What is CyberKnife® Radiosurgery?

CyberKnife® radiosurgery is a high precision, pain-free, robot guided radiation treatment which in certain cases can be an alternative to invasive surgery.

Multiple high energy beams are focussed on a target within the body where they become effective and destroy the tumour. One single beam cannot cause damage, but bundling of all beams in the target leads to destruction of the tumour tissue without harming the adjacent healthy tissue.

Some treatments offered by CyberKnife® are not otherwise available by radiotherapy. Other treatments may be conducted more quickly, more conveniently, or more economically with CyberKnife® than by alternative methods. In some cases a single CyberKnife® treatment may take the place of a four-week course of conventional radiotherapy.

CyberKnife® offers pain-free, outpatient "surgery", with no need for uncomfortable fixings to secure the patient in position, no anesthesia and no surgical incisions. There is no inpatient hospital stay and no time is required for recovery or rehabilitation.

Introducing the European CyberKnife® Centre

CyberKnife® is made by Accuray Inc in the USA and there are CyberKnife® centres across the USA, with a number in Asia and Europe. As yet there are none in the UK or Eire but the European CyberKnife® Centre in Munich (Europäisches CyberKnife® Zentrum München or ECZM) takes patients from many countries.

ECZM offers modern, state-of-the art facilities and was named as the leading CyberKnife® Centre in the world for treatment of tumours in the central nervous system at the annual Cyberknife® Users meeting in San Diego in January 2006.

Medilux Healthcare Limited is proud to have been appointed as the sole Representative in the UK and Eire for ECZM. We handle all initial enquiries from patients, doctors, hospitals and health insurers, providing information on the range of treatments available, the relevant costs and the procedures and time scale for obtaining treatment.

We provide information of a general nature but we do not give medical advice on specific cases. Where it is felt that these may be suitable for CyberKnife® treatment and the patient or doctor wishes to pursue their enquiry further we introduce them to the relevant doctor at ECZM and all clinical decisions, diagnosis and treatment are conducted entirely by ECZM or under their supervision in Munich.

Professional Presentations

For Medical Professionals we offer formal presentations with the opportunity to meet ECZM personnel and we arrange places at on-site practical seminars in Munich. See below for details. If you would like to be notified of the next presentation please e-mail us with your contact details and let us know if you have any special area of interest.

What are the principal treatments offered by ECZM, the European CyberKnife® Centre, Munich?

Head Region

• Acoustic neuroma
• Meningeoma
• Other Neuromas
  
• Metastases
• Gliomas (selected cases)
• AVM (arterio-venous malformations)
• Trigeminal neuralgia
• Haemangioblastomas
• Jugular foramen tumours
  
  ECZM has recently installed the new Siemens Emotion 16 detector CT which enables very fast scanning times (30 seconds for a brain scan).

Spine

• Metastases
• Neuromas
• Meningeomas
• MPNST (malignant peripheral nerve sheath tumours)
• Haemangioblastomas
• Tumour pain
  
  Spine lesions are treated with the brand new Xsight software package, which enables a treatment without the need to place invasive fiducials for spinal tracking. ECZM is currently the only CyberKnife® Centre in Europe operating this software.

Body

• Lung metastases (single)
  
• Lung cancer (Stage I)
  
  

Body lesions are treated with the Synchrony (breath triggered robot movement) system. Note: these treatments are more complex than brain and spine treatments and patients are carefully selected for suitability. Preparatory procedures are required one week before CyberKnife® can be used and these are conducted in the adjacent University Hospital.

When conventional radiotherapy has been insufficient CyberkKnife® treatments can sometimes be performed for patients after conventional therapy when the tumour could not be controlled. This is an important advantage because traditionally there was no other option for these patients.

Why travel to Munich for treatment?

Cancer therapy is a difficult time for patients but CyberKnife® radiosurgery eases this considerably. ECZM goes further however, by incorporating the latest software to make treatments even easier, faster and more comfortable. Treatment is provided in clean, pleasant and modern premises and the patient is in full communication with English-speaking doctors throughout the treatment.

Everything is done to make the patient feel more relaxed and confident and there are set price treatment packages to relieve financial uncertainty.

ECZM offers a complete service including hotel bookings and transfers from and to Munich Airport. CyberKnife® treatments are painless, mostly very short and require no recovery time so the stay need not be expensive. There are direct scheduled flights to Munich from Birmingham, Bristol, Cork, Dublin, Glasgow, London (City, Gatwick, Heathrow and Stansted) and Manchester and Munich is also a popular destination for charter flights and city breaks.

