Focused Issue of This Month Hyun Tai Chung, MD Dong Gyu Kim, MD Department of Neurosurgery, Seoul National University College of Medicine E mail : gknife@plaza.snu.ac.kr htchung@korea.com J Korean Med Assoc 2008; 51(1): 5-15 Abstract Radiosurgery, or stereotactic radiosurgery, is a minimally invasive modality to treat a lesion with stereotactically focused ionizing radiation without surgical incision. Because there are no incision procedures, general anesthesia or transfusion is not required, and complications related to incisional procedures do not occur in radiosurgery. As a result, radiosurgery shows much low rates of complications than conventional open surgery with comparable cure rates. In the beginning, radiosurgery was applied only to a few intracranial diseases because a stereotactic frame was applied to the skull. Along with the development of technologies and accumulation of knowledge on radiosurgery such as medical imaging, computer, radiation physics, and radiobiology, indications of radiosurgery have been expanded in various ways. Nowadays, radiosurgery is accepted as an adjuvant treatment or a primary treatment option for many neurosurgical diseases and cancers. Cranial nerve schwannomas, brain meningiomas, pituitary adenoma, and other benign brain tumors are good indications for radiosurgery. Intracranial arteriovenous malformation, brain metastases from extracranial cancers, and trigeminal neuralgia are also well controlled by radiosurgery. Spinal metastases and various cancers are emerging indications for extracranial radiosurgery, which has been recently introduced. In this article, the authors summarized the basic concept, history, development, and future of radiosurgery as an introduction to radiosurgery. Keywords : Radiosurgery; Basic concept; Indications 5
Chung HT Kim DG 6
Figure 1. The first trial of stereotactic radiosurgery used a 200 kvp X ray tube mounted on a stereotactic frame (Courtesy of Elekta AB. Stockholm, Sweden). Figure 2. Lars Leksell (left) is preparing a radiosurgery with a proton beam generated by the Uppsala synchrocyclotron in 1960 (Courtesy of Elekta AB. Stockholm, Sweden). ö 7
Chung HT Kim DG Figure 3. Lars Lekell and the first Gamma Knife (Courtesy of Elekta AB, Stockholm, Sweden). 8
A B C D Figure 4. A) Gamma Knife Perfexion (Courtesy of Elekta Korea). B) Novalis Shaped Beam Surgery (Courtesy of BrainLAB Korea). C) CyberKnife G4 (Courtesy of CyberKnife Korea). D) Tomotherapy (Courtesy of Oncology Total Solution). 9
Chung HT Kim DG 10
11. Larson DA. Introduction to radiosurgery. Clin Neurosurg 1992; 38: 391-404. 12. Larson DA, Gutin PH. Introduction to radiosurgery. Neurosurg Clin N Am 1990; 1: 897-908. 13. Maciunas RJ. Stereotactic radiosurgery. Nat Med 1996; 2: 712-713. 14. Flickinger JC, Barker FG 2nd. Clinical results: Radiosurgery and radiotherapy of cranial nerve schwannomas. Neurosurg Clin N Am 2006; 17: 121-128. 15. Kondziolka D, Lunsford LD, Flickinger JC. Acoustic neuroma radiosurgery. Origins, contemporary use and future expectations. Neurochirurgie 2004; 50: 427-435. 16. Kondziolka D, Lunsford LD, Flickinger JC. Acoustic tumors: operation versus radiation--making sense of opposing view- 11
