PNUEUMOMEDIASTINUM AFTER CYBERKNIFE STEREOTACTIC RADIOSURGERY

1
PNUEUMOMEDIASTINUM AFTER CYBERKNIFE STEREOTACTIC
RADIOSURGERY Christine Turner August 10, 2006
2

• CASE PRESENTATION
• CW is a 51 y/o non-smoking male chemist diagnosed
  w/ Stage III colon cancer in 1999.
• S/p hemicolectomy and adjuvant chemo
• Liver mets in 2001 s/p partial liver resection
  and radiofrequency ablation
• 3 lung mets in 2005 s/p multiple
  chemotherapeautic regimens
• Lung only dz progression and referred for ESR
  (extracranial stereotactic radiosurgery)

3

• WHAT IS ESR?
• (EXTRACRANIAL STEREOTACTIC RADIOISURGERY)
• Targeted high dose radiation w/ minimal
  toxicity to normal tissue
• Traditionally for brain tumors
• Expanded to treat intrathoracic and
  intrabdominal tumors
• Limited by target movement/respiratory
  variation
• Surgical resection gold standard for T1 and
  T2 lung tumors
• ESR emerging treatment option for inoperable
  patients

4

• CYBERKNIFE WITH THE SYNCHRONY MOTION TRACKING
  SYSTEM
• ESR used here at GUH
• Real-time image tracking that adjusts for resp.
  variation
• Fiducials used as markers
• Highly accurate with minimal damage to
  surrounding tissue

5
CYBERKNIFE SYSTEM
6

• CASE PRESENTATION
• Cyberknife to 3 lung lesions sequentially
• 6 weeks later-treated for radiation pneumonitis
  w/ oral Prednisone.
• 3 weeks later-admitted to MICU with hypoxia
• Started on O2, empiric abx and increased
  steroid dose
• CT showed PE-started on anticoagulation
• Prognosis appeared poor and discharged to home
  hospice

7

• PNEUMOMEDIASTINUM
• 4 months after treatment, developed acute onset
  neck swelling.

• Pneumomediastinum with subQ air and a ?small
  PTX at LUL treatment site
• Conservative Treatment (O2, monitoring, pain
  control)
• Discharged to Hospice
• Resolved on imaging in 1 month
• Condition improved, discharged from hospice

8

• DISCUSSION/CONCLUSIONS
• Preliminary data from ESR local tumor control
  with minimal toxicities
• Rare complications, usually minor
• Risk of a radiation toxicity
• Further studies to evaluate optimal doses and
  treatment tolerance

9

• WHY DO YOU CARE? (I.E WHAT CAN YOU LEARN?)
• What is Cyberknife?
• Pneumomediastinum (Signs, Sx, Dx, Tx)

10

• PNEUMOMEDIASTINUM
• Signs and Symptoms
• CP
• SOB
• Neck swelling
• SubQ emphysema
• Dysphagia
• Hoarse voice
• Hammans sign (crunching sound w/ heart beat)
• Dx CXR/CT

11

• PNEUMOMEDIASTINUM
• Spontaneous (tall, thin males) vs. secondary
• R/o trauma, espophageal perforation, infection
  with gas producing bacteria, PTX (especially
  tension), tension pneumomediastinum
• Risk factors steroid use, malignancy, fibrosis
  (interstitial or radiation fibrosis),
  inhalational drugs, asthma, valsalva maneuver
• Tx Conservative (O2, monitoring, pain
  control)
• Follow up imaging

