CYBERKNIFE The most advanced Radiosurgery platform New Hope for Cancer Patients

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1 Bus 6, 15, 66 Central Bus Station 76 Causeway Bay 19, 63, 41A North Point Minibus 5/24M CYBERKNIFE The most advanced Radiosurgery platform New Hope for Cancer Patients Taxi Available to and from the front entrance of Hospital Car Park Parking is available for a fee for patients and visitors. Address : 40 Stubbs Road, Hong Kong Tel : (852) Web : The first Hong Kong Hospital to be Accredited by JCI in 2006 Trent Accreditation since 2000.

2 What is CyberKnife? Invented at Stanford University, CyberKnife is a radiosurgery machine which can deliver radiation to tumor from up to 1,200 different angles. Its extreme accuracy allows it to deliver a very high dose of radiation to the pre-determined target throughout the body. The dose is so intense that it can cause destruction of tumor similar to an excision with a surgical knife and that is why it is called radiosurgery. CyberKnife is an FDA and European CE Mark approved radiosurgery platform. 1

3 Structural Components Structural Components CyberKnife s Multiplan system utilizes CT and MRI data to re-construct patient s detail structures and target. Under the instruction of the doctor and physicist, the planning software will work out the best possible safe and effective treatment plan. 2 3

4 Software Hardware What makes CyberKnife unique? Its uniqueness is based on its extreme accuracy enabling CyberKnife to treat tumors that were considered untreatable with conventional surgery and radiation. How does CyberKnife achieve this submillimeter accuracy? New Planning Software All modern radiotherapy treatment goes through a process of computer planning to ensure minimal damage to normal tissues and maximum tumor kill. CyberKnife planning software is unique in the following aspects : 1. Non-isocentric beam direction: This allows treatment beams to shoot at different parts of the target off center. This is unlike all other systems in the market in which all beams shoot through one point in the target (Isocentric). 2. The non-isocentric beam direction makes possible the potential choices of 1200 shooting angles. with Unmatchable Tracking Hardware A perfect treatment plan is useless unless it can be executed accurately. This task is performed by the tracking hardware. The paired ceiling mounted X-Ray tubes and the Synchrony eyes monitor the motion of the patient, as well as the motion of the tumor due to the patient s breathing. A corresponding adjustment is made to ensure a sub-millimeter level of targeting accuracy. This real-time detection and correction allows this platform to perform without the use of the screw-on rigid head-frame for head treatment commonly used in other radiosurgery platforms. Without the screw-on head frame, the fear and pain associated with the treatment is significantly reduced. Ms. Ting lives in Hong Kong, but when I first contacted her, she was at her place of work on the Mainland. I was amazed when I heard her cheerful laughter on the telephone because she didn t sound like a patient at all. Two years ago, Ms. Ting found out that she When I was told that I had to have an open surgery on my head, I felt even more scared than when I was first told I had a brain tumor Fortunately, there is now an alternative CyberKnife! Ms. Ting (Meningioma) had a brain tumor. The tumor was situated next to the optic nerve, presenting the real risk of loss of vision. Due to her positive nature and general optimism, Ms. Ting refused to give up and continued looking for the best treatment available. However, each doctor she consulted assured her open surgery was her only option. Since the tumor was beneath the front of my brain, the doctors stated they would have to open my head from above, extending the incision to the area near my ear. Next, they would prop my brain up and remove the tumor. After I was told these details, I was even more depressed than when I first found out about the tumor. Appearances are important to women, and Ms. Ting is no exception. I have a friend who underwent open brain surgery. It took her a very long time to recover, plus, she had to have her head shaved, and she was left with a very long scar on the left side of her head. If the surgery had gone wrong, it could have left her with injury to one or more cranial nerves! Due to these concerns, Ms. Ting was very worried and chose to avoid having treatment. Fortunately, Ms. Ting heard about the CyberKnife Center, and was most impressed by the option of non-invasive treatment. After 5 treatments, my tumor was much smaller, and the headaches which had bothered me for many years have now completely gone. I am really happy. A few weeks after the treatment, Ms. Ting went back to the mainland to resume her business. I am still very young and need to make a living. There is no way that I will stop working because of the treatment. If I had chosen to have open surgery, I am afraid I would still be in bed resting. Fortunately, by undergoing CyberKnife radiosurgery, the impact on my life and work has been minimal. 4 5

