2012-2010 print media mkt. projects

The Department of Radiation Oncology at the University of Alabama at Birmingham (UAB) has partnered with Varian Medical Systems to become a showcase site for excellence in cancer care. UAB Radiation Oncology is proud to provide other cancer centers the opportunity to preview Varian equipment in a clinical setting.

Tours of Excellence

EXTENSIVE EXPERIENCE with delivering the most advanced radiation therapies available goes hand in handwith compassionate patient care at the UAB Department of Radiation Oncology.

About UABThe University of Alabama at Birmingham (UAB) Health

System is a network of services that provides a completecontinuum of care, including comprehensive cancer care, for patients from Alabama and all over the world. As one of theoriginal National Cancer Institute-designated comprehensivecenters created, the UAB Comprehensive Cancer Center hasmaintained the designation for 40 years. As a part of theUAB Comprehensive Cancer Center, the UAB Department of Radiation Oncology is a world leader in the delivery of cancercare with highly experienced clinical faculty, utilizing themost advanced treatment modalities and technologies availablein radiation therapy.

Depth of Expertise The UAB Department of Radiation Oncology has achieved an

international reputation for leadership through:

• A multidisciplinary approach to diagnosis and treatment • An extensive and highly experienced clinical faculty that

sub-specializes in the breadth of tumor types• A clinical care team of dosimetrists, nurses, and radiation therapists

who are trained and certifi ed to the highest standards.

Twelve faculty physicians are board-certifi ed in radiation oncol-ogy. Each clinical faculty physician sub-specializes by tumor type.Many hold PhD degrees in addition to their MD. Physicians stay abreast of the latest breakthroughs and technologies through theirresearch into novel treatment modalities and methods to improveradiation delivery. Because UAB is a teaching institution, its physi-cians are training the radiation oncologists of tomorrow.

The department physics team is the largest in Alabama. Itincludes seven PhD, board-certifi ed, medical physicists. Faculty members support quality patient care, perform research toenhance cancer care via the use of radiation physics, and teach inthe UAB physics and resident physician program.

Leadership and Innovation The UAB Department of Radiation Oncology is proud of its

contributions to advancing the use of radiation to treat cancer.Notable achievements include:

• First in the world to use Intrafraction Motion Review tech-nology from Varian to continually monitor tumor locationduring radiosurgery for lung cancer (2011)

James A. Bonner, MDSpecialty: Lung, Head & NeckResidency: University of MichiganMD: Wayne StateUniversity

James A Bonner M John Fiveash, MDSpecialty: CNS,GU, Ocular Melanoma, SarcomaResidency: MedicalCollege of GeorgiaMD: Medical College of Georgia

John Fi eash MDJennifer De Los Santos, MDSpecialty: Breast, GYNResidency: Universityof Texas-MD Anderson Cancer CenterMD: University of Florida

Jennifer De Los Rojymon Jacob, MDSpecialty: GI, GU,Sarcoma, Benign DiseaseFellowship: RoyalCollege of Radiologists, LondonMD: Kerala University,India

Roj mon Jacob MDMichael Dobelbower,MD, PhDSpecialty: CNS, GI, GU, Head & Neck, Lung, Benign DiseaseResidency: Universityof Alabama at BirminghamMD: Medical College of OhioPhD: Ohio State University

Michael Dobelbo e

UAB Department of Radiation Oncology: Clinical Faculty

Advanced treatment.Compassionate care.

The Kirklin Clinic at Acton Road

O. L. Burnett III, MDSpecialty: GU, Lymphoma,Pediatrics, Breast,Sarcoma, GIMD: Emory University

O L B rnett III MD

• Among the fi rst to use the TrueBeam™ system to treat lung, liver, pancreas, head & neck, brain, and spine cancers (2010)

• First in the United States to treat cancer patients withRapidArc® radiotherapy (2008)

• First in the region to perform intensity-modulated radiationtherapy (IMRT) (1999)

• Among the fi rst to perform linear accelerator-based radiosurgery• First to clinically use ultrasound-based image guidance (1974).• First department in the region to separate therapeutic radiology

from diagnostic radiology (1969).