Useful Links
Hotels and tourism in Bavaria www.bayern.by
Airlines and flights to and from Munich www.munich-airport.de

Payment of treatment costs via EEC 112 - for United Kingdom patients click here for Government website and details
Payment of treatment costs via EEC 112 - for Ireland patients click here for Government website and details

O v e r v i e w

CyberKnife® radiosurgery in certain cases can be an alternative or adjunct to open surgery and standard radiation treatment lasting several weeks.

The therapeutic possibilities of the innovative CyberKnife® technology far exceeds other treatment modalities available to date.

Image  guided precision robotics

The innovation of the CyberKinfe® system is the technical integration of two components:

1. A particularly lightweight and compact high precision radiation source that is mounted on a robot arm. All regions in the body can be reached with high accuracy and lesions safely destroyed. The system is much more flexible than the other technologies in use today.
2. A computer assisted image guidance system allows the surgeon to track the lesion throughout the treatment and correct for small patient movements.

Actual treatment takes approximately one hour.

Benefits of treatment for patients

• no incisions
• no pain
• no head frame
• no anesthesia
• no hospitalisation
• no recovery time

P r e c i s e  -  c o n t r o l l e d  -  p a i n  f r e e

Brain and spinal cord tumours are destroyed safely and effectively.

There is no pain or stress caused by fixation of an invasive sterotactic frame, anaesthesia or an open surgical procedure. Treatment is on an outpatient basis.

CyberKnife® technology

How CyberKnife® works. The CyberKnife® system is a novel, revolutionary achievement in the medical field - it combines two modern advancements in medical high technology:

1. Precision robotics. The first innovation consists of a particularly lightweight and compact radiation device mounted on a robotic arm. The precision robot - which is also used in the automobile industry - can move freely in 6 planes. Thus all body parts can be accessed without problems for an optimal treatment. The system is clearly more flexible in handling and hence more effective than conventional systems.

2. Image guidance system.  The second innovation consists of a computer assisted image guidance targeting system. With this technology the CyberKnife® can target the tumour throughout the treatment and smaller patient movements can be compensated for. Thus it is no longer necessary to fix the head of the patient in a frame, to immobilize the body or to administer anaesthesia, as is required for conventional systems.

Treatment advantages  The newly developed design of the CyberKnife® system enables treatments not only in the area of the brain but also throughout the spine and spinal cord or in other parts of the body. In such a way also lesions in very sensitive body parts can be eliminated while minimising impact on the surrounding healthy tissue.

Pain free surgery  The newly developed CyberKnife® technology offers pain-free, outpatient "surgery". There are no complications from fixations, no anesthesia, no surgical incisions. No inpatient hospital stay is required, also no subsequent cure or rehabilitation time.

High quality of life  High quality of life during and after the treatment. The outpatient CyberKnife® treatment does not lead to limitations in normal daily life. Immediately after the treatment the usual activities can be resumed.

Treatment Example

This example shows a 46 years old female patient harbouring an intramedullary breast cancer metastasis at the level of C2 (left image). She was experiencing a life threatening disease with the beginning of complete paralysis. The patient was treated by a 1 hour single session radiosurgical CyberKnife® procedure.

4 weeks after CyberKnife® treatment the tumour was no longer visible any more (right image). The patient had a good quality of life and walked out of the outpatient department on her own feet.

Medical experience   The CyberKnife® system is based on radiosurgical principles which have been in clinical use for 30 years. Thousands of patients world wide have already been treated successfully with the CyberKnife® technology. A great number of scientific studies have also been published in international medical journals.

Indications of treatment   Generally, tumours in all parts of the body with a positive indication for radiosurgical therapy can be treated with the CyberKnife®.

The latest in medical high technology allows it to treat even very irregularly shaped tumours in the area of critical brain regions such as the visual or auditive nerve, without damage to these sensitive brain areas.

Such possibility to provide focussed treatment of tumour tissue while sparing the surrounding structures also allows for an effective treatment of brain lesions in various areas difficult to access by surgery, such as for example the brain stem or skull base.

Treatment Process  The treatment process consists of several components: a first interview, the imaging, the treatment planning, the actual precision radiation, and routine follow-up examination.

Preparation work   For lesions located in the brain, an individual head rest is moulded. This keeps the head still during the treatment as much as possible.

