Robotics

CyberKnife

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Surgical system for robotic surgery

DESCRIPTION

CyberKnife is an advanced high-tech robotic system. Due to the precision of the treatment it ensures, it allows for the increasing implementation of clinical protocols with a reduced number of treatment sessions.

With CyberKnife, patients have the opportunity to undergo a non-invasive, effective treatment with minimal impact on their quality of life.

Lucia Graziosi, sales manager

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System Operation

The robotic arm moves the linear accelerator in space around the patient. It generates a high number of radiation beams with different orientations in a non-coplanar 3D geometry. The treatment occurs along a predefined path in space and is divided into points, called “nodes,” where the robot can stop to allow the Linac to deliver the beam.

The image-guided system enables monitoring of the target position throughout the entire treatment and corrects the beam direction for any detected displacement, whether continuous over time or not. The imaging system consists of two X-ray tubes installed on the ceiling and two corresponding high-resolution detectors placed on the floor. This configuration allows for continuous monitoring of the patient’s and target’s position during the entire treatment, guiding the robot to direct the treatment beams so they hit the target with extreme accuracy.

The Collimation System

The Collimation System

The CyberKnife system is equipped with three different beam collimation systems. The collimators allow for the adjustment of the shape and size of the treatment beam.

  • Fixed Collimators
    These have a circular cross-section to treat localized lesions, including very small ones.

  • Variable Diameter Iris Collimator
    This replicates the twelve openings of the fixed collimators. It allows the use of different fields during treatment without the need to change the collimator.

  • Multileaf Collimator
    For the treatment of larger lesions, reducing the treatment time.

Radiosurgery Treatment with CyberKnife

The CyberKnife system is particularly suitable for targets that move with respiration. The treatment is delivered during the patient’s normal breathing cycle, without the need for the patient to hold their breath (as required with the breath-holding technique).
With CyberKnife, the beam continuously follows the target’s movement in real-time (not just when the target is in a certain area, as with the gating technique) and instantly adapts to variations in the respiratory pattern (this is known as dynamic tracking).

Before the treatment begins, a dynamic correlation model is created between the external movement of the body surface and the internal movement of the target. The internal target movement is detected by the imaging system using one of the tracking algorithms (fiducial tracking or XsightLung tracking), while the external movement is detected with optical LEDs applied externally to the patient’s chest. These LEDs are identified by an infrared camera, which tracks their position in real time.

The model is continuously updated throughout the treatment to ensure that the beam delivery is based on the patient’s current respiratory pattern.

Distinctive Features of the Technology

CyberKnife is a radiotherapy system equipped with a robot that moves the linear accelerator with six degrees of freedom around the patient.

Thanks to its imaging system and robot, it allows for tracking the movements of the target throughout the entire treatment, resulting in sub-millimeter accuracy. This enables the delivery of high doses to the target while sparing healthy tissues and reducing the number of treatment sessions. The significant benefit for the patient is the reduction in hospital visits for therapy, along with the associated cost savings for both the patient and the National Health Service (NHS).

The Synchrony respiratory tracking system is the only one that allows for continuous tracking of the target and delivery of the beams while the patient breathes freely (no breath holding) and without interrupting beam delivery (no gating) throughout the entire treatment, maintaining sub-millimeter accuracy (24, 25, 26, 27, 28).

Clinical benefits

  • It offers more effective treatments in terms of dose distribution and gradient while safeguarding organs at risk.

  • Thanks to its sub-millimeter precision, it allows for the delivery of high doses to the target while preserving healthy tissues.

Benefits for the patient

  • It allows for hypofractionated treatments (from 1 to 5 treatment sessions), providing the significant advantage of reducing hospital visits for therapy, with consequent cost benefits for both the patient and the National Health Service.

  • The patient can continue to maintain their daily routines, with minimal impact on their social life, particularly because the therapy is completed within a maximum of one week.

  • Thanks to the image-guided system, invasive patient immobilization systems are not necessary.

Clinical specialisms and areas of application

In the intracranial field, experience is well established in the treatment of brain metastases (2, 3, 4, 5, 6) and malignant tumors, as well as benign tumors such as meningiomas (7, 8, 9, 10, 11), acoustic neuromas (12, 13, 14), pituitary adenomas (15), functional disorders like trigeminal neuralgia (16, 17), and arteriovenous malformations (18).
The CyberKnife treatment is also applicable in the treatment of oropharyngeal tumors (19, 20), re-treatment of head and neck tumors (21), bone metastases, and benign and malignant spinal lesions (22, 23).

Excellent results have been achieved for central lung tumors near sensitive structures (29) and near the chest wall (30), as well as for inoperable peripheral lung tumors (31, 32, 33). Non-small cell primary lung tumors (34, 37, 38) and lung metastases (35, 38) are also treated.

Stereotactic radiotherapy with CyberKnife is chosen as an alternative to surgery or when surgery is not feasible; additionally, CyberKnife is used to treat recurrences of adenocarcinomas and squamous cell carcinomas previously treated with conventional radiotherapy.

The CyberKnife treatment is effective for low-risk and intermediate-risk prostate tumors (39, 40, 41), as well as for recurrences of localized prostate cancer previously irradiated with conventional radiotherapy (42, 43). Primary liver tumors and liver metastases (44, 45, 46, 47, 48, 49, 50, 51, 52, 53) are treated, as well as malignant pancreatic metastases and pancreatic tumors near the stomach and duodenum (54, 55, 56).

Regarding breast cancer, the protocols for Stereotactic Partial Breast Irradiation and Accelerated Partial Breast Irradiation (57, 58, 59, 60) are increasingly being applied for post-surgical radiation treatment. Additionally, there are initial studies on adjuvant treatment with CyberKnife in a single fraction before surgical intervention (61).

During the ESTRO 2021 Congress held in Madrid, Dr. Alison Tree (Consultant Clinical Oncologist at the Royal Marsden NHS Foundation Trust in London) presented the latest results of the PACE-B clinical trial (Prostate Advances in Comparative Evidence). Comparing various stereotactic radiotherapy techniques with hypofractionated treatments for prostate cancer, it was observed that CyberKnife is superior to other techniques in reducing the incidence of late Grade 2 toxicity and bladder toxicity.

VOLO™ Optimization Software

VOLO™ uses GPU technology to optimize the treatment plan, allowing the creation of a treatment plan in just a few seconds (reducing the treatment planning time by 90%). Thanks to more efficient plan optimization, the treatment time has been reduced by 50%.

PreciseRTX® Retreatment Option

The planning system allows for the import of previously delivered treatment plans from any linear accelerator; the contours and dose distributions of the old plan are deformed onto the new CT scan, enabling the summation of the old plan with the new plan.

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#andratuttobene con… la tecnologia CyberKnife

Intervista al Prof. Stefano Maria Magrini, Direttore della U.O. di Radioterapia degli Spedali Civili di Brescia

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