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Accuray Confidential

CyberKnife® Robotic Radiosurgery

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RadiosurgeryRadiosurgery

• Definition– Radiosurgery uses precisely targeted radiation to destroy

lesions anywhere in the body in 1-5 fractions/stages

– Alternative to surgery

– Adjunct to radiotherapy

• Benefits– No incisions

– No general anesthesia

– Lower risk of complications

– Improved patient quality of life

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CyberKnifeCyberKnife®® Robotic Radiosurgery System Robotic Radiosurgery System

• World’s first and only intelligent robotic radiosurgery system

• Tracks, detects and corrects for tumor and patient movements throughout the treatment

• Sub-millimeter clinical accuracy to lesions throughout the body

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• Broad clinical application– Intracranial radiosurgery

– Extracranial radiosurgery

• Spine

• Lung

• Liver

• Pancreas

• Prostate

• Other

• Staged/fractionated radiosurgery• Proven clinical experience

– Over 16,000 patients treated worldwide

– Over 130 clinical and technical papers

– Over 120 medical centers worldwide have chosen CyberKnife

Photo courtesy of St.Joseph’s Hospital

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Accuray IncorporatedAccuray Incorporated

• Founded in 1992• Mission: Make radiosurgery an option for every cancer patient• CyberKnife System FDA Clearance – August 2001

“To provide treatment planning and image-guided radiosurgery and precision radiotherapy for lesions, tumors, and conditions anywhere in the body when radiation treatment is indicated.”


CyberKnifeCyberKnife®® Technology Technology

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Intelligent Robotic Technology– Continuous feedback

– Automated system

– Detects any movement in tumor or patient location

– Corrects to ensure sub-millimeter accuracy

World’s Most Accurate Radiosurgery System

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Synchrony™

camera

Treatment couch

Linearaccelerator

Manipulator

Imagedetectors

X-ray sources

Targeting System

Robotic Delivery System

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CyberKnifeCyberKnife®® Treatment Treatment

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CyberKnifeCyberKnife®® Accuracy Accuracy

• Sub-millimeter accuracy • Treats all parts of the body• Treats lesions that were previously untreatable• So accurate, head and body frames are not

required


• 600 MU/min Linear Accelerator• In-floor Imaging System• Wizard Based Planning Tools• Contact Detection System

CyberKnife® The Next Generation in Robotic Radiosurgery

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CyberKnifeCyberKnife®® G4: Linear Accelerator G4: Linear Accelerator

*Higher dose rate compared to the previous generation of CyberKnife

• Delivers a 50% higher dose rate*• Significantly reducing treatment times

Powerful 600 MU/min X-band Linear Accelerator Powerful 600 MU/min X-band Linear Accelerator

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CyberKnifeCyberKnife®® G4: Image Guidance System G4: Image Guidance System

• Providing a significant increase in treatment workspace• Expanding the potential for extracranial applications

Flush-mounted, In-floor X-ray Image DetectorsFlush-mounted, In-floor X-ray Image Detectors

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CyberKnifeCyberKnife®® G4: Contact Detection G4: Contact Detection

• Contact Detection Sensor– CyberKnife stops if end of Linac contacts an obstacle– Backup safety system

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CyberKnifeCyberKnife®® Conformality Conformality

Non-Isocentric Beam Delivery– Highly collimated beams– Non-convergent beams– Superior conformality while

maximizing homogeneity

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CyberKnifeCyberKnife®® Conformality Conformality

Non-Coplanar Beam Delivery– Automatically minimizes entrance/exit beam interactions

– No patient or linac re-positioning required

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SynchronySynchrony™™ Respiratory Tracking System Respiratory Tracking System

• Synchrony camera• Synchrony tracking markers• Fiber optic sensing technology • Tracks patient’s respiratory

motion

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CyberKnifeCyberKnife®® Treatment with Synchrony Treatment with Synchrony

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CyberKnifeCyberKnife®® Treatment with Synchrony Treatment with Synchrony

Synchrony’s Benefits:• Patient breathes normally• Lesion tracked throughout treatment• Sub-millimeter tracking accuracy*• Minimal irradiation of healthy tissue

*Reference: Dieterich S, Taylor D, Chuang C, Wong K, Tang J, Kilby W, Main W. The CyberKnife Synchrony Respiratory Tracking System: Evaluation of Systematic Targeting Uncertainty

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CyRISCyRIS™™ MultiPlan MultiPlan™™ Treatment Planning Treatment Planning• Optimized for intracranial and extracranial radiosurgery

• Work flow management

• Advanced, automated and manual image fusion

• Automated planning and contouring tools

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CyRISCyRIS™™ MultiPlan MultiPlan™™ Treatment PlanningTreatment Planning

• Multiple optimization approaches including real-time visualization and interaction

• Powerful plan review tools

• Easily, efficiently generate highly conformal plans

• Windows XP/PC product platform

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Benefits• Fast, multi-modality image fusion• Simplified contouring• Supports forward and inverse

planning methods• Achieves desired plan results

quickly and efficiently• Streamlines overall planning

process• Maximize the capabilities of

CyberKnife System

CyRISCyRIS™™ MultiPlan MultiPlan™™ Treatment Planning Treatment Planning

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CyberKnifeCyberKnife®® G4: Treatment Planning Wizard G4: Treatment Planning Wizard

• MultiPlan Start-up Wizard• Template Based Treatment Planning Tools

Load PatientLoad Patient Select StudySelect Study Select ExamsSelect ExamsAnatomical