Varian Technology at UAB The UAB Department of Radiation Oncology delivers the

following advanced modalities with Varian equipment: IMRT;image-guided radiation therapy (IGRT); and stereotactic body radiation therapy (SBRT). Professionals visiting UAB will be ableto view Varian products in action in a high volume departmentthat handles 30,000 treatment visits annually. In addition,department staff are available to answer questions about security,

integration and interfaces, support, and many other issuescommon to large academic radiation oncology departments.During the tour, visitors can see the following Variantechnology in use:

• TrueBeam™ STx system• Clinac® iX linear accelerators• On-Board Imager® (OBI) kV imaging system for treatment

localization- OBI radiographic: kV-kV anatomy matching & OBI CBCT

• RapidArc® radiotherapy technology• Varian Real-time Position Management™ (RPM) system for

respiratory gating• VariSource™ high dose rate afterloader• Varian Acuity™ treatment planning, simulation, and verifi ca-

tion system for fl uoroscopic simulation • ARIA® oncology information system• Eclipse™ treatment planning system for RapidArc, IMRT,

IGRT, and SBRT

Hazelrig-Salter Radiation Oncology Center

Robert Kim, MDSpecialty: GU, GYN,Ocular Melanoma,Orbital tumorsResidency: University of Alabama at BirminghamMD: Yonsei University, Korea

Robert Kim MD Christopher Willey, MD, PhDSpecialty: CNS, Head & Neck, Lung, PancreasResidency: Vanderbilt University MedicalCenterMD: Medical Universityof South CarolinaPhD: MedicalUniversity of SouthCarolina

Christopher Wille Eddy Yang, MD, PhDSpecialty: Prostate, Breast, Head & Neck, LungResidency: Vanderbilt University School of MedicineMD: University of Miami School of MedicinePhD: University of Miami School of Medicine

Edd Yang MD PhRuby Meredith, MD, PhDSpecialty: Breast, CNS, Lung, Lymphoma Residency: MedicalCollege of VirginiaMD: Ohio State UniversityPhD: Indiana University

R b Meredith MDKimberly Keene, MDSpecialty: Breast, GI, Head & Neck,Pediatrics, SkinResidency: Universityof VirginiaMD: University of Florida

Kimberl Keene MD Sharon Spencer, MDSpecialty: Head & Neck, Lung,Lymphoma, Pediatrics,Sarcoma, SkinResidency: TheUniversity of Alabamaat BirminghamMD: University of Alabama at Birmingham

Sharon Spencer M

Joint venture clinic

3100 Hansen Way, M/S MGM, Palo Alto, CA 94304For more information, contact your Varian representative.

RAD 5832A © 2010, 2012 Varian Medical Systems, Inc. Printed in USA 5/12 (350)

UAB Department of Radiation Oncology: Physics Faculty

Ivan Brezovich, PhDProfessor and DirectorPhD: Physics,University of Alabamaat BirminghamMS: Physics, University of Alabama atBirmingham

I an Bre o ich Ph

Richard Popple, PhDAssociate ProfessorPostdoctoralFellowship: University of Texas-MD AndersonCancer CenterPostdoctoralFellowship: Rice University

Richard Popple Ph

Jun Duan, PhDAssociate ProfessorPhD: Physics, Florida State UniversityMS: Medical Physics,University of Florida

J n D an PhD Prem Pareek, PhDAdjunct ProfessorPost-DoctoralFellowship: AlleghenyGeneral HospitalPhD: University of Nebraska

Prem Pareek PhD Rex Cardan, PhDAssistant ProfessorMedical PhysicsResidency: JamesG. Brown Cancer Center, University of LouisvillePhD: University of Texas at San Antonio

Re Cardan PhD

Xingen Wu, PhDAssistant ProfessorPostdoctoralFellowship: St. JudeChildren’s Research HospitalPostdoctoralFellowship: ZhejiangUniversity, China

Xingen W PhDSui Shen, PhDAssociate ProfessorPostdoctoral Fellowship: Universityof California at Davis Medical CenterPhD: University of California at Davis

S i Shen PhD

Advanced treatment.Compassionate care.

