Philip,
In response to some of your posted comments:
You seem to have a personal vendetta against Dr Lederman. I would not dispute your right to hold those views and make them known. All doctors have their successes and failures. Our purpose is to inform patients of the good and the bad. Ex-Lederman patients I have met generally confirm his published results. You'll find the latest very detailed information from this doctor on our site (see the link on the radiation page to his presentation in Paris in Jan. 2008).And you seem to hold him up as the source of "radiosurgery gospel" which probably would not be a position supported by a large number of his peers today. In terms of a personal vendetta, I think that is a somewhat presumptuous conclusion from someone who has been on this board less than a week. I posted an article in response to a post from Katherine explaining why he was seen as controversial. Other than that I responded to Kate's point about the difference between reckless and pioneer and why some of his recorded behavior and treatment approaches could be construed as the former. A "personal vendetta" suggests I make it a point to actively bad mouth the guy which I take offense to, but I have 500 plus posts on this board over 7 years and your welcome to read them to see where I have even raised his name prior to this week. Do I really care about the guy one way or the other? nope. Do I think there are other clinicians that are of greater scientific credibility? Yep. Would I recommend him to others given the level of controversy and others who are proven to be at the top of the field without the baggage? Nope. Fair enough?
Everyone is biased so to insure impartiality we got together 4 separate patients with different backgrounds.More viewpoints is better and a good approach, but I'm not sure 4 "insures" no bias especially when there can be a wide gap in the overall and treatment knowledge base. Some of the feedback you've already received from here would seem to confirm a different impression , but I'm glad you are open to the comments with an intent to improve the content and value to patients who visit it, which I truly believe is your goal.
That's a good question. The clearest study I know of swelling after radiation (GK in this case) is given in a Japanese report at http://www.ajnr.org/cgi/reprint/21/8/1540.pdf. Look at the graphs on page 3; they tell the story at a glance. I don't know of any similarly detailed studies for CK or FSR but others may point some out.
I would think swelling depends on many factors such as individual variations, targeting expertise, dosage, etc. So a general statement that GK is better or worse in this respect compared to any other radiation protocol is probably meaningless. I would tend to agree with your last sentence to JB, but in terms of referencing the japanese study I think you also to keep in context that they were also comparing a wide range of dosage protocols ranging from essentially 10-20 GY. The standard 1 dose protocol today for either GK or Ck is typically 12 GY so to do a comparison, only the 10-12 GY patients should be looked at on those graphs which I suspect will across the board have lower enlargement results. Clearly GY doses on the high end would have a much higher incidence of swelling, so to draw a generalized conclusion of swelling from a sample inclusive of the whole range is flawed logic in my view.
Your "flat wrong" comment seems a bit exaggerated. The thinking behind the sentence you object to is explained in my response to Steve above. If you think it's wrong pray tell why. No more so than
""When the AN is between 20mm and 30mm ...with radiation GK is suitable at the lower end of this size range, but FSR is usually more suitable for the upper size limit.", although, in fairness I can't see where Steve found that quote on the AN world web site. That sounds like a web site opinion as opposed to a scientific study conclusion to me. Yes , it is true that preliminary studies show fractionating treatment increases hearing preservation about 10-15% from one dose in CK vs. GK. The studies on the 25-30 dose protocols show no better results than the 3-5 and marginally more complications. However, in facial nerve preservation and tumor control there does not seem to be a significant difference regardless of one dose or fractionation. I also think the web site comments regarding machine accuracy essentially being unimportant and not very different is errant. I think I'll post that over on the CPSG Doctors board for some thoughts
You asked for studies relative to one dose outcomes and FSR , especially in the 2-3 cm range
First, here is a link that you should put on your web site and I think ANA should as well. It is from the NIH and US library of Medicine data base. This board has already had a discussion about "scholarly and peer reviewed studies" and I think you would have a hard time finding ones in here that wouldn't qualify. I stopped looking at about 80 articles and the first two on this link should be from Stanford on CK. I'm sure you can find a number of worthwhile ones to add to your web site. Have a party
http://www.ncbi.nlm.nih.gov/sites/entrez?Db=pubmed&DbFrom=pubmed&Cmd=Link&LinkName=pubmed_pubmed&LinkReadableName=Related%20Articles&IdsFromResult=15918941&ordinalpos=1&itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_DiscoveryPanel.Pubmed_Discovery_RA&log$=relatedarticles&dbfrom=pubmed
I'll also cut and paste several for you that I think would challenge that there is a significant difference in the one dose with a highly accurate radiosurgery machine ( GK / CK) vs. extended FSR outside of hearing based on tumor size. It is hard to find anything that is so segmented to defend the point either way, but that would be my point that the statement is too general and not substantiated
Best
Mark
Single-fraction vs. fractionated linac-based stereotactic radiosurgery for vestibular schwannoma: a single-institution study.
Meijer OW, Vandertop WP, Baayen JC, Slotman BJ.
