Precision CyberKnife Referral Guidelines

PROCEDURE:

1. Consults are performed by the Radiation Oncologist.
2. At the time of consultation a medical history is obtained and records and imaging are reviewed.
3. The past medical and past surgical history is recorded and the social history, family history, and review of systems are noted.
4. After the physical examination is done, the findings are reviewed with the patient and family.
5. An impression is formulated as to whether or not the patient would be a suitable candidate for stereotactic radiosurgery with the CyberKnife. Typical tumors treated with Precision CyberKnife are generally small in size up to approximately 5cm or so and are usually surgically or medically inoperable.
6. If the patient is determined to be a candidate for the Precision CyberKnife then:
   • A consent for radiation treatment will be obtained.
   • The side effects of stereotactic radiosurgery will be reviewed based on the specific site of treatment.  Side effects of CyberKnife are site-specific and vary greatly by location.
   • After the intent of treatment and side effects are reviewed, the patient will be given a simulation appointment. Also, the patient will meet with the nurse coordinator who will review and coordinate the treatment process as well as obtain any further studies requested by the consulting physician.

General Guidelines
Radiosurgery is indicated:

• As an adjunct or planned “boost” after conventional external beam radiation therapy (XRT)
• As an alternative to conventional XRT, especially for radioresistant tumors.
• For tumor recurrence in previous irradiated regions.  These patients usually have no other option.
• As an alternative to conventional surgery:
  • Equivalent outcomes in some cases.
  • Medical condition may preclude surgery.
  • Patient preference is a large factor.

Intracranial Conditions

Benign Tumors:

• Meningioma
• Pituitary Adenoma
• Acoustic Neuroma
• Other Cranial Nerve Schwannomas
• Glomas Jugulare Tumors
• Residual/recurrent low-grade Astrocytoma, Oligodendroglioma, Hemangioblastoma

Malignant Tumors:

• Metastatic Tumors
• Malignant Gliomas

Vascular Lesions:

• Arteriovenous Malformations (AVM)
• Cavernous Malformations/AOVM

Functional Disorders

• Trigeminal Neuralgia
• Cluster Headache
• Vim Thalamotomy for tremor

Extracranial Conditions

Spine:

• Selected solitary metastases without bony spinal cord compression.
• Primary treatment of classically radioresistant solitary tumors, i.e., melanoma, renal cell, sarcoma
• Recurrent solitary metastases after conventional radiotherapy.

Lung:

• Stage I NSCLC if medically inoperable or if patient refuses open surgery.
• Advanced stage NSCLC as a boost treatment.
• Up-front treatment of obstructing endobronchial lesion with post-obstructive pneumonia.
• Metastases: solitary or limited (2-5) multiple metastases is symptomatic or enlarging on serial imaging with a favorable survival profile.

Liver:

• Metastases: solitary or limited (2-5) multiple metastases is symptomatic or enlarging on serial imaging with a favorable survival profile.

Pancreas:

• Up-front radiosurgery treatment of unresectable tumor “sandwiched” between chemotherapy doses.
• Boost treatment for persistent PET-positive region after conventional chemotherapy and radiation therapy.

Renal:

• Renal cell cancer in medically inoperable patients.

ENT:

• Recurrent or residual head and neck tumors after conventional treatment.

Prostate:

• Low to moderate risk prostate cancer as an alternate to multi-week IMRT, low-dose brachytherapy, or high-dose brachytherapy (HDR).

OB-GYN:

• For vaginal cuffs as primary or as boost.

Patients can be referred directly to Precision CyberKnife of New York for consultation.