Last Updated 10/17/02

Precision Radiation Techniques

Traditional External Beam Radiation therapy for cancer is very imprecise in its targeting - both tumor area and healthy tissue receive the same dose of radiation from a single beam. This limits the amount of radiation which can be delivered to a tumor, while simultaneously resulting in sometimes severe side effects due to the volume of healthy tissue radiated. Colon cancer patients typically do not have radiation except to a primary tumor located near the rectum (rectal cancer). Metastatic disease has historically NOT been treated with radiation due to lack of efficacy and side effects.

However, there is a new form of "precision" radiation therapy which uses multiple radiation beams all focused on the tumor, so that healthy tissue receives less radiation (i.e. the radiation in any one beam is low), the tumor is more precisely targeted, a much higher dose of radiation is delivered to the tumor than could be achieved by "conventional" radiation therapy, and the "usual" radiation side effects are GREATLY lessened. To picture this in your mind, imagine the analogy of a bicycle wheel where the spokes represent the radiation beams focused on a "tumor" at the axle. There are many variations of precision radiation having different names - go to www.google.com and try putting in the following search terms: Stereotactic Radiosurgery, Intensity Modulated Radiation Therapy, IMRT, Fractionated Radiosurgery, 3-D Conformal Radiotherapy, Respiratory Gating

The first type of Conformal Radiation to be developed was the Gamma Knife , and it has been used solely for brain tumors. The reason for this rather limited treatment is that the head is the most easily immobilized part of the body! Organs and structures elsewhere tend to move as the patient breathes, and this has slowed the development of precise radiation for extra-cranial applications. There have been several different methods developed to reduce patient movement thus increasing the precision of the radiation focus. For example, the Varian machines use a technique called Respiratory Gating by which the machine actually tracks the motion of the tumor as the patient breathes! Indiana University developed their own Stereotactic Radioablation system, using an "ordinary" linear accelerator along with custom milled lead "beam compensators" which adjust the intensity of 7 different radiation beams. Patient movement is restricted by the use of a "Body Frame" with compression device. The results of this therapy has been quite good, as shown in the following Presentation by Dr. Timmerman, one of the radiation oncologists who performes the procedure at IU. These slides/commentary show some interesting patient case histories you might want to take a look at. I have personally been treated with Stereotactic Radioablation at IU for a solitary liver met (around 1.5-2 cm). I experienced NO side effects at all from the treatment, and the met has since "disappeared" from scans! For a list of Bulletin Board posts about my background and further description of my experience with SR, return to the Main Page

Conformal Radiation may be used almost anywhere in the body except the intestines (may cause perforation or obstruction) - some common locations are lung, liver, prostate, spinal, and pelvic tumors. Good candidates for the procedure are those patients having "not too many", "not too large", visible on scan, well defined tumors. This type of radiation would NOT work for patients having "a lot of small mets" scattered over organ(s) or in the abdominal cavity (due to the fact that EACH TUMOR has to be individually targeted by the treatment). I have heard that some centers using precision radiation will treat up to 9 tumors (inclusion criteria for treatment will vary from center to center - for example, Indiana University will only treat a maximum of 4 tumors.

NOTE: I think that for liver tumors, the more commonly used Radiofrequency Ablation is probably preferable to radiation UNLESS the tumor is near a blood vessel and you have been told RFA will probably NOT work because of that. There seems to be a limit to the total amount of radiation you can receive from Conformal Radiation, so use sparingly and only when necessary!

For a "quick introduction" to Conformal Radiation, see the following links:

Simple Things on a Summer Day
Radiotherapy Targets Tumors
Revolutionary Treatment for Inoperable Lung Cancer
Steve Dunn - Body Stereotactic Radiosurgery
IMRT - A Patient Centered Guide
Varian IMRT
IMRT FAQ

Where to Go for Treatment - By Equipment Manufacturer

There are several primary manufacturers of CR equipment. One way to figure out where the nearest treatment facility is to you is to look at the list of treatment centers on these equipment manufacturer's websites.

Varian

Varian Homepage
Varian IMRT Page
List of Varian Treatment Centers

Cyberknife

Cyberknife Homepage
Cyberknife Stereotactic Radiosurgery
List of Cyberknife Treatment Centers

Peacock

Peacock Homepage
Peacock IMRT
List of Peacock Treatment Centers

Where to Go for Treatment - By Location

A partial list of cancer centers and other hospitals offering Conformal Radiation you might want to explore.