Department of Radiation Oncology, VU University Medical Center, Amsterdam, The Netherlands. owm.meijer@vumc.nl
PURPOSE: In this single-institution trial, we investigated whether fractionated stereotactic radiation therapy is superior to single-fraction linac-based radiosurgery with respect to treatment-related toxicity and local control in patients with vestibular schwannoma. METHODS AND MATERIALS: All 129 vestibular schwannoma patients treated between 1992 and June 2000 at our linac-based radiosurgery facility were analyzed with respect to treatment schedule. Dentate patients were prospectively selected for a fractionated schedule of 5 x 4 Gy and later on 5 x 5 Gy at the 80% isodose in 1 week with a relocatable stereotactic frame. Edentate patients were prospectively selected for a nonfractionated treatment of 1 x 10 Gy and later on 1 x 12.5 Gy at 80% isodose with an invasive stereotactic frame. Both MRI and CT scans were made in all 129 patients within 1 week before treatment. All patients were followed yearly with MRI and physical examination. RESULTS: A fractionated schedule was given to 80 patients and a single fraction to 49 patients. Mean follow-up time was 33 months (range: 12-107 months).
There was no statistically significant difference between the single-fraction group and the fractionated group with respect to mean tumor diameter (2.6 vs. 2.5 cm) or mean follow-up time (both 33 months). Only mean age (63 years vs. 49 years) was statistically significantly different (p = 0.001). Outcome differences between the single-fraction treatment group and the fractionated treatment group with respect to 5-year local control probability (100% vs. 94%), 5-year facial nerve preservation probability (93% vs. 97%), and 5-year hearing preservation probability (75% vs. 61%) were not statistically significant. The difference in 5-year trigeminal nerve preservation (92% vs. 98%) reached statistical significance (p = 0.048).
CONCLUSION: Linac-based single-fraction radiosurgery seems to be as good as linac-based fractionated stereotactic radiation therapy in vestibular schwannoma patients, except for a small difference in trigeminal nerve preservation rate in favor of a fractionated schedule.[Neuropathy in nearby cranial nerves after acoustic schwannoma gamma knife radiosurgery, a follow-up study]
[Article in Chinese]
Qi S, Yu X, Li S, Zhou D, Liu Z.
Department of Neurosurgery, General Navy Hospital, Beijing 100037, China.
OBJECTIVE: To investigate the risks of facial, trigeminal and acoustic neuropathies after acoustic schwannoma gamma knife radiosurgery. METHODS: The clinical data of forty-three patients with 46 masses of acoustic schwannoma who underwent gamma knife radiosurgery with the dose of 12 approximately 15 Gy to the tumor margin between January 1997 and October 2000 and were followed up for 6 approximately 24 months (on average 16.9 months) were studied.
The tumor diameter was 10 approximately 20 mm in 12 cases, 21 approximately 30 mm in 23 cases, >/= 31 mm in 11 cases, with the average value of 28 mm. RESULTS: The general tumor control rate was 91.3%. The useful hearing preservation rate was 100% immediately after radiosurgery, 87% 6 months later and 78% 2 years later. The hearing preservation rate was high for small tumors. The facial and trigeminal neuropathies began to appear after 6 months. The incidence rates of facial neuropathy was 15.3%, 7.6%, and 3.8% 6 months, 1 year and 2 years after radiosurgery respectively. The incidence rates of trigeminal neuropathy was 11.4%, 3.8%, and 3.8% respectively 6 months, 1 year, and 2 years after radiosurgery.
The incidence of neuropathy was 3.8% for tumors with a diameter < 30 mm for both facial and trigeminal nerves. The hearing in 2 out of 15 cases with dysaudia began to improve 6 months after radiosurgery. The incidence of neuropathy for tumors with the diameter > 30 mm was 3.8% for both nerves 2 years after raadiosurgery. The preservation rate of useful hearing for tumors with the diameter < 20 mm was 100% after radiosurgery. CONCLUSION: Stereotactic radiosurgery using gamma knife with a dose of 12 approximately 15 Gy to the tumor margin succeeds in controlling acoustic schwannoma and preserving useful hearing. The incidence of facial and trigeminal neuropathies are low. The neuropathy caused by gamma knife radiosurgery is sub-lethal and can be recovered gradually.CK with 3 fractions
CyberKnife radiosurgery for vestibular schwannoma.
Ishihara H, Saito K, Nishizaki T, Kajiwara K, Nomura S, Yoshikawa K, Harada K, Suzuki M.
Department of Neurosurgery, Clinical Neuroscience, Yamaguchi University School of Medicine, 1-1-1 Minamikogushi, Ube, Yamaguchi 755-8505, Japan. hishi@po.cc.yamaguchi-u.ac.jp
OBJECTIVE: The CyberKnife is newly developed equipment for radiosurgery and fractionated radiosurgery. The authors report on their experience using the CyberKnife in 38 patients with vestibular schwannoma who were treated between 1998 to 2002. METHODS: During this period, 38 patients with vestibular schwannoma were treated using CyberKnife fractionated radiosurgery. Before undergoing fractionated radiosurgery, 14 patients had Gardner Robertson classes I or II hearing (the serviceable hearing group), and 24 patients had classes III to V hearing (the non-serviceable hearing group).
