Raymond Schulz

Hepatocellular carcinoma (HCC) is the sixth leading cause of cancer globally (fifth in men and eighth in women) with 750,000 new cases per year.1 Its global prognosis is very poor with only a 7% 5-year survival.1 Because of such a poor survival rate, at 696,000deaths, it is currently the third leading cause of cancer mortality after lung and stomach cancer. Within 5 years, global HCC mortality is expected to be second only to lung cancer.1

In the United States (U.S.), while primary HCC… Show more

Hepatocellular carcinoma (HCC) is the sixth leading cause of cancer globally (fifth in men and eighth in women) with 750,000 new cases per year.1 Its global prognosis is very poor with only a 7% 5-year survival.1 Because of such a poor survival rate, at 696,000deaths, it is currently the third leading cause of cancer mortality after lung and stomach cancer. Within 5 years, global HCC mortality is expected to be second only to lung cancer.1

In the United States (U.S.), while primary HCC is small at ~20,000 cases, it is one of the few U.S.-based cancers whose death rate is rising primarily due an increase in hepatitis C and obesity induced nonalcoholic steatohepatitis (NASH).3 U.S. 5-year survival rates have improved only marginally in the past 40 years, from 4% in the early 70s to 14% currently,2 second only to pancreatic cancer, which has a 6% survival rate.

Eighty percent of HCC cases arise in developing countries and over 55% of all HCC cases are found in mainland China.1 Asia has a high incidence of chronic viral hepatitis infection (hepatitis B or C), which contributes to the high rate of HCC. Liver cirrhosis, a late-term effect of hepatitis infection, results in a 10-fold risk in HCC, hence the high Asian risk factor.1 Like lung cancer, HCC is a silent disease whose effects typically do not show up until late stage presentation. Early-stage diagnosis gives a poor 5-year survival of 26%, whereas late-stage diagnosis gives a miserable 2% survival.2
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The purpose of this study was to perform comprehensive measurements and testing of a Novalis Tx linear accelerator, and to develop technical guidelines for com-missioning from the time of acceptance testing to the first clinical treatment. The Novalis Tx (NTX) linear accelerator is equipped with, among other features, a high-definition MLC (HD120 MLC) with 2.5 mm central leaves, a 6D robotic couch, an optical guidance positioning system, as well as X-ray-based image guidance tools to provide… Show more

The purpose of this study was to perform comprehensive measurements and testing of a Novalis Tx linear accelerator, and to develop technical guidelines for com-missioning from the time of acceptance testing to the first clinical treatment. The Novalis Tx (NTX) linear accelerator is equipped with, among other features, a high-definition MLC (HD120 MLC) with 2.5 mm central leaves, a 6D robotic couch, an optical guidance positioning system, as well as X-ray-based image guidance tools to provide high accuracy radiation delivery for stereotactic radiosurgery and stereotactic body radiation therapy procedures. We have performed extensive tests for each of the components, and analyzed the clinical data collected in our clinic. ...Unshielded stereotactic field diode (SFD) overestimated dose by ~ 2% for large field sizes. ...Through a systematic series of quantitative commissioning experiments and end-to-end tests and our initial clinical experience, described in this report, we demonstrate that the NTX is a robust system, with the image guidance and MLC requirements to treat a wide variety of sites - in particular for highly accurate delivery of SRS and SBRT-based treatments. Show less

Provides a thorough and up-to-date account of Novalis® Shaped Beam Radiosurgery, which delivers highly accurate treatments Documents the clinical and technical basis for Shaped Beam Radiosurgery and Radiotherapy Examines a wide range of clinical applications, including brain and spinal tumors, arteriovenous malformations, and tumors located throughout the body Explores future developments and applications

Novalis® Shaped Beam Radiosurgery has set new standards by delivering highly… Show more

Provides a thorough and up-to-date account of Novalis® Shaped Beam Radiosurgery, which delivers highly accurate treatments Documents the clinical and technical basis for Shaped Beam Radiosurgery and Radiotherapy Examines a wide range of clinical applications, including brain and spinal tumors, arteriovenous malformations, and tumors located throughout the body Explores future developments and applications

