Dear RadOnc community,
Does anybody has some insights about this indiciation for radiotherapy or already discussed it with an ophthalmologist?
The Study sounds quite intriguing...
Maybe we finally have a new indication for radiotherapy? 🙂
Stereotactic radiotherapy for Macular Degeneration (STAR)
- Thread starter xyz01
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Dear RadOnc community,
Does anybody has some insights about this indiciation for radiotherapy or already discussed it with an ophthalmologist?
The Study sounds quite intriguing...
Maybe we finally have a new indication for radiotherapy? 🙂
New indication - super cool.
I wonder whether ophthalmologists are all that interested in "reducing the anti-VEGF burden" in their patients, given that anti-VEGF therapy has been allowing them to print money for years.
I wonder whether ophthalmologists are all that interested in "reducing the anti-VEGF burden" in their patients, given that anti-VEGF therapy has been allowing them to print money for years.
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There is zero chance anyone from optho/retina specialist refers to reduce use of anti-VEGF therapy...as mentioned that has been a major cash cow for years....unless an insurer gets heavy handed as in: "will not approve X more cycles unless patient has had SBRT" this is not going to happen out in the real world.
With that said, we need more of this type of stuff - expanding usage of radiation. Really happy to see it and see it in Lancet.
With that said, we need more of this type of stuff - expanding usage of radiation. Really happy to see it and see it in Lancet.
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Wow - so definitely this is a treatment that requires training and specialized equipment - not something that can simply be adapted to a linac.
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Expanding indications for radiation, that will never be used by a radiation oncologist. Cool for sure, but not super relevant to our board.
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I'm not sure the XRT is helping with vision here. I would probably not opt for it myself. Does spare a few drug administrations (which are not really fun).
Of course, not ever being done in my clinic.
Of course, not ever being done in my clinic.
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There was quite a hype when Intrepid came out.
Some real world data however later on were less favorable and raised concerns on safety, for example:
www.ncbi.nlm.nih.gov
I have briefly worked with the device.
It‘s very elegant, but I personally do not think the treatment is going to establish itself.
Some real world data however later on were less favorable and raised concerns on safety, for example:
Microvascular abnormalities and long-term efficacy after stereotactic radiotherapy under continued intravitreal anti-VEGF treatment for neovascular AMD - PMC
For treatment of neovascular age-related macular degeneration (nAMD), multiple intravitreal injections of drugs targeting vascular endothelial growth factors (VEGF) result in a high burden for patients and healthcare systems. Low-energy stereotactic ...
www.ncbi.nlm.nih.gov
I have briefly worked with the device.
It‘s very elegant, but I personally do not think the treatment is going to establish itself.
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If it makes dollars, it'll make sense. (In America)There was quite a hype when Intrepid came out.
Some real world data however later on were less favorable and raised concerns on safety, for example:
Microvascular abnormalities and long-term efficacy after stereotactic radiotherapy under continued intravitreal anti-VEGF treatment for neovascular AMD - PMC
For treatment of neovascular age-related macular degeneration (nAMD), multiple intravitreal injections of drugs targeting vascular endothelial growth factors (VEGF) result in a high burden for patients and healthcare systems. Low-energy stereotactic ...
I have briefly worked with the device.
It‘s very elegant, but I personally do not think the treatment is going to establish itself.
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Well, in my little corner of the world I'm trying to resurrect XRT for Graves' ophthalmopathy (just simmed a patient this morning actually)
I was excited to try to make this happen too...but I don't gots no fancy eyeball treatin' machine.
I was excited to try to make this happen too...but I don't gots no fancy eyeball treatin' machine.
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Oh we totally get those referrals once in a while. We treat a few per year
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This works extremely well. I have no idea why it is not utilized more.
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There was quite a hype when Intrepid came out.
Some real world data however later on were less favorable and raised concerns on safety, for example:
Microvascular abnormalities and long-term efficacy after stereotactic radiotherapy under continued intravitreal anti-VEGF treatment for neovascular AMD - PMC
For treatment of neovascular age-related macular degeneration (nAMD), multiple intravitreal injections of drugs targeting vascular endothelial growth factors (VEGF) result in a high burden for patients and healthcare systems. Low-energy stereotactic ...
I have briefly worked with the device.
It‘s very elegant, but I personally do not think the treatment is going to establish itself.
Eye treatment platforms are beautiful engineering. I have only ever seen the proton systems before, this is very cool. Seems like a no brainer to develop this at any proton center that has an ocular melanoma program.
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I recall that the IRay system has a very sharp penumbra, it would be interesting to compare this to protons. The next issue is likely the Bragg Peak, the "target" in the eye is likely very flat.
Thanks for the insight!
I still wonder if anybody would feel comfortable treating such patients with a linac based system... there are quite some papers on doing sbrt for uveal melanoma on LINAC, tough the target is probably larger... personally I have only treatet uveal metastases with sbrt but again much larger target..
actually as far as I understand, the study was done solely by opththamologists... after speaking with a fellow opththamologist (outside of the US) the burden is quite real... Pharma actually tries to develop drugs which can be administerd less frequently (e.g. bianually than monthly)...
I still wonder if anybody would feel comfortable treating such patients with a linac based system... there are quite some papers on doing sbrt for uveal melanoma on LINAC, tough the target is probably larger... personally I have only treatet uveal metastases with sbrt but again much larger target..
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This is not something to perform with a LINAC.
You are applying single-shot 16 Gy to a very delicate area.
Have a look at this article to understand more about the technique.