Imaging   For each treatment computed tomographic (CT) and MR examinations are required. The CT scan is acquired in the CyberKnife® Centre itself. Depending on the individual constellation of the disease, this examination can take place immediately before or one day prior to the actual treatment. Existing MR images may also be transferred via CD for the treatment planning.

Treatment Planning   The CT and MRI data are logged onto a computer so that the attending physicians and specialised medical physicists can plan and simulate the number, intensity and direction of the beams which the robot will deliver to the target. During this planning phase the patient does not need to be present.

Gentle treatment   Treatment is performed in the centres very modern practice rooms in an outpatient setting. On the day of treatment no special measures have to be taken. Have breakfast as usual and take any medicine, if applicable. An companion for your personal support is welcome. If desired, your favourite music CD can be played during the treatment.

Positioning   At the beginning of the treatment the patient is requested to lay down on the treatment table and if necessary the previously- moulded head rest is in place. Anaesthesia is not necessary since the treatment is entirely pain free.

Precision radiation During the treatment the patient should lie as still as possible, small movements however are tolerated. The patient is observed with video cameras by the treating physicians and can get into contact at any time with the attending doctor via microphone.

Duration and Termination of treatment  Normally only one treatment session is required which lasts from between 45 minutes to 90 minutes depending on the indication. Immediately after the treatment the patient can leave the CyberKnife® Centre and resume usual daily activities.

In rare cases it may be necessary to split the radiation dose over several sessions. In such cases the patient will be requested to return for the remaining treatment sessions. Treatment will commence on a Monday run for either three or five consecutive days.

Follow-up examinations  After each medical intervention a follow up examination is recommended after 4 to 6 months in your home country.

T h e   E u r o p e a n   C y b e r K n i f e®   T r a i n i n g   C e n t r e  has been designed as a training centre for interested colleagues from all over Europe. There will be regular training courses for smaller groups essentially comprising neurosurgeons, radiation therapists, medical physicists and medical technical assistants (MTA's).

To this effect modern conference rooms have been created with provision of all audiovisual equipment from where the treatment process can be observed via video cameras and details of the treatment can be discussed with the attending physicians. Please contact Timelines Group for details.

R o y a l   S o c i e t y   o f   M e d i c i n e,   L o n d o n   In addition with the support of the UK and Eire representatives, Medilux Healthcare Limited, a series of presentations are being prepared for 2006/2007. Please enquire for dates and further details. s.warren@mediluxhealth.net

D O W N L O A D S

To view VIDEOS of the history and CyberKnife in action please follow this link

All downloadable files are in Portable Document Format [pdf] and will require Adobe Reader® to be installed on your computer to open these files. If you find that the reader programme is not already installed on your computer you may download the reader for FREE from the following official download site

Medilux Healthcare Limited - CyberKnife Radiosurgery Introduction.
Illustrated overview of the technology, mode of action and treatment examples [2 pages] Click the icon to begin your download. . .

Medilux Healthcare Limited - CyberKnife Radiosurgery Complete Guide for Patients and Their Doctors.
Four page document outlining the following important questions and answers: How do I obtain treatment? Details of how the outpatient treatment is carried out and what will happen when you arrive at the clinic. Details of training seminar for doctors both at the clinic as well as here in London, England. Click the icon to begin your download. . .

Medilux Healthcare Limited - CyberKnife Radiosurgery - Detailed Travel Information for Patients, Family and Friends to The European CyberKnife in Munich, Germany.
Listing of airports and carriers throughout the UK along with details of rail connections as well as suitable accommodation in Paris, France, should you wish to break up your journey when travelling by rail. Click the icon to begin your download. . .

CyberKnife - Radiosurgery Details
(more information on CyberKnife® and on specific treatments). Check for the latest updates as these are issued and further treatment sections are added.

Acoustic Neuroma
Arteriovenous Malformations [AVM]
Brain Metastasis
Glioma
Hemangioblastomas
Lung Cancer
Meningiomas
Pancreatic Cancer
Pituitary Adenoma
Prostate Cancer
Spinal Tumour
Trigeminal Neuralgia

What is Radiosurgery and how is it different from radiotherapy?

