Srs cleveland clinic

She is very committed to this patient population and has been a long-standing advocate for their health and well-being. Ferrando sees patients and operates at the Main Campus. She also sees transgender patients at the Lakewood Family Health Center. She performs the majority of her procedures using minimally invasive techniques including laparoscopy, robotics, and vaginal surgery.

A summary of our spinal metastasis radiosurgery, including the equipment used, the treatment protocol and doses prescribed, localization, immobilization, image-guided radiation therapy IGRT methods, and quality-assurance QA procedure is presented.

The linear accelerator linac used at Cleveland Clinic is the Novalis Brainlab, Feldkirchen, Germany , a recent technological innovation in radiation therapy. The system integrates high-precision dose delivery and precise tumor localization, making it suitable for dose escalation to achieve higher control rates with fewer side effects. It uses the intensity-modulated radiosurgery IMRS mode to deliver high-precision conformal doses to irregularly-shaped tumors while sparing adjacent organs at risk.

This is achieved by dynamically modulating the intensity of the beams with a computer-controlled accelerator equipped with a fine mMLC. Image-guided targeting is ensured by high-resolution x-ray imaging ExacTrac Positioning System, Brainlab. Internal structures or implanted markers are imaged right before treatment using 2 x-ray tubes housed in the linac floor and two amorphous silicon flat panel detectors mounted in the ceiling.

Accurate target immobilization and localization and precise delivery of radiation are of utmost importance. Because high doses are given, often in a single fraction, errors may result in irreparable damage.

For spine lesions, the intra-fraction motion is due mostly to discomfort or pain for lying on a rigid surface for a long period of time.

Consequently, a robust immobilization device is a must. Historically, before the advent of IGRT, an invasive solution was proposed to immobilize the spine by skeletal fixation above and below the region of interest. At Cleveland Clinic, 2 types of custom-fitted immobilization devices are used, depending on the location of the lesion. For an average height patient, with a lesion between C1 and T5, we use the 5-point Efficast system Orfit Industries, Antwerp, Belgium , a thermoplastic head to shoulder mask illustrated in Figure 1.

The device is represented in Figure 2. The cutoff vertebra body T5 can be moved superior or inferior depending on the height of the patient. For example, we could use the five-point Efficast system up T4 for a tall person, and we may extend it to T6 for a short patient. Plain x-ray may be used to identify metastatic lesions and evaluate spinal stability, 7,11 but x-rays are insensitive in early stages of diagnosis. After the immobilization is constructed, all spine patients are scanned using 1.

To make counting the vertebral levels easier when the lesion is superior to T10, we scan from C1 to 2 vertebral bodies inferior to the lesion Figure 3. When the lesion is inferior to T10, we scan from 2 vertebral bodies superior to the lesion down to the sacrum Figure 4.

The scans are performed on a flat couch without immobilization. The imaging technologists strive to position the patient as close as possible to the treatment position.

In some cases, due to the presence of implanted hardware that makes MRI not very useful, the patient is sent for CT angiogram CTA for better visualization of the spinal cord.

The fusion is perfected around the region of interest. Occasionally, some rotation may occur outside the region of interest, but it may be ignored Figure 5. The cord or the cauda equina is delineated based on the high-definition MRI. In treating spinal metastasis with SBRT, our fractionation scheme is to deliver 16 Gy to the lesion in one fraction. We use IMRT techniques and 7 to 9 beams to generate the treatment plan. In general, we try to avoid anterior beams.

Usually, we use 7 posterior coplanar beams. The gantry angles would be: , , ,, , , and degrees. The beam arrangement might be different, depending on the shape of the tumor. Sometimes we obtain a better plan using mostly posterior coplanar beams with gantry angles: , , , , ,, and 60; or 9equidistant, coplanar beams with gantry angles: 0, 40, 80, , , , , , Also, the beam arrangement may vary to accommodate a particular condition of the case.

The median age at treatment was 59 years, the median Karnofsky performance status was 80, and the median follow-up was 5. The median dose was 15 Gy range, 9. The median survival was 5. Of the 33 patient with post-treatment imaging available, a complete radiographic response was achieved in 2 4.