Treatment of Orbital Lesions using CyberKnife Stereotactic Radiosurgery

Student Researcher: Emily Morahan

Faculty Mentor: Lorie Zelna, M. S., R. T. (R) (MR)

Introduction Orbital Lesions Treatment Process Considerations

The purpose of the research done was to evaluate the use • Damage or abnormal change in tissue in or around • Retrotubular anesthesia is administered, achieving Benefits
of CyberKnife Stereotactic Radiosurgery (SRS) for the orbit akinesis for 2.5-3 hours
treating orbital lesions. Efficacy and tolerability of such • Reduced tumor volume (size), offering immediate
• Cancer that has metastasized to the eye is more • T2- and contrast-enhanced T1-weighted MRI is symptom relief
treatment was analyzed with data drawn from multiple
common than a primary orbital cancer acquired (see Fig. 4)
sources, regarding dose and fractionation, quality of life (American Cancer Society, n.d.,) • Delays the need for surgery or enucleation
following treatment(s) and prognosis. CyberKnife SRS is • Melanoma is the most prevalent eye cancer, with • The doctor, dosimetrist and physicist spend 30-40
the newest, most advanced model of radiation delivery uveal melanoma being the most frequent primary minutes collaborating • Ideal for palliative treatment
(Desideri et al., 2019, p.2-5)
systems, featuring a robotic arm capable of manipulating intraocular tumor
(Klingenstein et al., 2016, p. 1005) • The visible tumor is contoured as the target volume • Short treatment length allows focus on other
the linear accelerator into thousands of unique angles.
procedures
The addition of new angles allows for a more precise Types of Orbital Lesions • Inverse treatment planning is done to create a steep (Riva et al., 2019, p. 65)
concentration of radiation delivered to the lesions. In the fall in dose outside the tumor volume Risks
case of optic lesions, it is crucial to minimize dose to
• Intraocular- within the orbit
adjacent structures such as optic nerve, lens and fovea. • Periocular-surrounding the orbit (muscles & adnexa) • The patient is positioned on the table with an • Orbital irradiation may lead to a wide spectrum of
CyberKnife SRS is superior for treatment in small immobilization mask acute and late toxicities such as: permanent
anatomical locations due to steep dose gradients and • Pseudotumor- swelling behind the orbit blindness, conjunctivitis, panophthalmitis, dry eye
• The linear accelerator delivers 100-150 beams at
target localization system, allowing maximum sparing of • Primary or Metastasized differing angles syndrome, cataract, keratopathy, retinopathy,
organs at risk. While CyberKnife SRS is rapidly neovascularization of the iris, and optic neuropathy
becoming the gold standard for orbital lesions, there is Etiology • MR images are taken at each new angle to account (Riva et al., 2019, p. 65)
still a likelihood that other treatments may be required as for position of tumor due to movement • Optic pathways and orbital adnexa are
an adjunct therapy for treatment purposes. However, • Age, thyroid disorders, systemic lupus erythematous, radiosensitive periocular structures that are prone to
rheumatoid arthritis, fibro-inflammatory disorders, • The entire process is completed within 2.5 hours late toxicity
current research identifies the high success rate of (Klingenstein et al., 2016, p. 1007)
(Desideri et al., 2019, p.2)
CyberKnife SRS but acknowledges the need for further sarcoidosis, and granulomatosis with polyangiitis
Fig. 4
• In the long term, functional and cosmetic
research in dosage and fractionation. • Mean age: 65 +/- 10 disturbances may reduce quality of life
(Yaprak et al., 2018, p.198)
• Orbital metastases could usually be associated with a
poor systemic prognosis
CyberKnife Stereotactic Radiosurgery is: (Riva et al., 2019, p. 64) Prognosis/Outcome
• Uveal melanoma is rare, but the most common
• the newest type of stereotactic radiosurgery; cancer spread to the eye • Primary lesion of the orbit 5-year survival rate: 85%
consisting of a 6-MV linear accelerator fixed on an
Usually developed in the choroid, which has a • Metastasized 5-year survival rate: 71%
image-guided, computer-operated frameless robotic (American Cancer Society, n.d.,)
arm similar function to skin cells • Most reported cases presented a monophasic
(American Cancer Society, n.d.,)
disease course, yet there was some reoccurrence
• 30 to 90 minutes per treatment Signs/Symptoms
• used to treat lungs, pancreas, brain, head and neck,
• Reoccurrence was more common among those
• Blurred or decreased vision
spine and prostate cancers Fig. 3 Treatment plan using CT images, showing tumor volume and beam angles below mean age,
Fig. 1
(Long et al., 2019, p. 451) • Limited ocular motility (Desideri et al., 2019, p. 2) bilateral disease,
Fig. 2
• Diplopia (double vision) Dose & Fractionation and/or partial
initial steroid
• Swelling • Treatments are non-isocentric response
• Proptosis (protrusion) • Dose ranges on the size of the tumor and facility (Sasaki et al., 2021, p. 199)

Yuan, Z., 2009 Daftari, I., 2009
CyberKnife room setup and patient in immobilization mask for treatment
• non-invasive and usually done in less than 5
fractions (days) at a high dose, with a more minimal
(Yaprak et al., 2018, p.198)
dose to surrounding tissue than conventional
radiotherapy
• proven superior by its specialized target spatial
localization system and steep dose gradient which
allow for maximum sparing of organs at risk
• image-guided which allows the robotic arm to track
patient movement within 0.5-10.0 mm and 1-3
degrees and remain aligned to the target area
preference
• Epiphora (watering) Before & after treatment with CyberKnife (Riva et al., 2019, p. 65)
• No standard recommendation for dose and
• Pain
fractionation exists (see examples below) Conclusion
• Redness (Sasaki et al., 2021) • 17-22 Gy in one fraction with 12/39 patient Most research points toward CyberKnife SRS as a
Orbital cavernous hemangioma before & after experiencing reoccurrence safe, efficient and effective treatment method for
(Desideri et al., 2019, p. 4) orbital lesions. Currently, no recommendation exists
Treatment Options • 15 Gy over 3 fractions with partial regression about correct doses and fractionations for this
after 12 months treatment. These factors should be carefully planned
• Radiation Therapy treatment- CyberKnife,
according to proximity of critical structures,
GammaKnife, IMRT, Proton therapy, • 15 Gy over 3 fractions with complete recovery
histology, and target lesion volume. Current research
Brachytherapy (Klingenstein et al., 2016, p. 1007)
• 19 patients treated with 24-35 Gy over 1-5 suggests CyberKnife is a safe and effective course of
• Enucleation or surgical resection fractions with 75% overall response rate treatment. Further research must be conducted to
(Klingenstein et al., 2016, p. 1005)
• Systemic treatments- immunotherapy, hormonal • 13 patients treated with 13-22 Gy over 3-5 fully understand the most efficient planning of
therapy, chemotherapy (Riva et al., 2019, p. 65) fractions with 100% overall response rate treatment for orbital lesions using CyberKnife SRS.
(Yaprak et al., 2018, p.199)