History of Radiosurgery

Dr. Lars Leksell

The word 'Radiosurgery' was coined by Prof. Lars Leksell in 1951. He experimented on electron accelerators, heavy particle beams and radiofrequency lesioning to create a cut in the brain. Finally, he could achieve his aim by using an orthovoltage X-ray beam attached to a stereotactic frame, which he himself developed. Using cartesian coordinates and arc principle, he focused X-ray beams from multiple directions, creating dose escalation at a target which could produce a lesion in the normal brain. Later on, Dr. Leksell, with Börje Larsson, developed and installed the first prototype in 1968 at Sophiahemmet Hospital in Stockholm, Sweden. Elekta Instruments AB, a company promoted by Dr. Leksell, took up further development of the machine.

Dr. Lars Leksell experimented using proton beams for radiosurgery with Borje Larsson, at synchrocyclotron at Gustav Werner Institute, University of Uppsala. Produced accurate radiosurgical lesions. Established the concept of cross firing of beams.

Early Treatment:

A case of Dr. Erik Oluf Backlund, Craniopharyngioma, operated and injected with Talcum powder to make it visible. Head with Plaster-of-Paris cap in Gamma Knife prototype. Manual planning using 2 shots through elliptical collimators (3x5mm, 20 Gy) to centre of the tumour.

First 10 patients

Early treatments were mostly in Sella region and for functional disorders.

Gamma Knife Prototype, 1958

Dr Georg Noren

Dr Georg Noren treated the first Acoustic Schwannoma in 1969.

Dr Ladislau Steiner did the first treatment for Arteriovenous Malformation at Karolinska Institute in 1970.

Dr Ladislau Steiner

Dr. Leksell defined radiosurgery as 'the delivery of a single, high dose of irradiation to a small and critically located intracranial volume through the intact skull'. His main aim was to treat functional diseases like pain and movement disorders. We now know it as ‘Stereotactic Radiosurgery’. Here, ‘stereo’ means solid or with three dimensions and ‘stereotactic’ means a three-dimensional approach to reach a target. The Leksell Gamma Knife has come a long way over the past 50 years with constant development, offering both frame-based and frameless immobilization, and inbuilt CT verification.

O. Betti and V. Derechinsky

In 1983, in France, O. Betti and V. Derechinsky defined a technique to perform radiosurgery using Linac. Later, Colombo in Vicenza, Italy, and Stump in Heidelberg, Germany described the use of Linac for radiosurgery. Various methods were developed by different companies to perform a Gamma Knife-like conformal single fraction radiosurgery. Various frames and immobilization devices were developed. Conformal radiation using coplanar arcs gave promise to the technique. Later, CT scan-based computerized planning was developed.

Prof. John Adler graduated from Harvard and did his Neurosurgery residency at Massachusetts General Hospital and Brigham and Women’s Hospital. He joined a fellowship to learn radiosurgery at Karolinska Institute under Dr Leksell. He was fascinated by radiosurgery. In 1987, he joined Stanford University in California. At Stanford, he participated in the development of various methods like 3D-Volumetric digitization, image-based automatic recognition of skull structures in axial CT scans, and image-to-image correlation with computer simulation, which became the foundation for frameless radiosurgery.

Dr. John Adler

Images taken from two oblique orthogonal cameras were digitally registered and matched with 3 CT scan-generated images to localize the position of the skull and structures within.

‘Neurotron 1000’ was the precursor of Cyberknife which ultimately achieved sub-millimetre accuracy. Cyberknife clinical use started in 1991, and the US FDA approval in 1994 established Frameless Stereotactic Radiosurgery for the brain, and later, for the whole body.

Dr. John Adler, in 2014, established Zap Surgical Systems Inc. which developed a new Gyroscopic Radiosurgery system called ZAP-X. It was a new ground-up system with everything unique. The system is self-shielded, so you do not need a concrete vault; X-ray verification and beam detection are built in. A unique collimator system and a 3 MeV Linac mounted on a gyroscope created multiple angles to deliver radiation with high accuracy. US FDA approval was achieved in 2017, and the first patient was treated in 2019.

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