Staten Island University Hospital (the first hospital in the western hemisphere to perform pinpoint Body Radiosurgery)
St. Vincents (New York)
Buffalo Cancer Center (New York)
East Bay Radiation Oncology Center
Duke University (North Carolina)
Duke University - Stereotactic Radiosurgery
Valley Radiotherapy Associates
The James (Ohio State) Radiation Oncology
Michegan University Radiation Oncology Trials
Conformal Radiation Therapy for Patients with Intrahepatic Malignancies University of Michegan 1998
Kimmel Cancer Center
Mayo Clinic
Chicago Area Cancer Care
Cancer Treatment Centers of America (Oklahoma)
St. Luke's Hospital
Sarah Cannon Cancer Center
University of Iowa
Oakwood Cancer Center Radiation Oncology
IMRT- Beverly Hills Radiation Oncology
BC Cancer Agency
Willis Knight Cancer Center (Shreveport LA)

Combining Conformal Radiation with Hyperthermia

Hyperthermia is the application of heat therapy to the tumor area. It is not commonly used in the US, although there appears evidence that it has the potential to greatly enhance the efficacy of radiation and/or chemotherapy.

BSD Medical Corporation manufactures the most advanced hyperthermia equipment - they recently rolled out the BSD-2000/3D/MR machine, allowing a PRECISE application of heat in a manner somewhat analogous/similar to Conformal Radiation. You should carefully explore the links here for online papers and other information. BSD Corporation has also compiled a list of treatment sites - look for the ones capable of "deep hyperthermia", which is what one would need for most metastatic colon cancer tumors (e.g. pelvic). Another compilation of hyperthermia treatment centers is here

One of the primary academic institutions involved with hyperthermia research in the US is Duke University . One of the things that makes Duke somewhat unique is that it has the capability to use BOTH Conformal Radiation AND hyperthermia in a complementary fashion. Heat may be able to enhance the effectiveness of Radiotherapy. They sometimes run clinical trials of hyperthermia therapy (although currently 10/18/02 there do not seem to be any). I would suggest contacting Duke to find out more about their hyperthermia programs and treatment options. Otherwise, coordinating therapy between cancer centers capable of treating with Conformal Radiation and those capable of treating with "deep hyperthermia" might be a valuable combination therapy to consider.

More Information - Search Bulletin Board Posts

Experimental and Unconventional Search on Stereotactic
Colon Cancer Support Search on Stereotactic