Stereotactic radiosurgery (SRS) combines the principles of stereotaxy, or 3-D target localization, with multiple cross-fired beams from a high-energy radiation source to precisely irradiate an abnormal (oftentimes cancerous) lesion within a patient's body. This technique allows maximally aggressive dosing of the target, while normal surrounding tissue receives lower, non-injurious doses of radiation. The ideal objective is the ablation or destruction of the targeted area without damaging any normal tissue outside of the defined target area.
Stereotactic radiosurgery differs from conventional radiotherapy in several ways. The efficacy of radiotherapy depends primarily on the greater sensitivity of tumour cells to radiation relative to normal brain tissue. With all forms of standard radiotherapy, the spatial accuracy with which the treatment is focused on the tumour is a secondary concern; normal tissues are protected by administering the radiation dose over multiple sessions (fractions) daily for a period of a few to several weeks. In contrast, radiosurgery, by its very definition, requires much greater targeting accuracy. With SRS, normal tissues are protected by both selectively targeting only the abnormal lesion, and using cross-firing techniques to minimize the exposure of the adjacent anatomy. Since highly destructive doses of radiation are used, any normal structures (such as nerves or sensitive areas of the brain) within the targeted volume are subject to damage as well.
Typically, SRS is administered in one to five daily fractions over consecutive days. Nearly all SRS is given on an outpatient basis without the need for anaesthesia. Treatment is usually well tolerated, and only very rarely interferes with a patient's quality of life. Stereotactic radiosurgery has been used for more than 30 years to treat benign and malignant tumours, vascular malformations, and other disorders of the brain with minimal invasiveness. To date, more than 200,000 patients have been treated worldwide with radiosurgery. The success of SRS is based, to a large extent, on the use of a multidisciplinary approach, which requires close interaction between surgeons, radiation oncologists, medical oncologists, physicists, diagnostic radiologists, technicians, and nurses. This specialized team is responsible for the selection of appropriate patients for SRS, treatment delivery, and long-term follow-up.

What are the differences between the common radiosurgery technologies?

Several SRS systems are available for the treatment of patients. The most widely used SRS devices include: cobalt-sourced systems (Gamma Knife), modified linear accelerators, and the CyberKnife. All of these devices, if properly operated, are capable of delivering the desired radiation dose to a designated target. However, for certain clinical situations, there can be important differences between these devices, which for some patients may have a significant impact on clinical outcome.

Cobalt-Sourced Systems (Gamma Knife)
The first radiosurgical device was conceived and developed in the 1950s by Professor Lars Leksell at the Karolinska Institute in Stockholm, Sweden. His work culminated in the development of the Gamma Knife (Elekta Inc), which was used to treat patients beginning in 1968. This device is capable of precisely irradiating small intracranial [glossary term] (inside the skull) target with gamma ray photons. The treated lesion is targeted and the patient's head immobilized (held completely still) through the use of an external metal frame attached to the skull by four screws. A large helmet-shaped device with 201 separate, fixed "holes" or ports allows the radiation emitted by discrete (separate) radioactive cobalt-60 sources to enter the patient's head in small beams that converge on the designated target. The Gamma Knife is designed to treat intracranial targets only. Advantages of the Gamma Knife include:

1. Over 30 years of clinical use with a large number of studies published in the medical literature
2. Targeting precision within 2 mm
1. Multiple targets in the brain are easily treated during a single treatment session Disadvantages of the Gamma Knife include: The basic design limits use to the brain only
2. The procedure for radiation targeting requires the placement of a somewhat painful stereotactic head frame
3. It can be difficult to treat patients with lesions located in certain areas (e.g. the periphery) of the brain
4. It cannot be used for staged radiosurgery (delivering the radiation dose in more than one fraction or treatment session); staged radiosurgery can be particularly beneficial for larger tumours or lesions located near nerves and other sensitive structures

Modified Linear Accelerator Systems
An alternative to the Gamma Knife was developed in the mid 1980s and utilized the conventional linear accelerators (linac) that are commonplace in most large hospitals. By combining a series of small modifications to the radiation delivery mechanism of the linac with specialized planning software, it is possible to do many types of brain radiosurgery. There are both dedicated and non-dedicated linac-based radiosurgery devices. Dedicated linac systems are used solely for radiosurgery treatment. In contrast, non-dedicated systems are the daily workhorses for conventional radiation therapy departments which can also be temporarily modified to perform radiosurgery.
Compared to the latter multi-purpose linacs, dedicated systems tend to be more carefully calibrated for spatial accuracy and optimised for radiosurgical efficiency. Unlike the radioactive cobalt-based Gamma Knife, linac-based systems use X-ray beams generated from a linear accelerator. As a result, these devices do not require or generate any radioactive material. When treating brain tumours with linac radiosurgery, a metal head frame is attached to the patient's skull and used to precisely target the radiation beam. Common brand names for modified linacs include X-Knife (Radionics Inc). Advantages of Multi-Purpose Linac Radiosurgical Systems include:

