CyberKnife NeuroRadiosurgery A practical Guide Alfredo Conti Pantaleo Romanelli Evangelos Pantelis Scott G. Soltys Young Hyun Cho Michael Lim Editors CyberKnife NeuroRadiosurgery Alfredo Conti • Pantaleo Romanelli Evangelos Pantelis • Scott G. Soltys Young Hyun Cho • Michael Lim Editors CyberKnife NeuroRadiosurgery A practical Guide Editors Alfredo Conti Pantaleo Romanelli Associate Professor of Neurosurgery Scientific Director Alma Mater Studiorum University AB Medica of Bologna Milano, Italy Bologna, Italy Consultant and Scientific Director IRCCS ISNB Istituto delle Scienze Neurosurgery and Brain Radiosurgery Neurologiche di Bologna CyberKnife Center, CDI Bologna, Italy Milano, Italy Resident Research Scientist Visiting Scientist Charité University European Synchrotron Radiation Berlin, Germany Facility (ESRF) Grenoble, France Evangelos Pantelis CyberKnife Center, CDI Assistant Professor, Medical Physics Via Saint Bon 20 Laboratory, Medical School Milano, Italy National and Kapodistrian University of Athens Scott G. Soltys Mikras Asias 75 Associate Professor, Department Athens, Greece of Radiation Oncology Stanford University Cancer Center Young Hyun Cho 875 Blake Wilbur Drive Associate Professor, Department of Stanford, CA Neurosurgery and Radiosurgery Center USA Asan Medical Center, University of Ulsan, College of Medicine Michael Lim Seoul, Republic of Korea Department of Neurosurgery The Johns Hopkins University School of Medicine Baltimore, MD USA ISBN 978-3-030-50667-4 ISBN 978-3-030-50668-1 (eBook) https://doi.org/10.1007/978-3-030-50668-1 © Springer Nature Switzerland AG 2020 This work is subject to copyright. All rights are reserved by the Publisher, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilms or in any other physical way, and transmission or information storage and retrieval, electronic adaptation, computer software, or by similar or dissimilar methodology now known or hereafter developed. The use of general descriptive names, registered names, trademarks, service marks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use. The publisher, the authors and the editors are safe to assume that the advice and information in this book are believed to be true and accurate at the date of publication. Neither the publisher nor the authors or the editors give a warranty, express or implied, with respect to the material contained herein or for any errors or omissions that may have been made. The publisher remains neutral with regard to jurisdictional claims in published maps and institutional affiliations. This Springer imprint is published by the registered company Springer Nature Switzerland AG The registered company address is: Gewerbestrasse 11, 6330 Cham, Switzerland “Beautiful things have dents and scratches too” This book is dedicated to Nathalie Chadeau for her immense passion. Foreword 1 I am very delighted to write a foreword for this comprehensive book on image-guided robotic (CyberKnife) neuro-radiosurgery for at least three important reasons. The first reason is that single and hypofractionated stereotactic radiation therapy represents, nowadays, a well-established adjunct to our armamentar- ium for the treatment of several neurosurgical diseases. I am sure that the neurosurgical community will find a thorough assessment of appropriate indications, clinical benefits, risks, and pitfalls related to this technology useful. The second reason is related to the fact that I was proud to introduce the CyberKnife at the University Hospital of Messina, Italy, in 2006. At that time, I realized how important it was to make this novel technology available and to evaluate its role and limits in the neurosurgical practice. Since the begin- ning, Dr. Alfredo Conti, a gifted investigator and neurosurgeon working at that time with me in Messina, was able to bridge his knowledge and experi- ence of image-guided surgery of brain and spine lesions to a new robotic radiosurgical facility. The third reason is that I consider it extremely important to have a bal- anced view of the potential and limits of this technology. Sometimes, radio- surgery is proposed as primary option for neurosurgical diseases which could be definitively cured by microsurgical procedures. Thus, it is extremely important to neurosurgeons and radiation oncologists to cooperate in the patient selection and decision-making process and share common experi- ences and cultural background. Only this factual collaboration will result in the best treatment option for each individual patient. The occasional overindication for Stereotactic Radiosurgery (SRS) is due, on the one hand, to an understandable enthusiasm and familiarity of radiation oncologists with this technique. On the other hand, neurosurgeons with direct responsibility in SRS should reconsider the definition of SRS as a minimally invasive treatment that can be, to some extent, misleading to patients. As a matter of fact, although radiation is image-guided on targets with a sufficient safety, we cannot underestimate the fact that long-term adverse effects, poten- tially threatening the quality of life of patients, may occur. Nonetheless, SRS remains a strategic tool for the treatment of hazardous lesions, remnants, and recurrences for fragile patients. vii viii Foreword 1 These are all good reasons to welcome this book reporting the perspec- tives of clinicians and physicists with a large experience in the field of SRS gained through years spent in outstanding international institutions. The rationale for the use of radiosurgery is highlighted by each contributor in a very systematic discussion of personal data, an extensive literature review with special reference to safety-effectiveness, and a final summary of indica- tions and contraindications. The chapters cover different issues, an historical review, physics, imaging, and a thorough essay of brain and spine tumors, cerebral vascular lesions, and functional disorders. The structure of each chapter is perfectly organized in order to provide a practical guide and to make this book an excellent resource for residents, fellows, and practicing neurosurgeons. Definitely, I am impressed by the broad and deep insight into applications of this novel robotic tool with different radiation doses and modalities. I am confident that the invaluable scientific information delivered by this book will benefit the international neurosurgical community. The editors and contribu- tors are to be commended for their effort in making us aware of the current possibilities and limitations of radiosurgery for the treatment of neurosurgical disorders. Francesco Tomasello, MD University of Messina Messina, Italy Foreword 2 The concept of radiosurgery