References

Overview

2/3/02 The Group Room - Conformal Radiation Audio Files at this site
10/9/01 Stereotactic Radiosurgery Overview Good overall summary of the different types of machines - but the uses of these machines are beyond what is indicated here (brain tumors).
11/04/01 3D Conformal Radiation at St. vincents (NY)
5/5/02 Respiratory Gating at St. Vincents (NY)
11/02/01 Radiosurgery Questions Johns Hopkins
11/02/01 Three-Dimensional Conformal Radiation Therapy (3DCRT) for Prostate Cancer
10/9/01 Body Stereotactic Radiosurgery Steve Dunn
10/9/01 Fractionated radiosurgery for brain metastases in 43 patients with breast carcinoma Breast Cancer Res Treat 2001 Jan;65(2):145-54 Lederman G, Wronski M, Fine M. Considering our 7.5 months overall survival including patients with multiple metastases, and patients with progressive brain metastases despite extensive standard therapy and often systemic disease, these results suggest that radiosurgery could benefit breast cancer patients with brain metastases and extend life.
10/9/01 Radiation Therapy May Improve Prostate Cancer 1-Dec-98 Description: Prostate cancer patients are benefitting from a new radiation therapy technique that decreases side effects and may lead to higher cure rates, according to research presented at the 84th annual meeting of the Radiological Society of North America (RSNA). 12/1/98
10/9/01 RTPortal.com IMRT Links
10/9/01 OncoLink FAQ: "The Difference Between External Beam Radiation, Stereotactic Radiotherapy, And Stereotactic Radiosurgery" U Penn Oncolink Question: Can you tell me what the difference is between external beam radiation, stereotactic radiotherapy, and stereotactic radiosurgery?
10/9/01 Current status and optimal use of radiosurgery. Oncology (Huntingt) 2001 Feb;15(2):209-16; discussion 219-21 Chang SD, Adler JR Jr.
10/9/01 Fractionated radiosurgery for brain metastases in 43 patients with breast carcinoma Breast Cancer Res Treat 2001 Jan;65(2):145-54 Lederman G, Wronski M, Fine M. Considering our 7.5 months overall survival including patients with multiple metastases, and patients with progressive brain metastases despite extensive standard therapy and often systemic disease, these results suggest that radiosurgery could benefit breast cancer patients with brain metastases and extend life.
10/9/01 Radiation Oncology U Penn
10/15/01 Radiation Therapy Oncology Group Clinical Trials (GI)
10/15/01 New Advance In Radiation Therapy May Improve Cancer Treatment Sciencedaily Date: Posted 7/26/2000
11/02/01 Johns Hopkins Brain Tumor Radiosurgery Good explanation of Stereotactic Radiosurgery, applicable to other tumors as well
11/02/01 Radiosurgery Questions Johns Hopkins
10/19/01 TOMOTHERAPY: RETHINKING THE PROCESSES OF RADIOTHERAPY
9/18/01 Intensity Modulated Radiation Therapy from CTCA
9/18/01 Intensity Modulated Radiation Therapy: An Introduction for Patients and Clinicians U Penn Oncolink
11/18/01 Intensity Modulated Radiation Therapy (IMRT): A Patient-Centered Guide Affiliations: University of Pennsylvania Cancer Center Posted Date: June 18, 2000
11/02/01 Johns Hopkins Brain Tumor Radiosurgery Good explanation of Stereotactic Radiosurgery, applicable to other tumors as well
9/18/01 A Better Fit: Tailored Radiation Therapy
9/18/01 Taking better aim at cancer tumors: New radiation method eases up on good tissue Gishizky's treatment, which began last month, involves seven beam angles and more than 1,000 shapes of radiation doses, each slightly different dependingon the volume of tissue being targeted or avoided. He will undergo 40-minutesessions every day for five weeks at an estimated cost of $60,000.
9/18/01 Cancer Death Decline Reported by National Cancer Institute; Medical Technology Plays a Key Role Vol. 2, Issue 17 June 11, 2001 IMRT employs sophisticated computer technology to deliver a precisely sculpted, targeted radiation beam directly to the cancer tumor. It has been called the greatest advance in radiation oncology since the introduction of the linear accelerator in 1960. Recent clinical study results bear this out. They found that IMRT improves local tumor control by 71% and reduces complications related to surrounding healthy tissue from 10% to 2%.
11/06/01 American Society for Therapeutic Radiology and Oncology
11/11/01 Death Caused by Whole Brain Radiation and Cocktail Chemotherapy I am a spouse who saw his soul-mate being slowly tortured to death because of what he did not know before but who knows now, the insidious side effects they incurred on my wife with negligent practice. I never realized a patient or patient's loved one had to be just as knowledgeable or even more knowledgeable than the oncologists that treat these patients. Not having the knowledge beforehand resulted in the death of my loved one. Her death was chemo-radiation necrosis, a slow, arduous, neurological death. It is not preferable to a cancerous death.
5/5/02 List of Varian Treatment Centers
5/5/02 Revolutionary Treatment for Inoperable Lung Cancer Sciencedaily 2/7/2000
5/5/02 Radiotherapy Targets Tumors Stereotactic body radiotherapy is being tested at the Indiana University School of Medicine on patients with early-stage lung cancer. The technique combines a unique radiation treatment with 3-D imaging and a new body frame.
5/5/02 Indiana University Radiation Oncology 3D Conformal Treatment Planning, Stereotactic Body Frame
5/5/02 Slides and Transcripts - STEREOTAXIC RADIATION THERAPY Robert Timmerman, MD
5/5/02 Response Data for Stereotactic Radioablation
5/5/02 Simple Things on a Summer Day One patient's experience with Stereotactic Radioablation for lung tumor

Personal Stories
11/06/01 OncoLink Essay: My Journey Author: Marvin Blumberg Posted Date: November 30, 1997 Story of Prostate cancer patient using 3-D Conformal Radiation
1/20/02 Conformal Radiation Patient Stories
1/20/02 Stereotactic radioablation for lung tumors
1/20/02 Cliff's Story I
1/20/02 Cliff's Story II
5/5/02 Simple Things on a Summer Day One patient's experience with Stereotactic Radioablation for lung tumor

Peacock Machines (NOSMOS)
10/15/01 Intensity Modulated Radiation Therapy (IMRT) IMRT explanation at Nomos Corporation
11/06/01 List of NOSMOS Peacock system sites
11/02/01 The University of California, Irvine experience with tomotherapy using the Peacock system Med Dosim 2001 Spring;26(1):17-27
11/02/01 NOMOS Peacock IMRT utilizing the Beak post collimation device. Med Dosim 2001 Spring;26(1):37-45

