnife
Leksell’s Single Session SRS<br />
Frame-Based<br />
LINAC X-rays<br />
Heavy particle Protons/He<br />
GammaKnife 60 Co γ-ray
Image-Guided SRS Arrives<br />
X-ray sources<br />
Synchrony Robotic Manipulator<br />
camera<br />
Treatment Treatment couch Table<br />
6 MeV LINAC<br />
Image<br />
detectors
Image-guided SRS Evolution
Image-guided <strong>Radiosurgery</strong><br />
�Very Accurate<br />
�Can be fractionated<br />
�Able to treat tumors any<br />
where in the body
“Multi-fraction”<br />
“Multi-session”<br />
permits normal<br />
tissue repair<br />
Single fraction:<br />
Gamma Knife<br />
community
% patients<br />
Multi-session SRS: >5000 Patients<br />
GammaKnife-like Treatment<br />
New Clinical<br />
Applications
Hypofx <strong>for</strong> Large Vol Brain Lesions<br />
You have just resected a<br />
brain metastasis, now what?
Prediction: Brain Metastases<br />
The vast majority will soon be<br />
managed with SRS techniques &<br />
WBXRT will start to vanish
Even GBM???<br />
Maybe multi-session<br />
(hypofractionated) SRS deserves<br />
further investigation<br />
as technique <strong>for</strong><br />
primary irradiation<br />
of GBM?<br />
Lipani & <strong>Adler</strong>:<br />
Tech Cancer Res Treat. (2008)
SRS Near Critical Cranial Nerves<br />
3 x 7 Gy<br />
Pre SRS 9 mo post SRS
40 y.o. ♀ with Tinnitus (only)<br />
Glomus Jugulare Tumor
69 cc<br />
Glomus<br />
Jugulare<br />
7 Yrs Post SRS Ablation
Cervical Spinal Cord AVM<br />
Pre SRS 3 yrs Post SRS
SCAVM-SRS: Rebleeding
Recurrent C-2 Sarcoma Metastasis s/p XRT
C-2 Sarcoma: 5 Yrs s/p SRS<br />
Pre-SRS<br />
Post-SRS
5 dozen publications in 2010 alone
Spine SRS: Benign & Malignant<br />
Neurofibroma<br />
Schwan<br />
Chordoma<br />
Ependym<br />
Metastasis<br />
AVM<br />
Cav Mal<br />
Hemangiobl<br />
Misc<br />
Mening<br />
>600 Patients<br />
@ SUMC
“A fool with a tool is<br />
still a fool!!”<br />
Lars Leksell
C7-T2 Meningioma<br />
(post-op residual)<br />
3 x 8 Gy= 24 Gy
C7-T2 Meningioma @ 1 yr
Soft Tissue Targeting & SRS: <strong>Varian</strong>’s TrueBeam
Fiducial Tracking
Prostate Ca Best Treated with Big Fxs<br />
100%<br />
Cell Survival<br />
PCa<br />
Single dose size<br />
Cancers<br />
Normal Tissues
Prostate: SRS vs. IMRT<br />
100% dose line<br />
Fiducial-based targeting w/ Hypo-fractionation<br />
37.5 Gy in 5 Fractions
Early Stage Prostate Cancer: 5 x 7.5 Gy<br />
Median PSA SEM<br />
10<br />
8<br />
6<br />
4<br />
2<br />
0<br />
0<br />
Men are very attracted to<br />
the convenience of SRS!!<br />
6 12 18 24 30 36 42 48<br />
Months after RT
Augmenix Hydrogel<br />
If critical anatomy is too<br />
close, just push it away!
Respiratory Gated/Tracking SRS<br />
�Lung<br />
�Liver<br />
�Pancreas<br />
�Renal<br />
�Breast (?)<br />
T1N0 NSCLC<br />
Pre-SRS 5 wks post 10 wks post
RTOG 0236: Overall Survival<br />
• Median survival is 48.1 months<br />
Overall Survival (%)<br />
100<br />
75<br />
50<br />
/<br />
36 month<br />
overall survival = 56% (CI: 42-68%)<br />
25<br />
Dead:<br />
Total:<br />
26<br />
55<br />
MST: 48.1<br />
(95% CI): (29.6, not reached)<br />
0<br />
0 6 12 18 24 30 36<br />
Patients<br />
Months after Start of SBRT<br />
at Risk 55 54 47 46 40 35 24<br />
/<br />
/ / /<br />
R Timmerman / UT Southwestern / ASTRO 2009
Clinical stage<br />
Stage IA<br />
Stage IB<br />
Surgical Candidates<br />
Comparison of 5-year OS: SRS vs. Resection<br />
Mountain 1<br />
61%<br />
40%<br />
Surgery OS<br />
JNCCH 2<br />
(Japan)<br />
71%<br />
44%<br />
National survey 3<br />
(Japan)<br />
77%<br />
60%<br />
1: Mountain CF. Semin. Surg. Oncol. 18:106-115,2000<br />
2: Naruke T. Ann Thorac Surg. 71:1759-1764, 2001<br />
3: Shimokata K. Jap. J Lung Cancer 47:299-311, 2007<br />
SRS<br />
OS / LC<br />
76% / 92%<br />
64% / 82%
Image-guided SRS<br />
Has the potential to become the<br />
ablative tool of choice over<br />
surgery, RF, HIFU, TACE
If radiation works so<br />
well why isn’t it being<br />
used (& studied)<br />
more?