Planning Template

• Designed to streamline the treatment planning process• Simplified, intuitive user interface• Automatic workflow navigation• Predefined treatment planning parameters organized by

anatomical region• Emphasis on treating lesions throughout the body

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XsightXsight™™ Spine Tracking System Spine Tracking System• Automatically locates and

tracks tumors along the spine

• Eliminates the need for surgical implantation of radiographic markers

• Facilitates faster, less complex treatments

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XsightXsight™™ Spine Tracking System Spine Tracking System• An alternative that eliminates

risk for patients

• Sub-millimeter accuracy with non-rigid registration

• Utilizes the bony anatomy of the spine:

– Cervical– Thoracic– Lumber– Sacrum

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Standard X-ray Xsight Process

Standard DRR Xsight Process

XsightXsight™™ Key Features Key Features

• Enhanced Imaging Technology

– Skeletal features are emphasized and soft tissues are suppressed

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• Automatic ROI Seeking– Image is analyzed seeking an

optimal region of interest (ROI) that contains the target and maximal skeletal features.

– Image entropy is maximized to get the optimal ROI

Optimal ROIDefault ROI

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Step 3Step 2Step 1• Hierarchical Mesh Tracking

– Enables registration of non-rigid skeletal anatomy

– Estimates local displacements in bony features

– Important aspect because vertebrae move relative to each other (spine is not a rigid structure)


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Defining AccuracyDefining Accuracy

• Traditional Definition: Mechanical Accuracy

• New Definition: Clinical Accuracy

Tumor motion

Patient setup

Patient movement

Imaging (CT, MRI, etc.)

Treatment planning

Beam delivery

Clinical Accuracy

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CyberKnifeCyberKnife®® Robotic System Accuracy Robotic System Accuracy

• Mechanical Accuracy = 0.2 mm• Sub-Millimeter Clinical Accuracy*

Clinical Accuracy

CyberKnifeClinical Accuracy

References: • Yu C, Main W, Taylor D, Kuduvalli G, Wang M, Apuzzo M, Adler J. An Anthropomorphic Phantom Study of the Accuracy of CyberKnife

Spinal Radiosurgery. Neurosurgery, November 2004.• Dieterich S, Taylor D, Chuang C, Wong K, Tang J, Kilby W, Main W. The CyberKnife Synchrony Respiratory Tracking System:

Evaluation of systematic targeting uncertainty

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CyberKnifeCyberKnife®® System Accuracy System Accuracy

Reference: Yu C, Main W, Taylor D, Kuduvalli G, Wang M, Apuzzo M, Adler J. An Anthropomorphic Phantom Study of the Accuracy of CyberKnife Spinal Radiosurgery. Neurosurgery, November 2004.

Stationary Lesions – Fiducial Tracking• Yu C, et al. Anthropomorphic Phantom Study of the Accuracy of

CyberKnife Spinal Radiosurgery. Neurosurgery, Nov. 2004.– Objective: Evaluate clinically relevant accuracy of CyberKnife in treating

paraspinal lesions– Methodology: Clinically relevant accuracy measured at USC, Boulder

Community Hospital, Stanford University School of Medicine– Results: Mean clinically relevant error was determined to be 0.7 ± 0.3mm.– CyberKnife System accuracy specification: 0.95 mm

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Targeting Accuracy Using SynchronyTargeting Accuracy Using Synchrony™™

Moving Lesions• Dieterich, S, et al. The CyberKnife Synchrony™ Respiratory Tracking

System: Evaluation of Systematic Targeting Uncertainty

– Objective: Quantify systematic geometric uncertainties in treatment delivery using Synchrony for range of simulated respiratory motions

– Methodology: Accuracy measured at Georgetown University Hospital, Boulder Community Hospital, UCSF

– Results: Mean systematic error of 0.70 ± 0.33 mm

– Synchrony accuracy specification: 1.5 mm

Reference: Dieterich S, Taylor D, Chuang C, Wong K, Tang J, Kilby W, Main W. The CyberKnife Synchrony Respiratory Tracking System: Evaluation of Systematic Targeting Uncertainty

Site 1 Site 2 Site 3 Mean SD

0 deg 1.05 0.62 0.46 0.71 0.31

15 deg 1.05 0.74 0.11 0.63 0.48

30 deg 1.08 0.55 0.64 0.76 0.28

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Clinical BenefitsClinical Benefits

• Staged/Fractionated Radiosurgery– 1-5 fractions/stages

– Larger lesions

– Lesions next to critical structures/organs at risk

• Improved Patient Quality of Life– Short treatment course: 1-5 days CyberKnife vs. 6-8 wks

Radiotherapy• Optimal for patients • Optimal for patients with limited life expectancy• Increased convenience

– No infection risk

– No general anesthesia

– Minimal to no recovery time, as compared to open surgery


CyberKnifeCyberKnife®® Treatment Overview Treatment Overview

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Patient SetupPatient Setup• No rigid fixation required• Intracranial cases: Thermoplastic mask• Extracranial cases

– Spine: no fiducials or markers needed

– Soft-tissue lesions: Gold seed markers

– Moving lesions: Synchrony vest

Photo courtesy of Naples Community Hospital

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CyberKnifeCyberKnife®® Treatment Procedure Treatment Procedure

1. Patient Consult

2. Patient Setup

3. Image Acquisition

4. Treatment Planning

5. Treatment Delivery

Photos courtesy of Stanford University Hospital, Naples Community Hospital, University of Southern California, St. Joseph’s Hospital

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