The treatment volumes of these two groups were 0.5 to 24.0 cm (3) (mean 4.7 cm (3)), and 0.5 to 41.6 cm (3) (mean 8.2 cm (3)). Target irradiation was administered in 1 - 3 fractions (mean 2.5 fractions). The total marginal radiation doses were 15.0 to 20.5 Gy (mean 17.0 Gy), and 11.9 to 20.1 Gy (mean 16.9 Gy), respectively. RESULTS: After a mean follow-up period of 31.9 months (range 12 to 59 months, median 27 months),
94 % of the tumors were controlled. Only one patient in the group with non-serviceable hearing underwent additional surgical resection for a presumed increase in tumor size.
The hearing preservation rate was 93 %. Facial weakness did not develop in any of the patients in the serviceable hearing group. New trigeminal symptoms did not develop in any patients in either group.
CONCLUSION: Although a longer and more extensive follow-up is needed, CyberKnife fractionated radiosurgery is considered to be safe and effective, even in patients with large tumors.Netherlands study comparing radiosurgery and radiotherapy with no discernible difference
Fractionated stereotactic radiation therapy and single high-dose radiosurgery for acoustic neuroma: early results of a prospective clinical study.
Meijer OW, Wolbers JG, Baayen JC, Slotman BJ.
Department of Radiation Oncology, University Hospital VU-Ziekenhuis, Amsterdam, The Netherlands. owm.meijer@azvu.nl
PURPOSE: To prospectively assess the local control and toxicity rate in acoustic neuroma patients treated with linear accelerator-based radiosurgery and fractionated stereotactic radiation therapy. METHODS AND MATERIALS: We evaluated 37 consecutive patients treated with stereotactic radiation therapy for acoustic neuroma. All patients had progressive tumors, progressive symptoms, or both.
Mean tumor diameter was 2.3 cm (range 0.8-3.3) on magnetic resonance (MR) scan.
Dentate patients were given a dose of 5x4 Gy or 5x5 Gy and edentate patients were given a dose of 1x10 Gy or 1x12.50 Gy prescribed to the 80% isodose. All patients were treated with a single isocenter. RESULTS: With a mean follow-up period of 25 months (range 12-61), the actuarial local control rate at 5 years was 91% (only 1 patient failed). The actuarial rate of hearing preservation at 5 years was 66% in previously-hearing patients. The actuarial rate of freedom from trigeminal nerve toxicity was 97% at 5 years. No patient developed facial nerve toxicity or other complications.
CONCLUSION: In this unselected series, fractionated stereotactic radiation therapy and linear accelerator-based radiosurgery give excellent local control in acoustic neuroma. It combines a high rate of preservation of hearing with a very low rate of other toxicity, although follow-up is relatively short.Stanford CK 2005
Staged stereotactic irradiation for acoustic neuroma.
Chang SD, Gibbs IC, Sakamoto GT, Lee E, Oyelese A, Adler JR Jr.
Department of Neurosurgery, Stanford University School of Medicine, Stanford, California 94305, USA. sdchang@stanford.edu
OBJECTIVE: Stereotactic radiosurgery has proven effective in the treatment of acoustic neuromas.
Prior reports using single-stage radiosurgery consistently have shown excellent tumor control, but only up to a 50 to 73% likelihood of maintaining hearing at pretreatment levels.
Staged, frame-based radiosurgery using 12-hour interfraction intervals previously has been shown by our group to achieve excellent tumor control while increasing the rate of hearing preservation at 2 years to 77%. The arrival of CyberKnife (Accuray, Inc., Sunnyvale, CA) image-guided radiosurgery now makes it more practical to treat acoustic neuroma with a staged approach. We hypothesize that such factors may further minimize injury of adjacent cranial nerves. In this retrospective study, we report our experience with staged radiosurgery for managing acoustic neuromas. METHODS:
Since 1999, the CyberKnife has been used to treat more than 270 patients with acoustic neuroma at Stanford University. Sixty-one of these patients have now been followed up for a minimum of 36 months and form the basis for the present clinical investigation. Among the treated patients, the mean transverse tumor diameter was 18.5 mm, whereas the total marginal dose was either 18 or 21 Gy using three 6- or 7-Gy fractions. Audiograms and magnetic resonance imaging were obtained at 6-months intervals after treatment for the first 2 years and then annually thereafter. RESULTS: Of the 61 patients with a minimum of 36 months of follow-up (mean, 48 mo),
74% of patients with serviceable hearing (Gardner-Robinson Class 1-2) maintained serviceable hearing at the last follow-up, and no patient with at least some hearing before treatment lost all hearing on the treated side. Only one treated tumor (2%) progressed after radiosurgery; 29 (48%) of 61 decreased in size and 31 (50%) of the 61 tumors were stable. In no patients did new trigeminal dysfunction develop, nor did any patient experience permanent injury to their facial nerve; two patients experienced transient facial twitching that resolved in 3 to 5 months.
CONCLUSION: Although still preliminary, these results indicate that improved tumor dose homogeneity and a staged treatment regimen may improve hearing preservation in acoustic neuroma patients undergoing stereotactic radiosurgery.
