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