Assessment of targeting accuracy of a low-energy stereotactic radiosurgery treatment for age-related macular degeneration - PMC
Age-related macular degeneration (AMD), a leading cause of blindness in the United States, is a neovascular disease that may be controlled with radiation therapy. Early patient outcomes of external beam radiotherapy, however, have been mixed. ...
www.ncbi.nlm.nih.gov
The radiosurgery system has a custom two-camera video imaging and tracking system that continuously monitors the positions of the fixture fiducials. For the initial alignment, the two fiducials on the stabilizer bar are used to bring the x-ray source into treatment position; the system has a mechanical targeting precision of approximately 200 μm. During treatment, the relative positions of all three fiducials are monitored in real time to calculate the gaze angle of the eye, the position of the eye relative to the starting position and the effective position of the treatment beam on the retina.
...
A prescribed absorbed dose of 16 Gy is delivered to a 4 mm diameter disc, which is the CTV, centered on the fovea.
...
The beams are 4 mm in diameter (90% isodose) at the location of the fovea. Each beam enters the globe through three distinct positions on the pars plana, at azimuthal angles of 150°, 180° and 210°, and converges on the CTV. These field orientations were selected so that the beams would avoid the lens, cornea and optic nerve
The penumbra is very steep, because the x-ray source is really very close to the eye.
Do you know how much this machine costs?This is not something to perform with a LINAC.
You are applying single-shot 16 Gy to a very delicate area.
Have a look at this article to understand more about the technique.
Assessment of targeting accuracy of a low-energy stereotactic radiosurgery treatment for age-related macular degeneration - PMC
Age-related macular degeneration (AMD), a leading cause of blindness in the United States, is a neovascular disease that may be controlled with radiation therapy. Early patient outcomes of external beam radiotherapy, however, have been mixed. ...
The radiosurgery system has a custom two-camera video imaging and tracking system that continuously monitors the positions of the fixture fiducials. For the initial alignment, the two fiducials on the stabilizer bar are used to bring the x-ray source into treatment position; the system has a mechanical targeting precision of approximately 200 μm. During treatment, the relative positions of all three fiducials are monitored in real time to calculate the gaze angle of the eye, the position of the eye relative to the starting position and the effective position of the treatment beam on the retina.
...
A prescribed absorbed dose of 16 Gy is delivered to a 4 mm diameter disc, which is the CTV, centered on the fovea.
...
The beams are 4 mm in diameter (90% isodose) at the location of the fovea. Each beam enters the globe through three distinct positions on the pars plana, at azimuthal angles of 150°, 180° and 210°, and converges on the CTV. These field orientations were selected so that the beams would avoid the lens, cornea and optic nerve
The penumbra is very steep, because the x-ray source is really very close to the eye.
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"John! John! Come here quick! No, I don't care what you're doing, get into my office NOW! You're not gonna believe this!"This is not something to perform with a LINAC.
You are applying single-shot 16 Gy to a very delicate area.
Have a look at this article to understand more about the technique.
Assessment of targeting accuracy of a low-energy stereotactic radiosurgery treatment for age-related macular degeneration - PMC
Age-related macular degeneration (AMD), a leading cause of blindness in the United States, is a neovascular disease that may be controlled with radiation therapy. Early patient outcomes of external beam radiotherapy, however, have been mixed. ...
The radiosurgery system has a custom two-camera video imaging and tracking system that continuously monitors the positions of the fixture fiducials. For the initial alignment, the two fiducials on the stabilizer bar are used to bring the x-ray source into treatment position; the system has a mechanical targeting precision of approximately 200 μm. During treatment, the relative positions of all three fiducials are monitored in real time to calculate the gaze angle of the eye, the position of the eye relative to the starting position and the effective position of the treatment beam on the retina.
...
A prescribed absorbed dose of 16 Gy is delivered to a 4 mm diameter disc, which is the CTV, centered on the fovea.
...
The beams are 4 mm in diameter (90% isodose) at the location of the fovea. Each beam enters the globe through three distinct positions on the pars plana, at azimuthal angles of 150°, 180° and 210°, and converges on the CTV. These field orientations were selected so that the beams would avoid the lens, cornea and optic nerve
The penumbra is very steep, because the x-ray source is really very close to the eye.
- CyberKnife practices everywhere
This machine uses 100 kv X-rays. Is that below the threshold for rad onc involvement?
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A SUSPICIOUS QUESTION BASED ON YOUR CHOSEN SCREENAME...
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I have no idea.
However, I do recall that there was a "pay-per-patient" fee. Meaning, you could only treat a patient if you had bought a key.
That key, when entered into the console, allowerd you to treat one patient with one session. The company that made those machines, sold the keys. Later on, that company was acquired by Zeiss. I have no idea, how the current business model works.
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Never gonna even think about doing it here...
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It’s not like we treat the trigeminal nerve root with 60 Gy single fraction prescribed to 60% of maximum dose with < 5 mm distance to brainstem . . . oh wait
Somebody actually did try this already with other machines (thou not linac)
Gamma knife radiosurgery in the treatment of choroidal neovascularization (wet-type macular degeneration) - PubMed
We evaluated retrospectively our institutional experience in the treatment of macular degeneration with gamma knife radiosurgery (GKR). Treatment was delivered in a single shot of 12 Gy. Seven patients were treated between March of 1999 and May of 2000. The median duration of follow-up was 2.2...
pubmed.ncbi.nlm.nih.gov
Gamma knife treatment of subfoveal, classic neovascularization in age-related macular degeneration: a pilot study - PubMed
Gamma knife radiosurgery seemed to have a beneficial effect on visual acuity in patients with AMD, but it failed to control growth of CNV in six patients. A longer follow up, a larger study population, and a randomized and controlled study are necessary for a final conclusion.
pubmed.ncbi.nlm.nih.gov