Novalis® Shaped Beam Radiosurgery has set new standards by delivering highly precise radiation treatments to tumors anywhere in the body through the use of a proprietary multileaf collimator. By shaping the radiation beam to the exact contours of the tumor or lesion, Novalis permits maximum dose delivery to the entire tumor while protecting healthy tissue; this makes it eminently suitable for the treatment of irregularly shaped tumors. Novalis features 360° gantry rotation, stereoscopic kV X-ray imaging, and 6D robotic patient positioning. Dose delivery is typically achieved through fixed conformal beams, dynamic conformal arcs, and IMRT, and most brain treatments do not require an invasive head frame. This book provides a complete guide to radiosurgery treatments with Novalis. After a thorough discussion of the clinical and technical basis for Shaped Beam Radiosurgery, current clinical applications are considered in detail, including brain, body, skull base, and spinal tumors as well as arteriovenous malformations. Careful consideration is also given to future developments and applications, including new technologies that promise to offer even more accurate treatments. This state-of-the-art book will appeal to a wide audience of physicians and their multidisciplinary clinical and technical collaborators.

Shaped_Beam_Radiosurgery, Eds: DeSalles AAF, Gorgulho A, Agazarayan N, Slotman B, Selch M, Burwick AJ, Schulz R. 316 p Springer-Verlag, Heidelberg. March 2011 [ISBN: 978-3-642-11150-1 (Print) ; 978-3-642-11150-8 (Online)]
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Stereotactic radiosurgery continues to evolve in ways that allow this powerful technology to reach and treat more tumors in more patients. This volume in the Robotic Radiosurgery series is devoted to theory and practice in the emerging field of stereotactic radiosurgery (also called stereotactic body radiation therapy) for extracranial tumors, particularly those that move as patients breathe.


The book is divided into six sections. The first three sections address tumor motion due to… Show more

Stereotactic radiosurgery continues to evolve in ways that allow this powerful technology to reach and treat more tumors in more patients. This volume in the Robotic Radiosurgery series is devoted to theory and practice in the emerging field of stereotactic radiosurgery (also called stereotactic body radiation therapy) for extracranial tumors, particularly those that move as patients breathe.


The book is divided into six sections. The first three sections address tumor motion due to respiration and tumor tracking techniques; dosimetry, radiobiology, and imaging; and fiducial placement systems. The fourth and fifth sections then discuss in depth the use of robotic radiosurgery to treat lung and abdominal tumors, respectively, and a final section explains emerging concepts and techniques. Within this framework, detailed information is provided on the technology and methodology for delivery of high doses of radiation to moving targets, radiobiological and radiological principles, and the challenges faced by clinicians performing extracranial stereotactic radiosurgery. Furthermore, there are thorough reviews of the general clinical literature on stereotactic radiation treatment of tumors of the lungs, liver, and pancreas, and the latest clinical data from clinicians conducting clinical studies using the CyberKnife® Robotic Radiosurgery System.

Efforts have been made to achieve a homogeneous structure throughout the book, and illustrations are of a very high quality. This volume is intended for practitioners and students in all areas of oncology and medicine who are dedicated to the treatment of patients with lesions in the lungs, pancreas, and liver, lesions that move as patients breathe.

Treating_Tumors_That_Move_with_Respiration Eds: Urschel HC, Luketich JD, Kresl JJ, Papiez L, Timmerman RB, Schulz RA; 320 p, Springer-Verlag, Heidelberg. July 2007 [ISBN 978-3-540-69885-2 (Print) ; 978-3-540-69886-9 (Online)]
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This hardbound book contains 33 chapters with 108 authors and editors covering a wide range of topics on robotic radiosurgery. General topics on robotic radiosurgery include: 9 chapters on history, physics, radiobiology and technology and 24 chapters on CNS, non-CNS and future applications in robotic radiosurgery. This book is co-edited by radiation oncologists, surgeons and medical physicists

Hardcover: 428 pages
Publisher: CyberKnife Society Press (September 9, 2005)
ISBN-10:… Show more

This hardbound book contains 33 chapters with 108 authors and editors covering a wide range of topics on robotic radiosurgery. General topics on robotic radiosurgery include: 9 chapters on history, physics, radiobiology and technology and 24 chapters on CNS, non-CNS and future applications in robotic radiosurgery. This book is co-edited by radiation oncologists, surgeons and medical physicists

Hardcover: 428 pages
Publisher: CyberKnife Society Press (September 9, 2005)
ISBN-10: 0975312413
ISBN-13: 978-0975312414
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Radiosurgery is defined as the delivery of high doses of ionising radiation, in mono- or hypo- fractionated treatments, to destroy tumours or focal areas of pathology. The clinical requirements of designing a radiosurgical treatment system include providing: a) a highly precise beam delivery to targets located throughout the body, b) a highly conformal dose distribution, c) the ability to irradiate both small and/or large complex-shaped lesions while minimising the dose to adjacent… Show more