5 I am over 70 years old. If receiving treatment means a large wound on my head, I would rather not have any treatment at all! Mr. Hung (Acoustic tumor) Three years ago, 71-yearold Mr. Hung realized he had a hearing problem. His sleep was disturbed by a persistent annoying sound in his head. Some time later he noticed his left eye had begun to water, and his left arm and leg had become shaky. I love going to a Chinese restaurant in the morning, but I found I could scarcely hold the tea pot, and I thought I must be having a stroke! Subsequently, Mr. Hung s children arranged for him to undergo a series of investigations, which revealed he had an acoustic tumor on the nerve to the inner-ear. However, Mr. Hung had serious reservations about undergoing any form of open surgery. The doctor stated open surgery was necessary, but that the success rate was only 50% in view of my age. I was 71 at that time, and really didn t want a large cut on my head. The treatment sounded terrible, so I would not agree to the operation. I decided to give up, even if it meant I only had one year, or even one month left to live. However, Mr. Hung s daughter did not give up and kept searching for a better treatment option for her father. This year, she learned about the CyberKnife Center, and Mr. Hung finally agreed to undergo the necessary treatment, due to the non-invasive method employed. When I heard that there was no need to open my head, I said yes immediately. After three treatments, the tumor is shrinking. Mr. Hung s eye no longer waters, and his limbs are no longer shaky. Now I can eat, I can walk, I can sleep well, and I can even play Mahjong in my free time! Some 22 years ago spinal AVM patient Mr. Pun was told, We might not be able to help you. You need a miracle. Two years later, Mr. Pun began to suffer severe headaches and nausea. I tried both Western and Chinese medicine, but neither has any help. After suffering for two years and consulting more than 10 doctors, I finally found out that I had a spinal Arterio-Venous- Malformation (AVM). Mr. Pun underwent several operations, but did not regain the ability to walk. Recently, his situation worsened. He became unable to move his left arm and leg and was really crippled. Some days he could do nothing but lie in bed. His doctor stated that it would be too dangerous to perform more surgery, The doctor told me the AVM tumor was next to a large artery, and that open surgery could damage the artery, or even kill me. CyberKnife is my last hope! Mr. Pun (Spinal AVM) My. Pun reconciled himself to being incurable after the doctor told him, that all he could do was to hope for a miracle. Fortunately, Mr. Pun didn t have to wait very long. Following the opening of the CyberKnife Center in 2006, Mr. Pun was referred to Hong Kong Adventist Hospital, I realized that this was my last hope, so I made the decision to have the treatment immediately. After three CyberKnife treatments, the tumor has shrunk, and Mr. Pun is regaining the ability to walk. 6 7