Varian Machines
9/18/01 Varian SmartBeam(tm) IMRT SmartBeam IMRT can be used to treat tumors that might have been considered untreatable in the past due to close proximity of vital organs and structures. Treating such tumors requires tremendous accuracy. For example, in the case of head and neck tumors, IMRT allows radiation to be delivered in a way that minimizes exposure of the spinal cord, optic nerve, salivary glands or other important structures. In the case of prostate cancer, exposure of the nearby bladder or rectum can be minimized. IMRT is being used to treat tumors in the brain, breast, head and neck, liver, lung, nasopharynx, pancreas, prostate, and uterus.
11/06/01 Listing of Locations using Varian system (IMRT)

CyberKnife (Accuray)
10/9/01 Cyberknife Stereotactic Radiosurgery (Accuray)
7/7/01 Radiosurgery device shows promise in treating nonresectable lung cancers A radiosurgery instrument, known as the CyberKnife, may offer an additional treatment option for patients with nonresectable forms of lung cancer. Dr. Crownover said that "anyone who has non-small cell lung cancer or metastatic disease is potentially eligible for the study." However, "the tumor has to be less than 5 cm and the patient must not have had prior radiation to the area," he noted. In addition, "if the patient appears to be a surgical candidate then that is the route they usually go," he said.
10/2/01 FDA clears Accuray's CyberKnife for radiosurgery use throughout body Tuesday, Oct 2 2001 The US Food and Drug Administration has granted a broadened indication to Accuray Inc.'s CyberKnife with Dynamic Tracking Software (DTS), making it possible for surgeons to use the device for radiosurgery ablation anywhere in the body, the firm said on Monday.
9/18/01 Non-invasive CyberKnife technology successfully tested in lung tumour therapy with image-guided radio-surgery Sunnyvale 27 June 2001Both at the Cleveland Clinic Foundation and Stanford University Medical Center, the first twenty-five lung tumour patients have successfully been treated using non-invasive CyberKnife ablation technology Dr. Richard Crownover, M.D., Ph.D., Radiation Oncologist at the Cleveland Clinic Foundation and Principal Investigator of the CCF lung protocol, noted: "In the past, lung movement hampered conventional radiation delivery. New modifications enable the CyberKnife to track tumour motion so that a higher dose of radiation can be administered to the patient with minimal toxicity to surrounding tissue. Delivering higher doses of radiation increases the chance to cure small primary lung tumours." As Dr. Crownover continued: "For the palliation of metastatic disease, the decreased morbidity of radio-surgery compared with conventional radiation allows us to shift the time of intervention forward, before symptoms interfere with the quality of life."
9/18/01 First CyberKnife radio-surgery systems delivered to University Hospitals of Georgetown and San Francisco Sunnyvale 10 July 2001 2001Accuray Incorporated, specialised in advanced image-guided radio-surgery, has received the first two orders for the newest CyberKnife radio-surgery system, for Georgetown University Hospital and University of California, San Francisco (UCSF) Medical Center. The CyberKnife, which was publicly unveiled for the first time at the Annual Meeting of the American Association of Neurological Surgeons this past April in Toronto, integrates proprietary image-guidance technology with robotic delivery to target and irradiate tumours with unprecedented accuracy and patient comfort
9/18/01 Advanced Stereotactic Radiosurgery/Radiotherapy a Reality Today
9/18/01 Georgetown University Hospital and UCSF Medical Center Are First to Get Newest Generation CyberKnife(R) Image-Guided Radiosurgery System The unique CyberKnife system technology was developed in cooperation with Stanford University and was cleared by the Food and Drug Administration (FDA) in 1999 for head, neck, and spine use down to the cervico-thoracic junction. The spine (below the cervico-thoracic junction), lung, prostate, and pancreas are currently treated under FDA Investigational Device Exemption (IDE) protocols. FDA 510(k) pre-market notification for treatment of lesions anywhere in the body where radiation is indicated is pending. Currently the CyberKnife is cleared only for head, neck, and cervical spine tumor treatments. These cases represent only a small portion of new tumors that are diagnosed each year
9/18/01 Radiation Oncology at the Cleveland Clinic
11/02/01 Posted by : Leona on 2001/10/12 21:09:49 BB Post - Experience with Cleveland Clinic

Proton Therapy

This appears to be primarily European but they are starting to do this a little in the US
11/06/01 National Association for Proton Therapy
11/06/01 Loma Linda University Proton Treatment Center
11/06/01 Proton Beam Radiosurgery Massachusetts General Hospital Harvard Medical School Seems to have mostly neurologic and prostate applications but maybe more (?)
10/9/01 Advantage of protons compared to IMRT in the treatment of medulloblastoma Posting Date: October 24, 2000