Chung HT Kim DG points. Part II. Acoustic neuromas: sorting out management options. Clin Neurosurg 2003; 50: 313-328. 17. Kondziolka D, Lunsford LD, Flickinger JC. Comparison of management options for patients with acoustic neuromas. Neurosurg Focus 2003; 14: e1. 18. Friedman WA, Foote KD. Linear accelerator based radiosurgery for vestibular schwannoma. Neurosurg Focus 2003; 14: e2. 19. Kondziolka D, Lunsford LD, Flickinger JC. Stereotactic radiosurgery for the treatment of trigeminal neuralgia. Clin J Pain 2002; 18: 42-47. 10. Kondziolka D, Lunsford LD, Flickinger JC. Controversies in the management of multiple brain metastases: the roles of radiosurgery and radiation therapy. Forum (Genova) 2001; 11: 47-58. 11. Friedman WA, Foote KD. Linear accelerator radiosurgery in the management of brain tumours. Ann Med 2000; 32: 64-80. 12. Friedman WA. Radiosurgery versus surgery for arteriovenous malformations: the case for radiosurgery. Clin Neurosurg 1999; 45: 18-20. 13. Kondziolka D, Niranjan A, Lunsford LD, Flickinger JC. Stereotactic radiosurgery for meningiomas. Neurosurg Clin N Am 1999; 10: 317-325. 14. Kondziolka D. Functional radiosurgery. Neurosurgery 1999; 44: 12-20; discussion 20-22. 15. Flickinger JC, Kondziolka D, Lunsford LD. Clinical applications of stereotactic radiosurgery. Cancer Treat Res 1998; 93: 283-297. 16. Flickinger JC, Lunsford LD, Somaza S, Kondziolka D. Radiosurgery: its role in brain metastasis management. Neurosurg Clin N Am 1996; 7: 497-504. 17. WA. Radiosurgery for arteriovenous malformations. Clin Neurosurg 1995; 42: 328-347. 18. Friedman WA, Bova FJ. Radiosurgery for arteriovenous malformations. Clin Neurosurg 1993; 40: 446-464. 19. Lunsford LD, Kondziolka D, Flickinger JC. Stereotactic radiosurgery for benign intracranial tumors. Clin Neurosurg 1993; 40: 475-497. 20. Lunsford LD, Linskey ME. Stereotactic radiosurgery in the treatment of patients with acoustic tumors. Otolaryngol Clin North Am 1992; 25: 471-491. 21. Lunsford LD, Kondziolka D, Flickinger JC. Stereotactic radiosurgery: current spectrum and results. Clin Neurosurg 1992; 38: 405-444. 22. Deinsberger R, Tidstrand J. Linac radiosurgery as a tool in neurosurgery. Neurosurg Rev 2005; 28: 79-88. 23. Gerszten PC, Welch WC. Cyberknife radiosurgery for metastatic spine tumors. Neurosurg Clin N Am 2004; 15: 491-501. 24. Rock JP, Ryu S, Yin FF. Novalis radiosurgery for metastatic spine tumors. Neurosurg Clin N Am 2004; 15: 503-509. 25. Thornton AF, Laramore GE. Technical advances in radiotherapy of head and neck tumors. Hematol Oncol Clin North Am 1999; 13: 811-823. 26. Mehta MP. The physical, biologic, and clinical basis of radiosurgery. Curr Probl Cancer 1995; 19: 265-329. 27. Attia M, Menhel J, Alezra D, Pffefer R, Spiegelmann R. Radiosurgery--LINAC or gamma knife: 20 years of controversy revisited. Isr Med Assoc J 2005; 7: 583-588. 28. Phillips MH, Stelzer KJ, Griffin TW, Mayberg MR, Winn HR. Stereotactic radiosurgery: a review and comparison of methods. J Clin Oncol 1994; 12: 1085-1099. 29. Luxton G, Petrovich Z, Jozsef G, Nedzi LA, Apuzzo ML. Stereotactic radiosurgery: principles and comparison of treatment methods. Neurosurgery 1993; 32: 241-259; discussion 259. 30. Goodman ML. Gamma Knife radiosurgery: Current status and review. South Med J 1990; 83: 551-554. 31. Bova FJ. Radiation Physics. Neurosurg Clin North Am 1990; 1: 909-931. 32. Leksell L. Stereotactic radiosurgery. J Neurol Neurosurg Psychiarty 1983; 46: 797-803. 33. Kondziolka D, Niranjan A, Lunsford LD, Flickinger JC. Radiobiology of radiosurgery. Prog Neurol Surg 2007; 20: 16-27. 34. Willers H, Held KD. Introduction to clinical radiation biology. Hematol Oncol Clin North Am 2006; 20: 1-24. 35. Niranjan A, Gobbel GT, Kondziolka D, Flickinger JC, Lunsford LD. Experimental radiobiological investigations into radiosurgery: present understanding and future directions. Neurosurgery 2004; 55: 495-504; discussion 504-505. 