6 The cancer had already spread to the bones, and traditional surgery could not help me. I thought it was my fate to remain lame. Fortunately, CyberKnife was introduced into Hong Kong that same year, and I knew that this would be my only hope. Pauline (Lung cancer with bone secondaries) Pauline, who is a primary school teacher, began to suffer from a bad cough and bone pains in Following investigations, she was found to have lung cancer which had already spread to her ribs and spine. The doctor showed me the X-ray, on which I could clearly see numerous black spots. I could hardly stand because of the extreme bone pain, and I was worried that I was going to lose the ability to walk. Pauline was forced to work part-time, to enable her to receive treatment and get more rest. Chemotherapy was tried first, but the tumors persisted, although some shrinkage did occur. Her doctor then recommended CyberKnife treatment. I didn t have another choice, as open surgery had nothing to offer for bone secondaries. Pauline decided to proceed with the CyberKnife treatment. I thought I was really lucky, as CyberKnife offered me new hope. While I hoped to regain the ability to walk normally, I also realized I could avoid becoming crippled she said. Pauline did not have major side effects after her three CyberKnife treatments. I have a friend who underwent another form of radiation treatment, and she had troublesome nausea and vomiting. From the moment my treatment was completed I felt absolutely fine. The bone pain has completely gone away, and now I am able to walk normally, and I can even go shopping with my friends! Two weeks after her treatments, Pauline returned to school as a part-time teacher, and two months later, she was able to resume full-time work. It was so boring staying home by myself. I couldn t hardly wait to get back to work and see all the children again! The doctor told me, you have final-stage lung cancer and you could possibly only have 3 months left to live. Treatment or no treatment will not make much difference. It sounds just like a TV drama, but this actually happened to Hilda. She was told that she had advanced lung cancer and that the cancer had already spread to her brain, with a total of 5 tumors. If I have a choice, I will always choose the safest treatment option! Joanna (Meningioma) The treatment is really simple. After the first treatment, I even went to Lau Fau Shan to have seafood with my husband and my friends. Hilda (Lung Cancer with Brain metastases) The doctor did not give my husband any hope, and said he should prepare for the inevitable. However, Hilda s husband, who is also a doctor, refused to give up hope and kept searching on the internet for beneficial treatment. Subsequently, he discovered that the latest model of CyberKnife had been introduced to Hong Kong at the Hong Kong Adventist Hospital. Following CyberKnife treatment and chemotherapy for about one month, there was no evidence of residual tumors found in Hilda s brain. Her blood tests had also returned to normal. Hilda said she owed it all to her loving husband and this amazing new technology, I really want to thank CyberKnife. It is such a comfortable form of treatment. All I had to do was lie down and sleep. No injection was required, and when I woke up, I was told that the treatment was all over. Joanna was sent to A&E after she experienced numbness down the right side of her body. Following a series of investigations, she was shown to have a brain tumor. The tumor was already 4.1 cm in diameter and her situation was quite critical. Her doctor advised her to undergo open surgery on her head, but this made her very worried, We were talking about opening my head! I knew this could cause serious complications and there were too many uncertainties. I didn t want to take that risk. In the end, Joanna chose to use the non-invasive CyberKnife treatment. After 5 treatments, the tumor had shrunk. Looking back, it was a wise choice to have CyberKnife, otherwise, I would still be in bed recovering. 8 9

7 Clinical Applications The concept of CyberKnife is based on and modified from the 30-year-old radiosurgery principle. It gives new hopes to patients suffering from vaious tumors: Brain tumors Radiosurgery was invented some 30 years ago by Dr. Leksell. The concept was simple; he focused X-ray beams onto a deep seated brain tumor, and destroyed it. The focusing intensified the effectiveness of the X-rays. This led to the development of the Gamma Knife, and subsequently, the X-Knife. Both the Gamma Knife and the X-Knife provided valuable radiosurgery information to the medical world. The rapid development of computer tracking technology in recent years has led to the invention of CyberKnife, which, although still based on the same radiosurgery concept, has set the patient free from the unpleasant screwed-down-headframe required by both Gamma Knife and X- knife. Lung cancer Lung cancer is a leading cause of cancer death world wide. Early stage lung cancer is best treated by surgery. However, in situations when surgery cannot be performed due to poor lung function. For example, or for some other reason cannot have the necessary anaesthesia, then conventional radiotherapy and chemotherapy are the next options. CyberKnife s capability of real time tracking makes it possible to follow tumor motion during the breathing cycle. This significantly reduces the amount of normal lung tissue being damaged by radiation, and allows a higher dose of radiation to be given to the patient, resulting in a higher cure rate. Indeed, there is currently a major clinical trial comparing the effectiveness of CyberKnife to conventional surgery in the treatment of lung cancer. Liver cancer Clinical Applications At the present time, surgery remains the best Nasopharyngeal cancer Nasopharyngeal cancer is a common cancer in Hong Kong, and there are cases where the cancer is located very close to the optic nerves. Traditionally, in order to secure a cure, many a time the patient s vision had to be compromised. Now, with the accuracy of Cyberknife, this type of patient can be treated with a much less risk of visual damage. Spinal tumors treatment option for liver cancer. However, in a situation where surgery cannot be performed, such as when the patient s liver function is poor, or the tumor location is not accessible to surgery, then CyberKnife treatment can be considered. Kidney cancer Kidney cancer has been considered resistant to conventional radiotherapy, and surgery has been the preferred treatment. The spinal cord lies in the vertebral canal, and as a result, any cancer affecting the bones of the spinal column, (most commonly secondaries from the breast, lung, or prostate,) poses a real threat to the spinal cord. Patients with this condition may develop pain, paralysis or incontinence, which adversely affects their quality of life. Conventional radiotherapy, limits by its relative inaccuracy, often unable to deliver a high effective dose to the spinal tumor and at the same time safe to the nearby spinal cord. The extreme accuracy of CyberKnife however perfectly fits into this scenario delivering high effective dose to the spinal tumor sparing the adjacent spinal cord. CyberKnife allows a very high dose of radiation to be delivered accurately and safely with minimal damage to the surrounding normal tissues, it can now be considered as an option for a patient who develops cancer in his only kidney or in situations when surgery cannot be performed