Gamma Knife

The Gamma Knife appears to be the oldest form of radiosurgery and in the past has been used primarily For neurosurgery. Some articles are starting to suggest a crossover to use for other tumor types, But I do not believe this form of radiation therapy is as good as the Linear Accelerator machines Such as the Cyberknife, Varian, etc.
10/9/01 International Radiosurgery Support Association Treatment Centers, Patient Stories. Seems mainly focused on GAMMA KNIFE.
9/18/01 Gamma Knife Within a few years, Duma says the Gamma Knife will be used to treat breast, liver and colon cancer, including tumors in other parts of the body that can't be removed without surgery, said Gutierrez
9/18/01 The Gamma Knife for Noninvasive Brain Surgery Not really a knife, the Gamma Knife is a device for delivering high-dose radiation that is shaped to the exact parameters of a targeted lesion. Developed and in use in Sweden for about 20 years, it has only recently come to the United States. Froedtert Hospital, which is affiliated with the Medical College of Wisconsin, recently acquired a Gamma Knife and is beginning to treat patients with benign brain tumors, brain metastases from other cancer sites, or abnormal blood vessels which were "inoperable" because the tumors are too deep inside the brain or too close to vital structures.
9/18/01 Gamma Knife The Regional Cancer Center at JFK Medical Center Using leading-edge technology in conjunction with a team of professionals specially trained in cancer diagnosis and treatment, the Regional Cancer Center at JFK Medical Center is able to offer its patients cost-effective programs and the most sophisticated treatments for head and neck cancer, breast cancer, prostate cancer, liver cancer, lung cancer, skin cancer, colon cancer and gastrointestinal cancer.
10/9/01 Elektra IMRT and Gamma Knife
9/18/01 Medical treatments STEREOTACTIC BODY RADIOSURGERY Stereotactic Body Radiosurgery at the Department of Oncology, Radiumhemmet, Karolinska Hospital in Stockholm Patients with up to 4 tumors in lungs or liver may be treated provided that the tumors are relatively small. Other tumors can also be treated if they are not adjacent to the stomach, or intestines or are growing into the skin

Miscellaneous
11/02/01 Cost Effectiveness of 3D Conformal radiotherapy ASCO 1999
10/19/01 Books on Radiotherapy
10/19/01 PREDICTING RISK OF LUNG DAMAGE FROM RADIATION SHOULD LEAD TO IMPROVED TREATMENT Duke Universtiy Oct 2000
10/9/01 Molecular Radiosensitizers Target Proliferation and Apoptosis Pathways in Tumor Cells MD Anderson Dec 2000
10/9/01 Stereotactic Unit Expands Treatment Options for Patients with Brain Tumors Oct 1999
9/18/01 A Protocol for Intensity Modulated Radiation Therapy
11/06/01 Radionics - X-Knife The X-knife is one of the most common machines but DOES NOT appear to be as good as the Varian or Cyberknife as it does NOT do "respiratory gating" (where machine tracks motion of tumor with breathing).

References
10/19/01 Reproducibility of Internal Target Positions for Breath-held Conformal External-beam Radiotherapy (FULL TEXT Paper) University of Rochester Cancer Center Recent advances in Stereotactic Radiosurgery/Conformal Radiotherapy have made it possible to deliver precise radiation therapy to small lesions while preserving function to surrounding structures. Unfortunately, the application of 3D conformal radiotherapy to mobile tumors in the lung and liver is geared toward slowing the progression of disease rather than obtaining a cure. Here, the traditional therapeutic approach is to measure the range over which the tumor moves during the respiratory cycle and to then irradiate a volume that encloses the entire tumor over its entire motion range. The oncologist's dilemma is that prescribing a lethal radiation dose to the area would not only kill the tumor but also damage a sufficiently large volume of healthy tissue to cause significant clinical repercussions, including death. Our ultimate goal is to hit, with a very focused and high-dose radiation beam, moving targets within the body with such high precision that we will cure these cancer patients of their disease while sparing the surrounding healthy tissue.
11/06/01 ASTRO Meeting Abstracts
10/9/01 Current status and optimal use of radiosurgery. Oncology (Huntingt) 2001 Feb;15(2):209-16; discussion 219-21 Chang SD, Adler JR Jr.
11/02/01 Comparison of intensity modulated radiation therapy (IMRT) treatment techniques for nasopharyngeal carcinoma. Int J Cancer 2001 Apr 20;96(2):126-31 Cheng JC, Chao KS, Low D.
1/20/02 Tissue Tolerance in Radiation Therapy Paper
2/3/02 The Physical Aspects of Three-Dimensional Conformal Radiation Therapy Paper

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