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Beyond the cutting edge in cancer surgery

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Published January 30, 2006

Beyond the cutting edge in cancer surgery

By Jeff Crooke

The room's massive skylight is two stories above but invisible from the treatment area. Still, it floods the room with natural light. A large bed of realistic plastic plants is the first thing the patient sees in this light, before turning the corner and finding the robot.

Stooped over the treatment area like a gleaming white egret, it is simultaneously imposing and elegant. It moves silently, gracefully and extraordinarily precisely over the patient's couch, aided in its tracking by an array of unobtrusive imaging devices, including cameras and infrared tracking. Directly over the couch a ceiling-mounted, wide-panel television allows the patient to watch a favorite program while receiving treatment. The radiosurgery system, called CyberKnife, is the first of its kind in the Commonwealth.

While the robot is impressive, more impressive yet is the program Carilion has assembled behind it, a team of talented neurosurgeons, radiation oncologists, radiation therapists and physicists. That team began forming during the research process, as Carilion sought input on which treatment technology would best benefit the community.

Bring it home

"What you try to do anytime you have a technology addition is bring something to the Roanoke Valley that people would have to travel elsewhere to get," says Alan Vierling, vice president of operating room services. "We know that your health care is better when you're at home, among friends and family."

With that in mind Carilion undertook six months of "heavy-duty research," according to Vierling, with a team traveling to San Francisco, the University of California at Los Angeles and Chicago to view various technologies in action. Carilion's neurosurgeons and radiation oncologists were asked for input, and the final stage of the selection process involved a seminar in which system vendors made one-hour presentations. CyberKnife was the favorite of administration, the radiation oncologists and the neurosurgeons.

When lead neurosurgeon Dr. Gary Simonds explains the advantages, it's easy to see why CyberKnife was chosen. Like UVa's Gamma Knife, CyberKnife is a stereotactic radiation treatment, but with numerous advances over its predecessors.

"First is patient comfort," says Simonds. While other stereotactic radiation treatments require complete immobility reinforced by a halo bolted directly into the patient's skull, CyberKnife is truly incision-free, relying upon its extraordinary tracking and precision movements to adjust to patient movements in real time. It even compensates for breathing.

No bolts in your head already registers as a huge plus to most of us, but as Dr. Simonds notes, his patients have more on their minds, literally and figuratively, than a bolt or two.

Smaller amounts

Because the treatment compensates for movement, says Simonds, "it's easy to stop treatment and restart it." This allows patients bathroom and comfort breaks as they need them, but more importantly, it allows for treatment fractionalization, which means the delivery of smaller amounts of radiation more precisely and more quickly than in other treatments.

"By fractionalizing it you're able to give more treatment in a shorter amount of time without having to worry about radiation spilling over into healthy tissue," says Simonds.

The next advantage also has to do with the technology's tracking and precision movements. "The ability to treat non-spherical lesions is a big deal," says Simonds. Traditional stereotactic treatment uses several beams of radiation that all form an intersection over the tumor.

A certain amount of radiation tends to spread in a circular pattern into neighboring tissues. CyberKnife can actually follow the outline of a tumor, sparing those neighboring tissues some of the radiation. Part of this is due to tracking, but part of it is due to the collaborative nature of the team and the CyberKnife software.

'Inverse process'

Neurosurgeons and radiation oncologists use imaging to suggest solutions to one another and the software. The software suggests solutions based on their input, and the process continues until a solution that is best for everyone is reached.

"It's truly an inverse treatment planning process," says Dr. David Buck, one of the team's radiation oncologists. "Most radiation treatment is prospectively planned, meaning we give the software the model for the treatment and it gives us information about it. With CyberKnife we give it feedback and it provides models."

In addition to that, the CyberKnife company Web site has a forum for physicians using the technology, allowing them to ask questions of other CyberKnife physicians around the world about various treatment approaches, serving as a sort of knowledge bank.

All these factors combined make CyberKnife a better choice for intracranial tumor treatment, allowing it to reach tumors that might otherwise be too risky for radiation therapy. But that is just the beginning for the technology. Those three factors also allow the technology to move into treatment of other areas.

As you are reading this article, the CyberKnife team is expanding, preparing to use the technology for the treatment of tumors on the spine, lung and pancreas. Literature provided by CyberKnife documents not only a steady increase in the total number of patients treated by the technology, but also in the number of non-intracranial tumors treated.

"I've been in health care 24 years," says Vierling, who is also a registered nurse. "When you're in it that long you get to where it takes a lot to get you really excited. I still get excited thinking about this technology." Like so many others, Vierling has lost significant people in his life to cancer. "With treatments like CyberKnife you can begin to see the transition from cancer's perception as a terminal disease to a perception of cancer as a chronic disease."

(Jeff Crooke is a Roanoke-based freelance writer.)

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