Can outpatient pallidotomies and thalamotomy be far behind?
 
Cruise Missile Technology Turns Spinal, Brain Surgeries
into outpatient procedures
 
Source: Business Wire via DowVision
Date: Jul 27, 1995              Time: 5:32 pm
 
STANFORD, Calif.--(BUSINESS WIRE)--July 27, 1995-- Three-dimensional body
maps that guide a robot arm offering pinpoint blasts of radiation are
starting to make possible -- on an outpatient basis -- many brain and
spinal cord surgeries that would have been impossible before, said
Stanford University neurosurgeon Dr. John Adler.
 
The new technique, called computer-mediated stereotaxic radiosurgery
(CMSR), draws on space-age missile tracking technology, flexible robotic
mainpulators and powerful X-ray machines to safely destroy cancerous
tumors in the brain or spine without opening the skull or risking the
partial paralysis that often follows traditional spinal surgery using a
knife, explained Adler, an associate professor of neurosurgery and medical
director of the stereotaxic unit at Stanford University Medical Center.
 
For 55-year-old Doris Stern, who suffers from lung cancer that has spread
through her body, the outpatient procedure removed a malignant brain tumor
and returned her to an active life. "I almost feel like playing tennis
again," said Stern, of Monterey, Calif., who received CMSR in July 1994.
Although the cancer outside her brain has not been contained, the
procedure has given her a year of quality life. Before her surgery, Stern
had slipped into a nearly vegetative state. She slept almost continuously,
and her loss of appetite was so severe, she said, that "my doctors told me
I would have starved to death months ago without the procedure."
 
For 40-year-old Mike Murray, of Princeton, N.J., an even newer version of
CMSR destroyed a spinal tumor on July 24 and 26, helping him avoid the
paralysis that almost certainly would have resulted from conventional
surgery. Murray is the first person in the world to receive spinal surgery
using CMSR, Adler said.
 
With CMSR, a computer-controlled robot arm locks the radiation beam on the
tumor, constantly readjusting its aim in response to the patient's natural
small movements, Adler said. Because it delivers its payload so accurately,
healthy tissue surrounding the tumor remains undamaged.
 
Stereotaxic radiosurgery is not an uncommon treatment for brain tumors.
However, older systems lack the sophisticated tracking devices of the new
technology Adler and his colleagues are fine-tuning. More conventional
stereotaxic units require screwing the patient's skull into a frame to
prevent movement, a process that requires anesthesia and postsurgical
hospitalization while the bolt wounds heal.
 
Most notably, the spinal procedure performed on Murray would have been
impossible without a noninvasive system that allowed surgeons to keep the
beam on target without skeletal restraint or fixation, Adler explained.
"Stereotaxic radiosurgery is a natural for spinal cord tumor removal, but
before the robotic tracking system, which accounts for slight, normal
movement of patients undergoing surgery, we had no feasible method of
holding spinal patients absolutely rigid," Adler said.
 
Murray, who has a rare genetic disorder that causes tumors to proliferate
in sensitive areas of the body, said he opted for the new procedure because
he did not wish to face the strain and potentially crippling effects of
"one more invasive surgery." He had already lost his eyesight and was in
need of kidney dialysis, he explained, and mid-spinal surgery when he was
21 left him temporarily paralyzed after the blood supply to one of his arms
was cut off during surgery. With his disorder, known as Von Hippel-Lindau
disease, life has been "a matter of how much surgery you can take before
you die," Murray said wryly. Nevertheless, he said, he's grateful for a
procedure that may help him gain quality time in his life and avoid the
trauma of a more invasive surgery.
 
For Doris Stern, conventional radiosurgery "would have been too
discomforting, especially since she had had two tumors removed during the
previous year and her health wasn't adequate," Adler said.
 
"The surgery did what it was supposed to do," said Stern. "It was not
particularly uncomfortable . . .. It was over before I knew it. I think I
got up and walked out of the treatment room and walked to my car for the
trip back home." "Well, we did stay the night in Palo Alto to be close
just in case," recalled Jerry Stern, her husband. "But we didn't have any
problems."
 