1. More commonplace technology in hospitals

Disadvantages of Multi-Purpose Linac Radiosurgical Systems include:
1. Less accurate
2. Less efficient than dedicated systems, which results in longer treatment time
3. Frame-based targeting only works for brain lesions

Shaped Beam Systems
The recent development of IMRT or Intensity Modulated Radiation Therapy has added another dimension to multi-fraction radiation therapy. These linac-based technologies use computer-controlled "beam-shaping" to do a better job of conforming the radiation dose to the shape of the tumour or other lesion. This form of advanced radiation therapy can be utilized at virtually any location in the body.
IMRT technology enables a mechanical device (called a multi-leaf collimator) that is typically attached to most modern medical linear accelerators, to dynamically reshape the outlines and intensity of the radiation field during cancer treatment. When combined with sophisticated planning software, IMRT fits the dose of radiation to a target much better than conventional radiation therapy, and thereby minimizes the volume of surrounding normal tissue that is injured by treatment. While it appears that IMRT may produce fewer side effects than conventional radiation therapy, IMRT is not as spatially precise as radiosurgery. Because of this imprecision, a full course of IMRT treatment is typically administered over multiple treatment sessions (typically 20-30+). Common brand names include X-Knife (Radionics) and Novalis (Brain Lab). Advantages of Shaped-Beam systems include:

1. The capacity to treat most regions of the body with IMRT
2. When coupled to an invasive stereotactic frame, precision targeting for brain tumours that approaches, but does not equal, that of the Gamma Knife or CyberKnife.
3. The capacity to more accurately target extracranial (non-brain) tumours than standard radiation therapy
4. An ability to deliver fractionated intracranial or extracranial treatment

Disadvantages of the Shaped Beam systems include:
1. The need for an invasive head frame (similar to the Gamma Knife) to assure treatment accuracy when used for brain radiosurgery (single fraction)
2. Less treatment accuracy when multiple fractions are used to treat areas of the brain where the use of an invasive head frame is impractical
3. A significantly lesser degree of targeting accuracy when treating extracranial tumours compared to brain radiosurgery
4. Treatment accuracy is degraded further when the target moves during radiation delivery from either natural breathing or patient movement

CyberKnife System
The CyberKnife System is an SRS system utilizing contemporary technology that is designed to be the most accurate and flexible tool available for aggressive therapeutic irradiation. The CyberKnife was designed to address the limitations of frame-based SRS systems and expands the application of radiosurgery to sites outside of the head. It is the only system to incorporate a miniature linear accelerator mounted on a flexible, robotic arm.
An image-guidance system that can track target location during treatment also enables the CyberKnife to offer superior targeting accuracy without the need for the invasive head frame. While Gamma Knife and linac-based systems can perform radiosurgery in the brain, true radiosurgery for areas outside of the brain is difficult if not impossible to perform with these systems.

For more detailed information on the CyberKnife, see CyberKnife Overview.

Advantages of the CyberKnife include:

1. No invasive head frame or other rigid immobilization device is required
2. The ability to perform radiosurgery (1-5 fractions) on targets throughout the body, not just the brain
3. Precise targeting (within 1 mm) of selected lesions in the brain and body
4. A unique ability to provide real time monitoring of the treated target throughout treatment using an advanced image-guidance system
5. A unique ability to correct during treatment for limited target motion (e.g. due to small patient movements)
6. The capacity to easily perform staged radiosurgery

Disadvantages of the CyberKnife include:

1. The need for placement of very small markers (fiducials) via a needle for the treatment of targets outside of the head
2. Compared to other radiosurgical devices, treatment takes longer when multiple tumours are ablated during the same treatment session.
    Because the CyberKnife system is so accurate as well as versatile and painless, it is often the radiosurgical procedure of choice from a patient's perspective.

PRIVACY STATEMENT

Medilux Healthcare Limited is a specialised marketing company. We promote devices on the basis of the Manufacturers' representations as to quality and efficacy and where possible we provide additional information as to the conditions which may benefit from their use but we do not guarantee that they will be suitable or effective for all purchasers. We do not examine or diagnose patients or recommend treatments and where we promote medical services this is on an information-only basis. Patients contract directly with these providers and all clinical decisions are made by them alone.

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