Radiosurgery is defined as the delivery of high doses of ionising radiation, in mono- or hypo- fractionated treatments, to destroy tumours or focal areas of pathology. The clinical requirements of designing a radiosurgical treatment system include providing: a) a highly precise beam delivery to targets located throughout the body, b) a highly conformal dose distribution, c) the ability to irradiate both small and/or large complex-shaped lesions while minimising the dose to adjacent radiosensitive tissues and d) the ability to interactively track lesion motion due to normal patient motion. To accomplish this, the CyberKnife radiosurgery system has pioneered in this area by taking advantage of the inherent geometrical targeting precision of a commercial arm-based robotic system carrying a compact X-band linear accelerator and integrated with X-ray imaging and visualisation feedback systems. The arm-mounted linear accelerator, equipped with patient specific anatomical models, registered to the patient in real-time with image guidance, dynamically and safely delivers conformal and homogeneous radiation for therapeutic benefit. This paper details the components of the CyberKnife system and their integration in the clinical workflow of radiosurgery. Show less

Stereotactic techniques for cannulation of cystic structures, within the brain, are well known. Superimposed structures may make this problematic as does the need to approach the cystic structure perpendicular to its tangent plane as with a craniopharyngioma cyst. To facilitate a three-dimensional visualization of the trajectory, we have employed digital holography. Transparent holographic images of cystic structures, ventricles, and sulci are rendered from T2-weighted MR data. Holographic… Show more

Stereotactic techniques for cannulation of cystic structures, within the brain, are well known. Superimposed structures may make this problematic as does the need to approach the cystic structure perpendicular to its tangent plane as with a craniopharyngioma cyst. To facilitate a three-dimensional visualization of the trajectory, we have employed digital holography. Transparent holographic images of cystic structures, ventricles, and sulci are rendered from T2-weighted MR data. Holographic images of vascular structures are rendered from CT or MR angiographic data. Vascular holograms are superimposed over the brain holograms, demonstrating the spatial relationships of these structures with regard to each other. Holographic images of the skull are rendered from CT slices. A Laitinen stereotactic frame (Sandstrom) is placed on the patient prior to obtaining the CT. The skull, pre-existing shunt catheters, and the stereotactic frame are all readily visible. The brain and vascular holograms are superimposed on these. The resulting image clearly demonstrates cystic structures, ventricles, vessels, pre-existing catheters, all within the skull and stereotactic frame. Using this holographic image as a "phantom", the actual Laitinen stereotactic frame is placed within its holographic image. The optical trajectory is then chosen, and the articulated arm of the stereotactic device is so adjusted. Subsequently, the frame is used to effect stereotactic placement of the cannula. Presumably, the surgeon's knowledge of anatomy would enable such knowledge to be apparent, but in complex cases the "safe" corridor may be rather small, and its limits may not be intuitively obvious. This is all the more the case, when obstacles along the pathway are pathologically distorted, or when they are not of tissue origin (shunt catheters, etc.). Employing this technique, we have successfully cannulated cystic structures in six patients, three of which presented with complex trajectory problems. Show less

A new holographic display technology for directly viewing 3D relationships contains visual properties heretofore unavailable in medicine. We classify these properties and describe their utility in the clinical setting. We also compare them to software simulated holograms for image preview.

A description of magnetic resonance angiography. Previously MRI only showed signal voids of in locations of vascular flow (venous and arterial flow). This review paper describes how pulse sequence techniques can be designed to highlight only flow. Eddy currents and turbulent flow effects are also discussed.

It is known that good CT reconstructions require that many views of the scanned object be obtained, where each view consists of many rays which traverse the patient. It is known that the required number of views depends on the diameter of the region reconstructed and the spatial resolution achieved. We present a new analysis of this question, valid for reconstruction from fan beam views, which shows that larger fan angles will require more views. Computer simulations, using a fan beam… Show more

