708 * SURGERY OF THE EAR wide variety of skull base neoplasms. These inchade the Peacock (NOMOS Inc. Cranberry Township, PA), the SmartBean IMRT (Vai Medical Systems Inc., Palo Alto, CA), the Precise (Blekta, Inc,, Stockholm, Sweden), and the CyberKnife (Accuray, Sunnyvale, CA). Among the more commion of these modalities rerKnite, which will be briefly reviewed here. CyberKnife Stereotactic Radiosurgery The CyberKnife stereotactic radiosurgery system utilizes a con AREE-MeV LINAC, computer-controlled robotic arm wit six degrees of freedont, and an image-guidance technology that does not depend on a rigid stereotactic frame and thereby enables treatment of extracranial sites (Figure 39-9), Potential benefits of this approach include: (1) inéreased access to and cov age Of any target Volume including the ability to treat lesions in and around the cranium that are unreachable with other systems, for example, in the lower posterior fossa and foramen magnum: (2) enhanced ability to avoid critical structures; (3) capability to treat lesions in the neck and spine; (4) ability to treat lesions throughout the body; (5) delivery of highly confor mal dose distributions; (6) option of fractionating treatments and (7) potential to target multiple tumors at different locations’ during a single treatment, eg, skull base and neck. The CyberKnife® treatment planning system is designed to support the radiosurgery team in determining the optimal plan, including beam weight, targeting positions, dose distributions, and other factors for each patient's treatment. The CyberKnife stereotactic radiosurgery system permits the following planning and delivery options: (1) inverse planning; (2) nonisocentric delivery; and (3) hypofractionation. In contrast to most gamma life procedures, CyberKnife is CI-based: MRlimages can be ith the CT to provide optimal information on soft tissé as well as skeletal anatomy. CT angiography can be used when vascular skull base lesions such as arteriovenous malformations _ecqomisjiqubis UOT ATE ODED yy, i | of the robotic arm supporting the Y he CyberKnife to implement a wider accelerator ethan other systems: Furthermore, bgt of treatment Fe ine the use of a stereotactic head f ire cotactic thesystem does not the patient's head, it allows scangn® temporarily ag and quality assurance t0 take place treatment Par ent itsll. The CyberKnife system provi! time prior to rep options, including the ability to sesige a range of ease treatment planning. With forward iy, forward of the radiation oncologist determines what men iar froma particular targeting position. The total deg to deliv ain then calculated BY thesystem software Wig Xan ae ant planning, the radiation Oncologist speci invert ast be delivered 0 the tumor. The surgeon and raj tol os git are then able to set boundaries to protect ay. io ae taaructures, The software subsequently determing coring postions and the dose to be delivered from each tz. ting ponition. While other stereotactic radiosurgery syste ang Pe nverse planning option, the number of possible plan, erTanited by the constraints of the delivery system. orextens techniques’ “The flexibilit allows Tinea, ran, Dose Distribution ' : ‘The CyberKnife system offers a choice of a nonisocentric oray isocentric treatment approach. With other stereotactic radi surgery systems, a fixed calculated isocenter is used. Isocentrc treatment, or multiisocentric treatment, involves filling the lesion with a single or multiple, overlapping spherically shaped dose distributions. Isocentric treatment is effective for spher ical lesions. However, with irregularly shaped lesions, isocen- tric delivery can produce significant dose heterogeneity. case the surgeon and radiation oncologist must account: relationship of the maxi cures: FIGURE 29-9 + Celling-mounted iagnostic-energy x-ray sources emit low-dose x-rays through the patients tumor treatment area. Amorphous silicon image detectors capture x-ray images fom Coling-mounted diagnostio-energy x9 sources to produce lve radiographs. 7 ‘operating system (typically located ce to the treatment room) correlates patient location detected by image guidance system with reconstructed CT scan and directs the robot to adjust positon ‘accordingly. The compact linear acces” mounted on a computer-contrlled 2 arm, which adjusts position to manta alignment with the target, compersatiNg {for any patient movement and uses X>8 technology for mobility. Published wi?Nonivoce Geesnilesysteni The daly ey ofthese te sbetcaeol ery ofthese af ficedont (isenssed lansispose oles degre elves ml saan pi Which, bee heh) ena the tocoes eaten ylomes they sary points in the workspace ny {rest fsa nage can lesion an asynmmettic tera Mlowsthe avoidance oferitial structures with the CyberKnife sy: ‘stem, the treatment pls lis {iaetionated OF hypotractionated approaches treme eee ave 8 posible ease localization of the eg ee usingitnage guidance teelnology. Dosedéllryenee eee treatment sessions, termed hpaiac ore (ETB ae wilh the Gyberkite span Alten a sana option c stem. Although ot ize pale xing toiors within he posterior fos tl gested