Imagine if there was a better way to address an inoperable brain tumor than dousing the entire organ with multiple radiation treatments. What if doctors could concentrate an array of radiation beams to a precise focal point and eradicate the metastasis at the tip of a high tech burn. As it turns out, the future is actually the past, according to Dr. Alain C.J. de Lotbinière.
The concept of radiosurgery was first envisioned in 1951 and the first Gamma Knife machine constructed in 1967, Dr. de Lotbinière assured.
Swedish Neurosurgeon pioneers technology and world follows.
Lars Leksell was the Swedish neurosurgeon who pioneered the technology that is now the standard of care for small brain tumors, said Dr. de Lotbinière, who is the Medical Director of the Gamma Knife Center at Northern Westchester Hospital in Mt. Kisco, NY.
Unfortunately, its actual implementation suffered the aforementioned lapse and took even longer for America to make the leap. The first Gamma Knife was introduced in Pittsburgh in 1987, according to Dr. de Lotbinière.
Precision ups survival ante.
The prevalence of radiosurgical devices exploded as CT and MRI scans were developed, and gave neurosurgeons access to the exact location of individual anomalies. Either way, the cost/benefit of utilizing the array of a cobalt-60 radiation beams of up to 192 sources is unmatched. “You can deliver a much higher intensity of radiation,” said Dr. de Lotbinière, while sparing normal brain tissue, he added.
In addition, whole-brain radiation was far less effective. “Patients didn’t live very long with brain metastases,” said Dr. de Lotbinière, and the numerous cognitive side effects were not appreciated, the neurosurgeon added. It’s also a one and done. "They can get back to normal activity the next day,” said Dr. de Lotbinière.
Of course, the machine has not solved the recurring nature of cancer. But the precision does allow patients to keep returning. “You can repeat treatments multiple times,” said Dr. de Lotbinière.
MRIs are performed every three months after the procedure. Once again, the technology far outweighs the limited options previously available. Whole brain radiation treatment subjects patients to the maximum tolerance, and once completed, the treatment cannot be repeated. Otherwise, irreparable damage to the brain would occur.
The Gamma Knife still has limitations.
The most common side effect of a Gamma Knife treatment is brain tissue swelling and is usually addressed by a steroid regimen. But that leaves large tumors out of reach for radiosurgery, because they may already be putting too much pressure on the brain. This means tumors must be an inch or under to be considered for Gamma Knife treatment.
However, the Gamma Knife can still play a role by cleaning up the mess. “You remove the bulk of the tumor, and if bits and pieces are left behind, that can be treated very effectively with the Gamma Knife,” said Dr. de Lotbinière.
So why not let the Gamma Knife make the cut elsewhere? The Gamma Knife was designed only to treat targets in the head, and if a body tumor is easily accessible, it’s best to remove. “So there’s still a role for surgery,” said Dr. de Lotbinière.
On the other hand, radiosurgery using linear accelerators is playing an increasing role depending on the location in the body and nature of the tumor.
The Gamma Knife is everywhere.
But he points to the growing distribution of Gamma Knives in New York State to illustrate its growing prevalence. “Two in Manhattan, two in Long Island, one in Syracuse, one in Buffalo, and our own in Westchester," he says, “It’s become, for a major hospital, a necessity if they want to put themselves competitively on the map.”
With over 350 facilities offering Gamma Knife treatments worldwide and over a million treatments to date, the cost to acquire the machine is about $4 Million. But leasing the device is a cheaper option, where the hospital is charged per use. The facility also has to provide the proper infrastructure to meet (NRC) Nuclear Regulatory Commission regulations.
Up to specs and seeing about 100 patients per year at Northern Westchester, he assumed the leadership role at Northern Westchester Hospital in 2005 and has served as a pioneer in radiosurgical treatments himself.
Dr. de Lotbinière on the Ground Floor at Yale
After completing training in Neurosurgery at the Montreal Neurological Institute at McGill University in 1988, he directed the Functional and Stereotactic neurosurgery program in the Department of Neurosurgery at Yale University, where the Linear Accelerator was initially the tool of choice. But there were definite restrictions on usage. “I was getting nowhere fast, and so I looked into getting the Gamma Knife,” Dr. de Lotbinière remembered.
After much convincing, Yale acquired one in 1996. Of course, the success of the program was not self-contained, and Northern Westchester sent out feelers that he accepted in 2006 after acting as a consultant.
Patients in the Present
The process usually begins with a referral. If the patient is a candidate, an MRI is taken after a head frame is attached, and the physicist tabulates the data. From there, either the neurosurgeon or radiation oncologist develops a plan and programs the computer. All three professionals must then sign off before the treatment can take place.
On the day of the procedure, a mask is fixed to stabilize the patient's head. This helps ensure that there is no unintended movement of the patient’s head, while a series of sensors monitor any patient movements that might put an undue strain on the frame. “There’s lots of checks and balances,” said Dr. de Lotbinière, and the neurosurgeon and radiation oncologist are on hand to implement the human component.
Looking forward, Dr. de Lotbinière is sure the future will bring continuing upgrades in software and hardware. But abandoning this technology for something else isn’t really part of the equation since the concept will remain akin to what was originally conceived.
Either way, he's satisfied that his expertise allows patients an efficient approach to a serious problem. "Patients are very happy and appreciate the side effects are few and far between," Dr. de Lotbinière concluded.