12

• El Sherif A, Luketich JD, Landreneau RJ, Fernando
  HC. New therapeauticapprorachesforearaly stage
  non-small cell lung cancer. Surgical
  Oncology20051427-32.
• Nagata Y, Negoro Y, Aoki T, Mizowaki T, Takayama
  K, KokuboM, Araki N,Mitsumori M, Sasai, K,
  Shibamoto Y, Koga S, Yano Ss, Hiraoka M. Clinical
  Outcomes of 3D Conformal Hypofractionated Single
  High-Dsoe Radiotherapy for One or Two Lung Tumors
  using a Stereotactic Body Frame. International
  Journal of Radiation Oncology, Biology and
  Physics 200242(4)1041-1046.
• Hara R, Itami J, Kondo T, Aruga T, AbeY, Ito M,
  Fuses M, Shinohara D, Nagaoka T, Kobiki T.
  Stereotactic Single High Dose Irradiation of Lung
  Tumors Under Respiratory Gating. Radiotherapy
  and Oncology 200263159-163.
• Undreberg RWM, Lagerwaard FJ, Slotman BJ,
  Cuijpres JP, Senan S. Benefit of
  Respiration-Gated Stereotactic Radiotherapy for
  Stage I Lung Cancer An Analysis of 4DCT
  Datasets. 200562(2)554-560.
• Wulf J, Hadinger U, Oppitz U, Olshausen B,
  Flentje M. SttereotacticRadiotherapyof
  Extracranial Targetts CT-simulation and Accuracy
  of Treatment in the Stereotactic Body Frame.
  200057225-236.
• Kuo JS, Yu Cheng, Petrovich Z, Apuzzo M. The
  Cyberknife Stereotactic Radiosurgery System
  Description, Installation, and an Initital
  Evaluatioin of Use and Functionality200353(5)123
  5-1239.
• Chang SD, Main W, Martin D, Gibbs I, Heilbrun M.
  An Analysis of the Accuracy of the Cyberknife A
  Robotic Frameless Sereotactic Radiosurgical
  System. Neurosurgery 200352(1)140-147.
• Uematsu M, Shioda A, Suda A, Fukui T, Ozeki Y,
  Hama Y, Wonng JR, Kusano S. Computed
  Tomography-Guided Frameless Stereotactic
  Radiotherapy for Stage I Non-Small Cell Lung
  Cancer A 5-Year Experience. International
  Journal of Radiation Oncology, Biology and
  Physics 200151(3)666-670.

13

• Lee S, Choi EK, P HJ, Ahn SD, Kim JH, Kim KJ,
  Yoon SM, Kim YS, Yi BY. Steroactic Body Frame
  Based Fractionated Radiosurgery on Consecutive
  Days for Primary or Metastatic Tumors in the
  Lung. Lung Cancer 2003 40309-315.
• Timmerman R, Papiez L, McGarry R, Likes L,
  DesRosiers C, Frost S, Williams M. Exracranial
  Stereootactic Radioablation. Chest
  20031241946-1955.
• Song DY, Benedict SH, Cardinalee RM, Chung TD,
  Chang MG, Schmidt-Ulrich RK. Stereotactic Body
  Radiation Therapyof Lung Tumors Preliminary
  Experience Using Normal tissue Complicatiton
  Probability-Baased Dose Limits. American
  Journalof Clinical Oncology 200528(6)591-596.
• Whyte RI, Crownover R, Murphy MJ, Martin DP,
  RiceTW, DeCamp Jr. MM, Rodelbaugh R, Weinhous MS,
  Le Q. Stereotactic Radiosurgery for Lung Tumors
  Preliminary Report of a Phase I Trial. Annals of
  Thoracic Surgery 2003751097-1101.
• Hof H, Herfarth KK, Muntter M, Hoess A, Motsch J,
  Wannenmacher M, Debus J. Stereootactic
  Single-Dose Radiotherapy of Stage I Non-Small
  Cell Lung Cancer (NSCLC). International Journal
  of Radiation Oncology, Biology and Physics
  200356(2)335-341.
• Wulf J, Haedinger, Oppitz U, Thiele W, Muellerr
  G, Flentje M. International Journal of Radiation
  Oncology, Biology, and Physics 200460(1)186-196.
  
• Newcomb AE, Clarke CP. Spontaneous
  Pneumoomediaastinum A Bennign Curiossity or a
  Significant Problem? Chest 2005128(5)3298-3302.