1. Stanford
CyberKnife
LONG-TERM RESULTS
OF RADIOSURGERY IN
THE TREATMENT OF
PARAGANGLIOMAS
STANFORD CYBERKNIFE CENTER
DEPARTMENTS OF NEUROSURGERY
AND RADIATION ONCOLOGY
ROBERT LIEBERSON, JOHN ADLER,
GRIFF HARSH, MARCO LEE,
CLARA CHOI, SCOTT SOLTYS,
IRIS GIBBS, ROB LOBER,
AND STEVEN CHANG

2. Stanford
CyberKnife
Paragangliomas
 Indolent, locally
invasive, tumors of
sympathetic and
parasympathetic
ganglia cells
 Difficult to resect,
especially when
intracranial
 1941, Guild coined the
term “glomus jugulare”
Stacy Rufus Guild

3. Stanford
CyberKnife
Patient Characteristics
35 patients with 39 tumors, age 54 (21 to 86)
7 previously treated (7 surgery, 1 embolization)
4 with multiple tumors
3 syndromic (2 NF2, 1 inherited)
Location
31 Cranial
6 Carotid
2 Spinal
Sex
13 Men
22 Women

4. Stanford
CyberKnife
Small Lesions
 0 - 8 cm3
 1905 cGy (1600-2000)
 One fraction
 79% Isodose
 1.43 Conformality Index
 8 - 16 cm3
 2000 cGy (1800-2200)
 Two fractions
 80% Isodose
 1.39 Conformality Index

5. Stanford
CyberKnife
Medium Lesions
 16 - 32 cm3
 2250 cGy
(1800-2400)
 Three fractions
 76% Isodose
 1.34 C.I.

6. Stanford
CyberKnife
Large Lesions (1)
 42 cm3
(8.4 x 3.1 x 2.8)
 2400 in three for
each of two
sections
 Isodose 76%/79%
 C.I. 1.27/1.18
12/2006
3/2007

7. Stanford
CyberKnife
Large Lesions (2)
69 cm3
(8.6 x 3.5 x 2.8)
 2500 in five
 Isodose 80%
 C.I. 1.32

8. Stanford
CyberKnife
Follow-Up
Clinical 56 months
MRI 47 months
≥ 5 years 10 patients
≥ 10 years 4 patients

9. Stanford
CyberKnife
Local Control
Feigl and Horstmann Radiosurgery Response Classification
RRC Grade Definition
I Tumor shrinks at least 10%
II Tumor unchanged
III Tumor grows
 21 of 39 tumors smaller (grade I)
 16 of 39 tumors stable (grade II)
 None enlarged (grade III)

10. Stanford
CyberKnife
0.0
.2
.4
.6
.8
1.0
LocalControl
0 2 4 6 8 10 12 14 16 18
Years
Open Surgery
CyberKnife
Local Control

11. Stanford
CyberKnife
Complications
 Two patients with transient cranial neuropathies
 One patient with permanently increased vertigo
 One patient, severely cachexic before SRS, died
1.3 months after treatment (malnutrition)
 One with spinal tumors
and radiculopathies
did not improve and
required open surgery

12. Stanford
CyberKnife
Other SRS Series
 18 centers, 345 patients, 1994-2009
 86 patients previously operated
 56.2 mean age, 9.38 cm3 mean size
 1622 cGy mean, 39 mo. mean f/u
 97.7 % local control
 4.3 % complication rate
(CN deficits, vertigo, serous otitis, headache)

13. Stanford
CyberKnife
Surgical Series
 21 series, 769 patients, 1988-2005*
 82.9 % (568/685) local control
 ~48 % (~261/539) complications
(at least 40% CN palsies but also 3 deaths,
> 10 CVA’s, > 30 wound infection/meningitis,
cholesteotomas, aspiration pneumonias,
tracheostomies, dysphagia)
* Reviewed by Hinerman RW, Amdur RJ, Morris CG, Kirwan MA, MendenhALL WM. Definitive
Radiotherapy in the Management of Paragangliomas Arising in the Head and Neck: A 35-Year
Experience. Head and Neck, 30:1431 (2008).

14. Stanford
CyberKnife
Conclusions
 SRS near 100% local control
 SRS complications rare, less
severe than from surgery
 SRS should be the primary
treatment for new or
recurrent paragangliomas

15. Stanford
CyberKnife
Thank you
NEUROSURGERY
Steven Chang
John Adler
Mike Edwards
Griff Harsh
Jon Park
Jaimie Henderson
Stefan Mindea
Rob Lieberson
Marco Lee
RADIATION ONCOLOGY
Iris Gibbs
Scott Soltys
Quynh Le
Don Goffinet
Chris King
Albert Koong
Billy Loo
Sarah Donaldson
Steve Hancock
Dan Chang
Phuoc Tran
Dan Kapp
RADIOLOGY
Mary Marcellus
Nancy Fischbein
ENT, GENERAL
THORACIC, AND
UROLOGIC SURGERY
Robert Jackler
Nick Blevins
Richard Whyte
George Yang
Ralph Greco
Joe Presti
Harash Gill
PHYSICS AND RT
Sonja Deiterich
Tony Lo
Tony Ho
Lei Wang
Laurence Jang
Jackei Lo
Sandra Kuerth
NURSING
Elizabeth Lee
Ami Lombardi
Christine Rico Erb
Laurie Tupper
Michelle Klesczewski
SUPPORT
Kai Ko
Scarlett White
Lucy Tovar
Merna Godoy
Barbara Pedrick
Aisha Ali
Treatments by Year