8 Clinical Applications Prostate cancer There are several equally effective treatments for early prostate cancer. These include surgery, conventional radiotherapy, and the implantation of radioactive gold seeds. With the arrival of CyberKnife, we have another option for accurate, short, but effective outpatient treatment. A 5-day Cyberknife course of treatment is as effective as a 7-week course of traditional radiotherapy. Breast cancer Women with early stage breast cancer can now preserve their breast by removal of the lump, followed by radiotherapy to the whole breast. Although this treatment is effective, the side effects of whole breast irradiation should not be underestimated. Recent research suggests that in some of these early cases of breast cancer, only the tumor bearing area needs to be irradiated, and not the whole breast. This is good news for these patients, because the accuracy of CyberKnife with its real time tracking of any chestwall movement, allows for destruction of the tumor cells, and preservation of the surrounding normal tissue. The overall treatment time is also reduced from 5 or 6 weeks to just 1 week. Head and neck tumor treatments require that a simple plastic mask be made for the purpose of gentle immobilization. This is in sharp contrast to other radiosurgical platforms that require screws to fix the skull in a frame. OR Treatment to other body parts may require the insertion of gold fuducials for tracking. This is performed under CT Scan guidance. The whole process is carried out under local anesthesia. The next step is to perform a CT Scan and/or MRI to obtain detailed information on the area requiring treatment. This information is sent to the CyberKnife computer, for treatment planning and trial treatment. Treatment Flow A brand new treatment concept The invention of CyberKnife is a major milestone in the history of radiotherapy. In conjunction with advances in chemotherapy and targeted therapy. CyberKnife can control gross cancer with its higher doses of accurately focused radiation, and modern chemotherapy and targeted therapy will control any associated micro-spread of the cancer. CyberKnife is an important part of modern cancer management, extending the frontier of effective treatment, and bringing new hope to many patients. Once the definitive management plan is accepted, the real treatment will begin. Normally, one to five sessions is all that will be required, with each session lasting from 45 minutes to 2 hours

9 Commonly asked questions 1. What do patients need to do during treatment, and do they feel any pain? Patients are required to lie relaxed on the treatment table in a comfortable position. By keeping still, their treatment time will be shortened. The treatment is pain-free. 2. How long does the treatment take? Depending on the complexity of the tumor and the dose of radiation required, the treatment time per session ranges from 45 minutes to 2 hours. The number of treatment sessions varies from a single treatment to 5 treatments. 3. What is the price for a course of CyberKnife treatment? The treatment price starts from HK$165,000 and it goes up if the number of treatment and the complexity increase. This price excludes medication during the procedure, diagnostic tests, and the doctor s consultation fee. Patients referred from Hospital Authority will receive discount. 4. How long is the initial consultation? The initial consultation takes between 30 and 60 minutes. 5. How soon will I learn if I am a suitable candidate for CyberKnife treatment? After all necessary tests have been completed, you will be informed of the result within a few days. Hong Kong Adventist Hospital is a Christian, private, not-for-profit hospital, that provides high quality healthcare to the residents of Hong Kong, including expatriates, and to patients from overseas seeking a higher standard of medical care. Thanks to its state-of-the-art equipment and the competency of its staff, Hong Kong Adventist Hospital offers all the advantages of a high-tech medical center in a personalized setting, where physicians and healthcare personnel provide patients with attentive care in a safe and friendly environment. 6. Does my insurance cover CyberKnife treatment? We advise you to check with your insurance company directly, as it depends on your particular policy. Accreditation The Hong Kong Adventist Hospital is proud to have been the first hospital in Hong Kong and Macau to receive full accreditation from the Joint Commission International (JCI). It has also achieved full accreditation each year since 2000 from the Trent Accreditation Board of the United Kingdom

10 Useful information Theresa Po CyberKnife Center Consultation hours : Monday to Friday 9am to 5pm For appointments, please contact us on: Phone : (852) Address : 40 Stubbs Road, Hong Kong Website : CyberKnife@hkah.org.hk Reference websites :