36. Shrieve DC, Klish M, Wendland MM, Watson GA. Basic principles of radiobiology, radiotherapy, and radiosurgery. Neurosurg Clin N Am 2004; 15: 467-479. 37. Kondziolka D, Lunsford LD, Flickinger JC. The radiobiology of radiosurgery. Neurosurg Clin N Am 1999; 10: 157-166. 38. Joensuu H, Tenhunen M. Physical and biological targeting of radiotherapy. Acta Oncol 1999; 38(S13): 75-83. 39. Altschuler E, Lunsford LD, Kondziolka D, Wu A, Maitz AH, Sclabassi R, Martinez AJ, Flickinger JC. Radiobiologic models for radiosurgery. Neurosurg Clin N Am 1992; 3: 61-77. 40. Levivier M, Massager N, Wikler D, Devriendt D, Goldman S. Integration of functional imaging in radiosurgery: the example of PET scan. Prog Neurol Surg 2007; 20: 68-81. 41. Lee JK, Liu RS, Shiang HR, Pan DH. Usefulness of semiquantitative FDG PET in the prediction of brain tumor treatment response to gamma knife radiosurgery. J Comput Assist Tomogr 2003; 27: 525-529. 12
42. Kondziolka D, Lunsford LD, Loeffler JS, Friedman WA. Radiosurgery and radiotherapy: observations and clarifications. J Neurosurg 2004; 101: 585-589. 43. Laitinen LV. Personal memories of the history of stereotactic neurosurgery. Neurosurgery 2004; 55: 1420-1428; discussion 1428-1429. 44. Leksell L. A stereotactic apparatus for intracerebral surgery. Acta Chir Scand 1949; 99: 229-233. 45. Spiegel EA, Wycis HT, Marks M, Lee AJ. Stereotaxic apparatus for operations on the human brain. Science 1947; 106: 349-350. 46. Horsley V, Clarke RH. The structure and funtions of the cerebellum examined by a new method. Brain 1908: 31: 45-124. 47. Levy RP, Schulte RW, Slater JD, Miller DW, Slater JM. Stereotactic radiosurgery--the role of charged particles. Acta Oncol 1999; 38: 165-169. 48. Levy RP, Fabrikant JI, Frankel KA, Phillips MH, Lyman JT. Charged particle radiosurgery of the brain. Neurosurg Clin N Am 1990; 1: 955-990. 49. Fabrikant JI, Levy RP, Steinberg GK, Phillips MH, Frankel KA, Silverberg GD. Stereotactic charged particle radiosurgery: clinical results of treatment of 1,200 patients with intracranial arteriovenous malformations and pituitary disorders. Clin Neurosurg 1992; 38: 472-492. 50. Lyman JT, Phillips MH, Frankel KA, Levy RP, Fabrikant JI. Radiation physics for particle beam radiosurgery. Neurosurg Clin N Am 1992; 3: 1-8. 51. Wu A. Physics and dosimetry of the gamma knife. Neurosurg Clin N Am 1992; 3: 35-50. 52. Saw GB, Celi JC, Huq MS. Therapeutic radiation physics primer. Hematol Oncol Clin North Am 2006; 20: 25-43. 53. Friedman WA. Linear accelerator radiosurgery. Clin Neurosurg 1992; 38: 445-471. 54. Podgorsak EB. Physics for radiosurgery with linear accelerators. Neurosurg Clin N Am 1992; 3: 9-34. 55. Friedman WA. LINAC radiosurgery. Neurosurg Clin North Am 1990; 1: 991-1008. 56. Podgorsak EB, Pike B, Olivier A, Pla M, Souhami L. Radiosurgery with high energy photon beams: a comparison among techniques. Int J Radiat Oncol Biol Phys 1989; 16: 857-865. 57. Flickinger JC, Kondziolka D, Niranjan A, Lunsford LD. Dose selection in stereotactic radiosurgery. Prog Neurol Surg 2007; 20: 28-42. 58. Andrews DW, Bednarz G, Evans JJ, Downes B. A review of 3 current radiosurgery systems. Surg Neurol 2006; 66: 559-564. 59. Smith RP, Heron DE, Huq MS, Yue NJ. Modern radiation treatment planning and delivery from Rˆntgen to real time. Hematol Oncol Clin North Am 2006; 20: 45-62. 60. Ting JY, Scarbrough TJ. Intensity modulated radiation therapy and image guided radiation therapy: small clinic implementation. Hematol Oncol Clin North Am 2006; 20: 63-86. 