title: Radiosurgery with the world's first fully robotized Leksell Gamma Knife PerfeXion in clinical use: a 200-patient prospective, randomized, controlled comparison with the Gamma Knife 4C.
abstract: OBJECTIVE
  The world's first Leksell Gamma Knife PerfeXion (Elekta Instrument AB, Stockholm, Sweden) for radiosurgery of the head and neck became operational at Timone University Hospital in Marseille on July 10, 2006. To allow strict evaluation of the capabilities, advantages, disadvantages, and limitations of this new technology, patients were enrolled in a prospective, randomized trial.
  
  
  METHODS
  In 66 working days, between July 10 and December 20, 2006, 363 patients were treated by gamma knife surgery at Timone University Hospital, Marseille. Of these patients, 200 were eligible for the comparative prospective study (inclusion criteria were informed consent obtained, tumor or vascular indication, and no previous radiosurgery or radiotherapy). In accordance with the blinded randomization process, 100 patients were treated with the Leksell Gamma Knife 4C (Elekta Instrument AB) and Gamma Knife 100 (Elekta Instrument AB) with the Leksell Gamma Knife PerfeXion. Dose planning parameters, dosimetry measurements on the patient's body, workflow, patient comfort, quality assurance procedure, and a series of other treatment-related parameters were systematically and prospectively evaluated in both arms of the trial.
  
  
  RESULTS
  No technical failure of the treatment procedure was encountered. The new dose-planning system led to the use of composite shots in 39.4% of the patients. The median number of different collimator sizes used was larger with the PerfeXion than with the 4C (2 and 1, respectively). The mean number of isocenters used was lower (10.67 and 13.08, respectively). The median total treatment time was significantly shorter with the PerfeXion (40 and 60 minutes, respectively), but there was no significant difference in the median radiation time (34.02 and 33.40 minutes, respectively). The procedure was performed using only a single run in 98.99% of the PerfeXion cases and in 42% of the 4C cases. Collision risk on the 4C forced us to change the frame gamma angle for at least 1 shot in 24% of the patients and led to treatment in manual mode for at least 1 shot in 21% of the patients. Collision risk requiring technical adaptation did not occur with the PerfeXion. In 1 patient treated with the PerfeXion, the system required a direct collision check. In terms of dose to structures outside the target area, the PerfeXion delivers 8.2 times less to the vertex, 10 times less to the thyroid, 12.9 times less to the sternum, and 15 times less to the gonads.
  
  
  CONCLUSIONS
  Our prospective study indicates that procedures with the PerfeXion were collision-free, even with very eccentric lesions (e.g., multiple metastases). The duration of the surgical procedure, the amount of time required for nurse, physicist, and physician intervention on the machine, and the duration of the quality assurance procedure were all shown to be dramatically reduced with the PerfeXion gamma knife. Patient protection is greatly improved with the PerfeXion. In our experience, the technological advances of the Leksell Gamma Knife PerfeXion will make a very significant contribution to future progress in head and neck radiosurgery.
authors.affiliation: INSERM U751; Faculté de Médecine, Aix Marseille Université; and Assistance Publique-Hôpitaux de Marseille, Service de Neurochirurgie Fonctionnelle, Hôpital de la Timone, Marseille, France. jregis@ap-hm.fr
authors.forename: Jean
authors.initials: J
authors.lastname: Régis
authors.forename: Manabu
authors.initials: M
authors.lastname: Tamura
authors.forename: Cécile
authors.initials: C
authors.lastname: Guillot
authors.forename: Shoji
authors.initials: S
authors.lastname: Yomo
authors.forename: Xavier
authors.initials: X
authors.lastname: Muraciolle
authors.forename: Mariko
authors.initials: M
authors.lastname: Nagaje
authors.forename: Yasser
authors.initials: Y
authors.lastname: Arka
authors.forename: Denis
authors.initials: D
authors.lastname: Porcheron
mesh_terms: D001927:Brain Diseases / Q000601:surgery*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D016634:Radiosurgery / Q000295:instrumentation* / Q000706:statistics & numerical data; D012371:Robotics / Q000295:instrumentation* / Q000706:statistics & numerical data; D025321:Surgery, Computer-Assisted / Q000295:instrumentation / Q000706:statistics & numerical data; D016896:Treatment Outcome