Multi-disciplinary Stan<strong>for</strong>d SRS Team<br />
Neurosurgery Radiation Oncology Thoracic Surgery<br />
Steven Chang Iris Gibbs Richard Whyte<br />
John <strong>Adler</strong> Scott Soltys Joseph Shrager<br />
Mike Edwards Quynh Le<br />
Griff Harsh Don Goffinet ENT<br />
John Park Chris King Robert Jackler<br />
Rob Lieberson Albert Koong Nick Blevins<br />
Rob Dodd Billy Loo<br />
Nursing Radiation Physics & RT Urology<br />
Elizabeth Lee Tony Ho Joe Presti<br />
Laurie Tupper Tony Lo Harash Gill<br />
Michelle Klesczewski Lawrence Jang<br />
Radiology Coordination/Support General Surgery<br />
Huy Do Scarlett White George Yang<br />
Stephen Keys Barbara Pedrick Ralph Greco<br />
Mary Marcellus
SRS Atrial Ablation <strong>for</strong><br />
AFib (a leading cause<br />
of stroke)
Embolic Stoke: Atrial Fibrillation<br />
Posterior Views of Atria<br />
pulmonary veins pulmonary veins<br />
cavotriscupid cavotriscupid<br />
Catheter RF Ablation<br />
<strong>Radiosurgery</strong>?
CARTO: 3D-Electroanatomical Mapping<br />
PIG Right Atrium, RAO<br />
subject 3659_5/22/06-8/19/06
control<br />
3D Overlays<br />
SVC<br />
RA<br />
RV<br />
IVC<br />
subject 3659_5/22/06-8/19/06
Rx Resistant HTN: SRS Lesioning<br />
of Renal Sympathetics?
Thoracic SRS Lesioning?<br />
�Pulmonary Fibrosis <strong>for</strong> lung volume<br />
reduction in patients with bullous<br />
emphysema<br />
�Stellate gangionectomy<br />
<strong>for</strong> hyperhydrosis
Imaging Correlates of Psychiatric Pathology<br />
Obsessivecompulsive<br />
SRS<br />
Targets?<br />
Depression<br />
Compulsive<br />
Hoarding
Radiomodulation <strong>for</strong> Resistant Bipolar<br />
Brodmann 25:<br />
Depression<br />
Subgenual Cingulate Gyrus
HDRS21<br />
30<br />
25<br />
20<br />
15<br />
10<br />
5<br />
screen<br />
27<br />
bsline<br />
26<br />
remitted<br />
1wk<br />
16<br />
2wk<br />
1<br />
8<br />
4 wk<br />
16<br />
15 15<br />
8wk<br />
HDRS-21<br />
Subject LK<br />
12wk<br />
6mo<br />
12
Functional NS: Non Ablative, Radiomodulation??<br />
�Parkinson’s Disease<br />
�Tremor, Dystonia, misc movement ds<br />
�Obsessive Compulsive<br />
�Depression<br />
�Obesity<br />
�Addiction
Neuro “NAL” surgery?<br />
“Beam me, Scotty”?
Better Imaging = More SRS<br />
� Accurate staging<br />
� Must be able to visualize tumor to target<br />
effectively<br />
� Multimodality imaging provides<br />
complimentary in<strong>for</strong>mation needed to<br />
accurately define tumor volume<br />
� Assess response to treatment<br />
Imaging is only getting better!!
Tectonic Plates Colliding<br />
Debate over terminology reflects broader<br />
struggle over future SRS:<br />
�Multi-disciplinary approach?<br />
�Clinical applications?<br />
�Process?<br />
�Culture?<br />
�Risk profile?<br />
Alps
<strong>Radiosurgery</strong> is the Future of<br />
Radiation Oncology<br />
& Therapeutic Radiation is the<br />
Future of Much of Medicine!!
Thank you <strong>for</strong> your attention!<br />
References may be made in this presentation to devices and their potential use that have not yet obtained regulatory<br />
clearance and are hereby presented with the aim of promoting a meaningful scientific in<strong>for</strong>mation exchange. <strong>Varian</strong> is in no<br />
way advocating <strong>for</strong> or recommending off label uses of its medical devices
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