61. Hogle WP. The state of the art in radiation therapy. Semin Oncol Nurs 2006; 22: 212-220. 62. Klish MD, Watson GA, Shrieve DC. Radiation and intensity modulated radiotherapy for metastatic spine tumors. Neurosurg Clin N Am 2004; 15: 481-490. 63. Rosenzweig KE, Amols H, Ling CC. New radiotherapy technologies. Semin Surg Oncol 2003; 21: 190-195. 64. Flickinger JC, Kondziolka D, Lunsford LD. Dose selection in stereotactic radiosurgery. Neurosurg Clin N Am 1999; 10: 271-280. 65. Corn BW, Curran WJ Jr, Shrieve DC, Loeffler JS. Stereotactic radiosurgery and radiotherapy: new developments and new directions. Semin Oncol 1997; 24: 707-714. 66. Graham JD, Nahum AE, Brada M. A comparison of techniques for stereotactic radiotherapy by linear accelerator based on 3 dimensional dose distributions. Radiother Oncol 1991; 22: 29-35. 67. Solberg TD, Boedeker KL, Fogg R, Selch MT, DeSalles AA. Dynamic arc radiosurgery field shaping: a comparison with static field conformal and noncoplanar circular arcs. Int J Radiat Oncol Biol Phys 2001; 49: 1481-1491. 68. Solberg TD, Selch MT, Smathers JB, DeSalles AA. Fractionated stereotactic radiotherapy: rationale and methods. Med Dosim 1998; 23: 209-219. 69. Romanelli P, Schweikard A, Schlaefer A, Adler J. Computer aided robotic radiosurgery. Comput Aided Surg 2006; 11: 161-174. 70. Steffey Stacy EC. Frameless, image guided stereotactic radiosurgery. Semin Oncol Nurs 2006; 22: 221-232. 71. Kuo JS, Yu C, Petrovich Z, Apuzzo ML. The CyberKnife stereotactic radiosurgery system: description, installation, and an initial evaluation of use and functionality. Neurosurgery 2003; 53: 1235-1239; discussion 1239. 72. Ross PJ, Ashamalla H, Rafla S. Advances in stereotactic radiosurgery and stereotactic radiation therapy. Radiat Ther 2001; 10: 57-72. 73. Mackie TR, Balog J, Ruchala K, Shepard D, Aldridge S, Fitchard E, Reckwerdt P, Olivera G, McNutt T, Mehta M. Tomotherapy. Semin Radiat Oncol 1999; 9: 108-117. 74. Mackie TR, Holmes T, Swerdloff S, Reckwerdt P, Deasy JO, Yang J, Paliwal B, Kinsella T. Tomotherapy: a new concept for the delivery of dynamic conformal radiotherapy. Med Phys 1993; 20: 1709-1719. 75. Kondziolka D, Lunsford LD, Witt TC, Flickinger JC. The future of radiosurgery: radiobiology, technology, and applications. 13
Chung HT Kim DG Surg Neurol 2000; 54: 406-414. 76. Barnett GH, Linskey ME, Adler JR, Cozzens JW, Friedman WA, Heilbrun MP, Lunsford LD, Schulder M, Sloan AE; American Association of Neurological Surgeons; Congress of Neurolofical Surgeons Washington Committee Stereotactic Radiosurgery Task Force. Stereotactic radiosurgery an organized neurosurgery sanctioned definition. J Neurosurg 2007; 106: 1-5. 77. Kavanagh BD, Timmerman RD. Stereotactic radiosurgery and stereotactic body radiation therapy: an overview of technical considerations and clinical applications. Hematol Oncol Clin North Am 2006; 20: 87-95. 78. Pollock BE, Lunsford LD. A call to define stereotactic radiosurgery. Neurosurgery 2004; 55: 1371-1373. 79. Adler JR Jr, Colombo F, Heilbrun MP, Winston K. Toward an expanded view of radiosurgery. Neurosurgery 2004; 55: 1374-1376. 80. Ostertag ChB. Stereotactic radiation therapy and radiosurgery. Stereotact Funct Neurosurg 1994; 63: 220-232. 81. Lunsford LD, Alexander E, Chapman P, Coffey R, Friedman W, Harsh G IV, Maciunas R, Olivier A, Steinberg G, Walsh J, Larson DA, Bova F, Eisert D, Kline R, Loeffler J, Lutz W, Mehta M, Palta J, Schewe K, Schultz C, Shaw E, Wilson JF. Consensus statement on stereotactic radiosurgery: quality improvement. Neurosurgery 1994; 34: 193-195. 14
Peer Reviewer Commentary 15