tobe particularly useful in the tetmentoflaner en’ The argument for fractionation i tht lower cash of aber of treatm dase, lls healthy The abvantageo native area afm ge tumors, : ng the dose for ns as oppose to a single, larger toner teen ete ionated or sing gation and del fixation that occurs with securing th leradiation dose remains le, Because ofthe tereotaci head ganna kf surgery, raetionated o hypofactionated delivery of radiation isnot possible. Furthermore it remains tobe dt anined if equal accuracy cam be achieved by thesetwo systems oF ifthere isan advantage of fractionation or hypoftactionaion in the treatment of skull base tumors Localization ‘The CyberKnife stems Use of stereotactic principles for tumor localization differs from other stereotactic radiosurgery ystems by using an image guidance technology that depends on the skeletal structure ofthe body asa reference frame: In addition, itcontinually monitors and tacks patient postion during eat ‘ment, The CyberKnife’ operating system correlates live radio- phic images with preoperative CT scan to determine patient and tumor poston repeatedly over the cours of treatment imaging information is transferred from the computers ope ating system to the robot so that it may compensate for any changes in patent position by repositioning the LINAC. Treatment Delivory “The CyberKnife ystem’s computer-controlled robotic arm has he tion the LINAC |sixidegrees(of freedom:/The robot can position the LINAG = than 100 specific locations or nodes. Each node 2 angles, transl issibl nea laming een determines : ‘beam weights, and dose dis- sc inemenaliy prod Cty atu dele los seis ped in poston eean, Image detectors acquire radiographs of the tumor region. ‘The image Cee on rr pres he inept athe sa eerie oberon Hn afrmation jt te robtitize e paining oni ra ic ar ten moves th LINAC Oh ‘beam positions. set sequence of approach angles tributions. The calculated plan ie sequen pest nodes surrounding the patients Ateach a IS LMG sear ew pi of aes ae equied O1n which the position is determined again. Corrected posi- tion is transmitted tothe robot which adapts beam pointing to compensate for any movernent. LINAC delivers the preplanned «lose of radiation for that position. The entire process is repeated ich node, The total tine from imaging to robot compensa ils abot 7 to 10 sec. The total treatmen epends on the complexity ofthe plan and delivery paths but is comparable to standard LINAC treatmentd. Each treatment session ranges / eats in, Physicians may elect to treat with a single dose, « hypofractionated dose, typically of two to five sessions, ‘or amore traditional fractionated regimen. Outcomes following (Gyernife treatment of vestibular schwannomas are emerging aU thistime2” © SUMMARY Stereotactic radiosurgery and radiotherapy are increasingly uti- lized in the management of skull base tumors and other dis orders, Whether driven by the consumer, or the surgeon, the field continues to evolve rapidly. Advances are being made in improving accuracy, effective radiation dose, and parameters necessary to maximize patient outcome. These methods have advantages and disadvantages that must be openly discussed with patient having vestibular schwanniomas or other skull base tumors, It remains the responsibility ofthe surgeon to provide a balanced view a to the relative risks and benefits of observation, microsurgery, stereotactic radiosurgery or radio- ‘therapy, ora combination ofthese methods. References 1. Kondziolka D, Lunsford LD, MeLaughlin MR, Flickinger JC. Long-term outcomes after radiosurgery for acoustic neuroma. [NEngl J Med 1998;339:1826-33, 2. Wacky PA. Stereotactic radiosurgery, microsurgery, and expec- tant management of acoustic neuroma: Bass of informed con sent, Otolaryngol Clin North Am 2005;38:653-70. 5. Wackym PA, Runge-Samuelson CL, Poetker DM, etal, Gamma knife radiosurgery for acoustic neuromas performed by a neurotologist: Ealy experiences and outcomes. Otol Neurol 2004;25:752-61, 4. Knisely IPS, Linskey ME. Less common indications for stereo tactic radiosurgery or fractionated radiotherapy for patients with, ‘benign brain tumors. Neurosurg Clin N Am 2006:17:149-167, Pollock BE. Stereotactic radiosurgery in patents with glomus jugulare tumors, Neurosurg Focus 200817:63-67, 6. Gottfried ON, Liv JK, Couldwell WT, Compatison of radiosur- gery and conventional surgery forthe treatment of glomus jug Tare tumors. Neurosurg Focus 2004; 17:22-30 7 Goldsmith B, McDermott MW. Meningioma, Neurosurg Clin N Am 2006;171114120, 8 Elia AE, Shih HA, Loeffler J. Stereotactic radiation treatment for benign meningiomas. Neurosurg Focus 200723:1-9. re W,Loggin Fuchs fetal. Long term experience ofgamima knife adiosurgery for benign skull base meningiomss J Neural ‘Neurosurg Psychiatry 2005;76: 1425-1430. Gorgulho AA, DeSalles AAF.Impactofradosurgery onthesurgical lucatment of rgeminal neural, Surg Neuel 2006;65:380-356, nerve); anterior anterior xusisan face and roid sul- teendo- ssa, the adalym- periorly, wall of, beinter- the tem- ‘surface erally, along lylem fundus, aby the artment impulla tory te Bills