by Dr. John Lipani
The year I entered college to begin the long journey to become a neurosurgeon was also the same year doctors began using radiosurgery to treat brain tumors in the United States. Little did I know back then what a big part radiosurgery would play in my professional career as a neurosurgeon.
The year was 1987 when Dr. L. Dade Lunsford, a neurosurgeon at the University of Pittsburgh, installed the first Gamma Knife radiosurgery device in North America. Despite being new and innovative technology, the use of Gamma Knife was restricted to treating brain tumors. Therefore, it could not be used to treat tumors located elsewhere in the body such as the spine.
It wasn’t until Stanford neurosurgeon John R. Alder, MD brought his knowledge and experience gained during his fellowship under Swedish neurosurgeon Lars Leksell (inventor of Gamma Knife) to Silicon Valley in the late 1990s that the possibility of delivering radiosurgery to the whole body became a reality. Dr Adler’s invention was named CyberKnife — a non-invasive robotic radiosurgery system that could treat tumors virtually anywhere in the body.
I had the privilege of training under the esteemed Professor Alder at Stanford University School of Medicine. It wasn’t long before I recognized the great potential of radiosurgery in the fight against cancer and decided to integrate this new technology into my neurosurgical practice. I was also surprised to realize how the knowledge and use of radiosurgery was limited to relatively few specialists throughout the world and that although the technology existed, clinical teaching and expertise was lacking. That’s why I founded the Brain and Spine Radiosurgery Institute in an effort to help promote awareness and education of this extremely valuable cancer-treating technology.
The power of radiosurgery lies in its ability to focus high dose radiation with extreme precision. This allows surgeons to treat tumors anywhere in the body without cutting. The effect of treatment however, is similar to cutting in that the high radiation dose selectively destroys cancer tissue. Traditional radiation therapy exposes good and bad tissue to radiation during treatment. Therefore, there are limits as to how much radiation can be used before damaging healthy tissue. Such limitations may result in treatment failure. With radiosurgery however, higher and more effective radiation doses can be used to treat tumors that are relatively resistant to traditional radiation therapy.
Another great advantage of radiosurgery is that it can be used to treat tumors that are otherwise considered inoperable. Such tumors are generally impossible to access during traditional open surgery without damaging vital structures along the way. This is especially useful for brain and spine tumors that form within delicate neuronal tissues that cannot be disturbed by a surgeon’s scalpel.
Of course, with metastatic disease it may not always be appropriate to use radiosurgery for treatment. For example, when cancer spreads within a particular tissue and the tumor margins are not well defined, traditional radiation therapy and/or chemotherapy may be necessary. However, when tumor margins are discernible from the surrounding tissue, radiosurgery may be an effective treatment option. Too often however, despite the availability of radiosurgery, traditional radiation therapy and open surgery are still being used in cases when radiosurgery is a viable option. I believe this is largely due to the paucity of clinical knowledge and expertise in radiosurgery compared to traditional treatment methods.
In many cases, radiosurgery offers an option to defer or avoid whole brain radiation therapy and may also be used in lieu of open brain or spine surgery. Radiating the whole brain can have serious side effects on patients such as memory loss, dementia, and personality changes. Likewise, open brain and spine surgery are not without considerable operative risk, and are also often associated with lengthy recovery periods. Unfortunately, many patients receive whole brain radiation therapy and/or open surgery before learning about radiosurgery as a potential treatment alternative.
Why is radiosurgery so underutilized? In part, the reason involves the fact that radiosurgery is performed by both radiation oncologists and neurosurgeons together. Radiosurgery training is considered a specialty within both fields of medicine. Therefore, it is relatively uncommon to find both radiation oncologists and neurosurgeons who specialize in radiosurgery and who work together in the same facility. Furthermore, radiosurgery requires the expertise of medical physicists who, again, have specialized training in radiosurgery. Once these three super-specialized professionals get together, the hospital system must then purchase the specialized radiosurgery equipment and house it in a multi-million dollar bunker designed especially for radiosurgery. Therefore, a multitude of events must occur that involve clinicians, hospital administrators, and politicians in order to establish and fund a successful radiosurgery program.
Despite the obstacles, medical research supporting the use of radiosurgery continues to grow which encourages more facilities to incorporate radiosurgery into their cancer treatment arsenals. It will take more time however before radiosurgery becomes mainstream, and until then, many cancer treatment centers throughout the world will continue to limit their cancer treatments to traditional modalities. It is therefore of utmost importance that patients are well informed of alternative advanced treatment methods such as radiosurgery. Increasing patient education and physician awareness are essential.
The appropriate treatment for a patient with metastatic brain and/or spine cancer is dependent on many factors and each case should be carefully considered individually. Radiosurgery may or may not be necessarily indicated. It is therefore important for patients and doctors to be well informed of all treatment options in order to take the best approach.
Dr. John D. Lipani, MD, PhD, FAANS, FACS, is a neurosurgeon, author, and lecturer who specializes in radiosurgery for the brain and spine. He practices in Hamilton and performs radiosurgery procedures at a number of New Jersey hospitals. Follow him on Google+.
Princeton Neurological Surgery, 3836 Quakerbridge Road, Suite 203, Hamilton. 609-890-3400. www.princetonneurologicalsurgery.com.