is, and always has been, a genuine neurosurgical concept. The ability to treat and control neurosurgical pathologies with an (invisible) sharp knife, at low risk, has been a success story since its introduc- tion by neurosurgical pioneers. In addition, the therapeutic approach, decision-m aking, perception of perilesional surgical anatomy, and the pre- interventional risk assessment strongly benefit from decades of lessons learned from open neurosurgical operations. While radiosurgery was initially reserved for benign intracranial tumors, the indications have been broadened over the years into vascular, functional, pediatric, and spinal arenas. This is the reason why skull base, stereotactic, functional, and so on hybrid neurosur- geons, active in radiosurgical and open neurosurgical fields, seem to have an easier career pathway than endovascular/open vascular neurosurgical hybrids, for unknown reasons (although I have my ideas). Being a hybrid neurosur- geon or working in an interdisciplinary setting allows us to better appreciate the advantages and disadvantages of each therapeutic modality that we are able to offer to our patients. This will finally eliminate therapeutic bias from the decision-making process. The patients will benefit most from this devel- opment, and this is what counts. I am also a strong supporter of hybrid neu- rosurgeons since a thorough dual training is the most effective strategy to prevent therapeutic extremism, as we have observed in the past, also in the field of radiosurgery. By this, not everything will look like a nail since one has not only a single hammer. One reason for this smooth and successful develop- ment in radiosurgery is the trustful collaboration with our friends and col- leagues from radiooncology, to whom we are, and always will be, grateful for their support and friendship. This view, however, as appealing as it may sound, is currently regarded as “romantic,” “unrealistic,” or “useless” by critical neurosurgeons and radiation oncologists, even among my friends. This just demonstrates that many still need to be convinced by science- and evidence-based success and progress in the field, and maybe also by overcoming classical borders when it comes to neurointerventions. The single most important aspect that will consolidate the hybrid neurosurgical concepts is the thrive for high-end clinical and aca- demic training in both fields, in order to tackle the argument that one person cannot be good at both therapies. Admittedly, there is still room for improve- ment in this field for the next years or so. Having said all this, it is a pleasure to hold this textbook that comprises all aspects of radiosurgery, traditional and innovative ones in my hands. The ix x Foreword 2 leaders in the field are discussing these aspects in a very balanced and scien- tific way to highlight areas of opportunities, challenges, controversy, and common sense. The real value of this book, however, is that all authors involved fulfill my introductory remarks about hybrid neurosurgeons or expe- rienced interdisciplinary teams. They stand for high-quality concepts and bal- anced views, always struggling for the best outcome in our patients. It is a pleasure to see Alfredo Conti, a role model of an academic hybrid neurosurgeon and to whom the Charité CyberKnife Program is grateful for his collaboration and expertise, as the editor of this book. I applaud him for this masterpiece. In addition, it is a pleasure to have Francesco Tomasello as author of the second foreword. Francesco, as a very prominent representative of the Italian Neurosurgical Society, has always been a mentor and close friend for me over many years, for what I am truly grateful. However, in the midst of the COVID-19 pandemic and all the associated suffering (when these words are printed), I cannot resist to acknowledge and congratulate the entire Italian Neurosurgical Society for their dedication to all the positive aspects of our neurosurgical life: friendship, positivity, humbleness, elegance, innovation, family, and strong shoulders that carry on and come up with excellent books like this. Peter Vajkoczy, MD Department of Neurosurgery Charité-Universitätsmedizin Berlin Berlin, Germany Preface This book aims to represent a practical guide for image-guided stereotactic radiosurgery and hypofractionated stereotactic radiotherapy of the brain and spine. Leading physicians and scientists from four continents will provide the readers with basic concepts, current evidence, and guidelines for the treat- ment of neoplastic and non-neoplastic disease of the central nervous system. Radiosurgery is one of the mainstreams of modern neurosurgery. Indeed, it perfectly complies with the current requirements of a minimally invasive neurosurgery and preservation of health-related quality of life. Neurosurgery is a formidable challenge that, during its 100-year history, has expanded the opportunities for healing many human diseases, previously invariably mortal. Nonetheless, despite the amazing evolution of techniques and technologies, it remains a substantially invasive and pervasive discipline that often produces a negative impact on the cognitive performance of patients and eventually dramatic effects on their quality of life. Image-guided radiosurgery represents a refinement of a revolution initi- ated almost 40 years ago through the introduction of frame-based radiosur- gery. As a matter of fact, it has introduced several advantages for both the patient and the physician. Image-guided radiosurgery offers greater comfort for the patient who does not need to be invasively attached to a stereotaxic frame. Treatment is usually delivered as an outpatient procedure; imaging and treatment should not be performed in a few hours, providing more time for physicians and physicists to work out the best possible treatment for the patient. Above all, image-guidance has introduced the concept of multisession radiosurgery or hypofractionation, a term that indicates a radiotherapy treat- ment with a shorter course than conventional radiotherapy with a dose distri- bution that cannot be significantly different to that of single fraction radiosurgery. This approach has significantly changed the horizon of radio- surgery by expanding its boundaries of curative potential. Actually, by multi- session radiosurgery it is now possible to treat larger brain tumors and tumors close to the most critical structures of the brain and spine. The great value of these features introduced through the first image-guided radiosurgery device, the CyberKnife (Accuray Inc., Sunnyvale, CA), is testi- fied by the adoption of image-guidance by other systems (i.e., Gamma Knife Icon). xi