It is known that good CT reconstructions require that many views of the scanned object be obtained, where each view consists of many rays which traverse the patient. It is known that the required number of views depends on the diameter of the region reconstructed and the spatial resolution achieved. We present a new analysis of this question, valid for reconstruction from fan beam views, which shows that larger fan angles will require more views. Computer simulations, using a fan beam reconstruction algorithm, confirmed the predicted fan angle dependence and demonstrated that streak artifacts will result if too few views are used. The effect is also demonstrated experimentally by a phantom scan on a clinical CT scanner. Implications for clinical CT scanning are discussed.
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The usefulness of a smoothed reconstruction CT algorithm was studied using raw data from the EMI Mark I head scanner. The reconstruction algorithm operated on an off-line computer, independent of the EMI algorithm. This technique greatly reduces image noise and improves the visibility of very low-contrast structures, but at the cost of reduced spatial resolution. Phantom tests with contrasts as low as 0.14% demonstrated the validity of the images. Clinical results showed greatly improved… Show more

The usefulness of a smoothed reconstruction CT algorithm was studied using raw data from the EMI Mark I head scanner. The reconstruction algorithm operated on an off-line computer, independent of the EMI algorithm. This technique greatly reduces image noise and improves the visibility of very low-contrast structures, but at the cost of reduced spatial resolution. Phantom tests with contrasts as low as 0.14% demonstrated the validity of the images. Clinical results showed greatly improved visualization of gray and white matter with no increase in dose. It was necessary to expand the CT density scale so that the range from air to water was divided into 2,000 parts.
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It is apparently well known that one particularly delicate tolerance in designing a tomographic machine is that on the error in alignment of the graticule. If the graticule, or strip which determines the location of the parallel measurements in each view, is displaced by as little as 0.05 mm consistently in each view, a characteristic artifact resembling a tuning fork can appear in the neighborhood of a small dense object (e.g., the petrous bone). In this paper, we give a mathematical analysis… Show more

It is apparently well known that one particularly delicate tolerance in designing a tomographic machine is that on the error in alignment of the graticule. If the graticule, or strip which determines the location of the parallel measurements in each view, is displaced by as little as 0.05 mm consistently in each view, a characteristic artifact resembling a tuning fork can appear in the neighborhood of a small dense object (e.g., the petrous bone). In this paper, we give a mathematical analysis of this artifact, leading to a simple quantitative estimate of this error in terms of the displacement. We also show that a rough correction can easily be made in software to remove this artifact by making the opposite shift in the weight function used. We show further that the displacement can be indirectly measured by using a pin phantom. Finally, we note that if the displacement were measured directly using, e.g., a triangular piece of lead, the above correction would then remove the artifact and eliminate the need for such a delicate tolerance Show less

A computer program has been written to produce lateral and frontal views of the brain from transverse slices generated by the EMI scanner. The resulting images have markedly facilitated the planning of surgical exploration of intracranial lesions by graphically indicating their locations in a manner consistent with the familiar lateral and frontal radiographs. Our image is formed from a distribution of the average EMI density number along the directio, of projection. Incorporated in the program… Show more

A computer program has been written to produce lateral and frontal views of the brain from transverse slices generated by the EMI scanner. The resulting images have markedly facilitated the planning of surgical exploration of intracranial lesions by graphically indicating their locations in a manner consistent with the familiar lateral and frontal radiographs. Our image is formed from a distribution of the average EMI density number along the directio, of projection. Incorporated in the program is a bone-searching algorithm which eliminated density from the cranium and extracranial air and water so that only brain is seen in the projection. Several enhancement algorithms are provided to enhance pathology. The images are displayed on the existing EMI viewer, where they are available for inspection and photography.

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In the field of x -ray reconstruction tomography, many sets of attenuation data are gathered at various angular orientations to the object. Each set of data is divided into many individual elements where each element represents a single pencil beam measurement of attenuated x -rays at some perpendicular distance from the origin.
Given this scheme of data collection, it is reasonable to ask the following question: For a given reconstruction diameter, is it more important to collect more sets… Show more

In the field of x -ray reconstruction tomography, many sets of attenuation data are gathered at various angular orientations to the object. Each set of data is divided into many individual elements where each element represents a single pencil beam measurement of attenuated x -rays at some perpendicular distance from the origin.
Given this scheme of data collection, it is reasonable to ask the following question: For a given reconstruction diameter, is it more important to collect more sets of projection data - views, or more elements per projection - rays? The answer to this question is basic to the design of computer assisted tomographic (CAT) scanners.
Using simulated projection data, we show that for the case of Rotate /Translate geometry, the reconstructed picture is much more sensitive to rays than to views. That is, given the design choice between increasing the number of views or increasing the number of rays per view, one would clearly prefer to sample rays more frequently. This concept may be generalized to any geometry CAT scanner being particularly relevant in the design of pure rotational fan beam CAT scanners. Show less