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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Brain Tumor Radiosurgery
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Surgical CAD/CAM Systems
Computer-assisted planning
Patient-specific Model
Update Model Update Plan
Computer-Assisted
Assessment
Preoperative Intraoperative
Atlas
PostoperativePatient
Surgical “CAD”
Surgical “TQM”
Surgical “CAM”
Computer-Assisted
Execution
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Brain Tumors Are
• The leading cause of death from childhood cancers among persons up to 19 years
• The second leading cause of cancer-related deaths in males ages 20-39
• The fifth leading cause of cancer-related deaths in women ages 20-39
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Incidence of Brain Tumorsin the US in 2005
• Total new cases of primary brain/CNS tumors (malignant and non-malignant):
• 200,000 metastatic• 43,800 primary
• They occur in 10-15% of people with cancer.
• Primary brain tumors generally do not metastasize to other parts of the body.
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Brain TumorsSome are lethally aggressive (glioblastoma multiforme)
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Brain Tumors
Some are inoperable – too big, intrusive, etc..
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Brain TumorsSome are inoperable (too deep, metastatic, etc.)
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
RadiosurgeryBlasting out tumors with high energy (25 MeV) X-ray
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Medical Linear Accelerator
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Linear Accelerator
Linear accelerator (LINAC) for electrons. A klystron (B) connected to a waveguide (C) generates traveling microwaves in the evacuated accelerator tube (D). Electrons are
injected in bunches by source (A) and are accelerated by the traveling microwaves. The pulsed electron beam is spread by a scanning coil (E), exits through a thin window (F) and
irradiates the target (G). (Adapted from O’Donnell and Sangster.)
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Multiple Beams
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Linac Motions
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
IMAGE MODEL PLAN REGISTER EXECUTE FOLLOWUP
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
IMAGE MODEL PLAN REGISTER EXECUTE FOLLOWUP
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Computed Tomography (CT)
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Computed Tomography – Images
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Head-ring Attachment
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Patient in Localization Frame
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Relocatable Headrest
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
CT Imaging
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
IMAGE MODEL PLAN REGISTER EXECUTE FOLLOWUP
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Segmentation of CT image
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D reconstruction
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Reconstruction
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Reconstruction
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Reconstruction
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Reconstruction
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Data Fusion
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Data Fusion
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Target Visualization
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Target Visualization
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D Target Visualization
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Target Volume in CT and MRI
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Arc Therapy
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Arc Design
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Dose from two isocenters
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Dose from two isocenters
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
“Thick” Pencil Beams
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Entry & Exit Beams
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Linear Accelerator Gun
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Beam Collimation
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Check collimator size
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Beam’s eye view
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
3D dose coverage
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
2D dose overlay on CT
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Dose coverage analysis – 2D
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Dose coverage analysis – 2D
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
IMAGE MODEL PLAN REGISTER EXECUTE FOLLOWUP
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Head-holder on linac table
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Linac target phantom
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Target phantom x-rays
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Run dry, then deliver the dose
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Radiosurgery CAD/CAM
IMAGE MODEL PLAN REGISTER EXECUTE FOLLOWUP
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Follow-up CT (3,6,12,24 mo)
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
The Ultimate Reward…
Ten years after treatment for a malignant pineoblastoma
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Gamma Knife
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Gamma Knife – close-up
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Gamma Knife – insideCobalt-60 sources
Helmet
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Gamma Knife – inside
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Gamma Knife treatment plan
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Linac versus Gamma Knife
Linac: Multiple useGamma Knife: Intracranial neurosurgery only
Linac: moving table, gantry and collimatorGamma Knife: all static
Linac: X-ray on demand (X-ray generator)Gamma Knife: beam “always on” (Cobalt60
source) – therapeutic beamtime is low, source replacement $0.5M in every five years, longer treatments are needed as Co60 source decays.
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Linac versus Gamma Knife
Linac: Multiple useGamma Knife: Intracranial neurosurgery only
Linac: moving table, gantry and collimatorGamma Knife: all static
Linac: X-ray on demand (X-ray generator)Gamma Knife: beam “always on” (Cobalt-60 source)
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Cyberknife = Robot arm + Linac
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
CyberKnife patient fixation
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
CyberKnife fluoro image guidance
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Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
CyberKnife treatment planing
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
CyberKnife- summary
•a compact 6-MV linear accelerator •mounted on a 6DOF computer-controlled robotic arm•intra-op X-ray image guidance•no need for rigid stereotactic frame.
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Yet another new way: TomotherapyMOVIE
Copyright © Gabor Fichtinger, 2008Percutaneous Therapy Lab – Perk Lab
Pros and ConsPros:• Sophistication
– High dose conformity• Simplicity
– No simulator– No separate treatment
planning computers– No block cutting &
compensator molding– No portal imaging systems.
• Safety– No bream shaping blocks– No dual e/X-ray mode– No beam stopper– No scatter
Cons:• Reduced case portfolio
– No electron beams– No 10+ MEV beams– Only one beam energy
• Only transverse beams• Not so good CT (beams are
too “hard”)