Stern was the second of four persons to receive stereotaxic brain surgery
without an invasive frame screwed into the head. All four patients
underwent the CMSR procedure at Stanford. The first patient later died of
advanced cancer unrelated to the brain tumor. One of the two other patients
is doing well, while the other is receiving chemotherapy for widespread
cancer elsewhere in the body, said Adler. "What's new here is extremely
sophisticated computer software that stores an accurate map of the surgical
target -- in this case, a portion of the brain or spine -- charted from a
CT scan taken before the procedure. The X-ray tracking system guiding the
robot arm then matches what it sees with the computer-stored map," said
Richard Cox, the radiation physicist at Stanford who prepares the
individual treatment plans.
 
Unlike most modern procedures in radiation oncology, CMSR relies on
powerful but precisely aimed doses that can kill malignant tumors with a
few -- often only one -- treatment sessions, Adler said. In traditional
radiation therapy, physicians administer small doses of radiation over
weeks or months in order to allow healthy tissue surrounding the tumor to
recover from the onslaught. CMSR attacks the tumor with short pulses of
high-energy radiation from a device called a linear accelerator.
 
"Because we crossfire in many different directions, we can minimize the
radiation dose reaching healthy tissue and prevent injury," explained Adler.
"The robot arm is extremely flexible and can position the beam at any of a
large variety of angles to treat a small site."
 
Adler said CMSR offers potential in the future for many other types of
surgery, although "the benefits for brain and spinal cord surgery are
particularly compelling. We can avoid invasive operations on the brain, and
we can gain access to the surgical site without removing portions of the
skull. In the spine, the opportunity to improve accuracy and avoid damage
near the surgical site is equally compelling."
 
In addition to improving treatment, said Adler, CMSR can provide an
important financial savings for patients and third-party payers. "Because
we can offer a potent dose safely, we can expect to limit the treatment
time to one or two outpatient visits," Adler said. "While the cost of the
equipment is and will remain relatively high, we expect that the use of
stereotaxis for brain and spinal surgery will result in substantial savings
for patients."
 
Among the areas for savings are a virtual end to overnight hospital stays
for patients undergoing the procedure, shorter and less labor- intensive
treatment sessions, and lower rehabilitation costs through more effective
outcomes, Adler said.
 
He added that CMSR, like many other high-technology services, will be most
efficient if the service and equipment are consolidated in regional centers
rather than purchased and put into use at scattered sites where they will
not be in continual operation. Stanford is the first center to have
received FDA approval to perform CMSR studies, although other centers are
expected to begin trials in the near future, Adler said.
 
Except for the image-processing software, the procedure relies on
integrating commercially available components. The Stanford system is a
$1.35 million prototype radiosurgery unit, the Neurotron 1000, designed and
built by Accuray Inc., of Santa Clara, Calif. This system includes the
X-ray-guided robot arm, the controlling software and the high-energy X-ray
source. The graphics software was developed by Silicon Graphics Inc., of
Mountain View, Calif., the same company that created the on- screen
graphic images of dinosaurs in the motion picture "Jurassic Park."
Additional technical support was provided by the Sarnoff Institute, of
Princeton, N.J.
 
Other Stanford faculty members involved with the stereotaxic program are
Dr. Steven C. Hancock, associate professor of radiation oncology, and Dr.
Joseph C. Poen, assistant professor of radiation oncology.
 
The CMSR unit at Stanford was made possible in part by a gift from Sheikh
and Madam Hassan Enany of Saudi Arabia.
 
Note to Editors:
 
 
A demonstration, including photo opportunities, of Stanford's new
stereotaxic surgery suite will be held at 2 p.m.Thursday, July 27.
Attending the demonstration will be patient Mike Murray, who this week
became the first person in the world to receive spinal surgery using the
new, computer-targeted procedure; Dr. John Adler, who helped develop the
technique; and other medical and technical personnel involved with the
procedure.
 
The stereotaxic suite is located at Stanford University Clinic in the
lower level of the 900 Blake Wilbur Drive building. Parking is available
across the street in either the parking lot at 900 Welch Road or the
Stanford University Hospital parking garage. Additional opportunities for
interviews, photography and videotaping may be available Tuesday, Aug. 1,
when a brain tumor patient is scheduled for stereotaxic surgery.
 
Photos available upon request.
 
           CONTACT:  Stanford Medical Center
                     Mike Goodkind, 415/725-5376 or 723-6911
                     Hassaun Jones-Bey, 415/725-8047 or 723-6911
17:02 ET   JUL 27, 1995
 
 
John Cottingham                     "KNOWLEDGE is of two kinds: we know
[log in to unmask]                      a subject, or we know where we can
OR                                   find information upon it."
[log in to unmask]            Dr. Samuel Johnson