1700 6th Avenue South, Birmingham, AL 35249

The Tour ExperienceWith approximately 250,000 patient visits over the past

10 years, the UAB Department of Radiation Oncology offers a unique experience for professionals who want to learn aboutVarian technology. In 2010 and 2011, the UAB Departmentof Radiation Oncology hosted 32 visiting delegations. They represented community hospitals and university medicalcenters in 15 states, Canada, Mexico, and Brazil. UAB seeks

to customize each tour to the expressed interests of our visitorsin technology and types of cases treated. Radiation oncologists,neurosurgeons, physicists, dosimetrists, radiation therapists,and administrators have the opportunity to meet with UABcounterparts to exchange information and perspectives.The tour is often the beginning of continuing collaborations.

2012 UAB Radiosurgery Program Outcomes

UAB RAdiOsURgeRy PROgRAmHazelrig-salter Radiation Oncology CenterHSROC 2248 • 1700 6th Avenue South619 19TH ST SBIRMINGHAM AL 35249-6832

Non-Profit Org.U.S. Postage

PAIDPermit No. 1256Birmingham, AL

THe UAB COmPReHensive CAnCeR CenTeR

To refer a patient to the UAB Radiosurgery Program or schedule

appointments, contact UAB MIST at 1.800.822.6478.

For information about the UAB Radiosurgery Program, visit

uabmedicine.org/radiosurgery or uab.edu/radonc

The 2012 UAB Radiosurgery Program Outcomes booklet continues our effort to

communicate the strides our team has made in providing the best possible care to

the citizens of Birmingham and beyond.

We believe that the innovative techniques being harnessed within our program

make UAB a standout in patient care, research, and education. Advancing

treatments for optimal patient care and outcomes, as well as contributing to the

body of radiosurgery knowledge, is helping us work toward our ultimate goal of

developing better cancer therapeutics.

Two of our most exciting and cutting-edge treatments are discussed in this

booklet: triggered imaging technique for thoracic radiosurgery and Gamma

Knife radiosurgery for pituitary tumors. Each of these care tactics builds on the

Radiosurgery Program’s culture of collaboration and aim of providing our patients

with care that is as individualized as they are.

Triggered imaging for thoracic surgery is the newest development in motion

management at UAB and allows our care teams to even more accurately deliver

treatment to our patients. Thoracic radiosurgery is a technically complex

procedure that requires advanced technologies and multidisciplinary care, which

in Alabama are available uniquely at UAB.

For the treatment of pituitary adenomas that require salvage treatment, Gamma

Knife radiosurgery offers a precise, successful treatment modality. This salvage

therapy offers a high rate of controlling the tumor while minimizing potential

radiation-induced damage to adjacent normal tissue—an advantage that

decreases the risk of neurocognitive impairment and secondary malignancy.

These strides in patient treatment combined with our comprehensive team

approach are a hallmark of our radiosurgery program. We strive to deliver these

treatments with a patient-centered approach that allows for compassionate and

superior care for each and every patient.

We welcome any questions and comments you may have. If you would like to

learn more about the progress of our program, you may contact the Department

of Radiation Oncology at 205.934.5670.

John B. Fiveash, MDJames A. Bonner, MD

James M. Markert, Jr, MD, MPH

Kirby I. Bland, MD

At UAB, a new technique called triggered imaging is being

used to monitor tumor position in real-time during thoracic

radiosurgery. Triggered imaging is improving the accuracy and

precision of radiosurgery.

Radiosurgery is becoming an increasingly important tool for

managing lung cancer in non or marginally operable patients,

with outcomes comparable to surgery [8]. Numerous multi-

institutional clinical trials are ongoing, with early results showing

that this approach is safe and can result in cancer-free survivals

at three years similar to surgery with less morbidity in the short

term [8,10-13]. Reported control rates for thoracic tumors treated

with radiosurgery have reached more than 90 percent [14].

Thoracic radiosurgery is technically challenging, requiring accurate

targeting of the radiation beam so that the tumor receives the full,

ablative radiation dose while dose to healthy tissue is minimized. To

assure the best possible outcome, radiosurgery at UAB is performed

by a multidisciplinary team comprised of thoracic surgeons, radiation

oncologists, and medical physicists. Team members work in close

collaboration throughout the entire treatment process, from initial

consultation to the radiosurgical procedure, to patient follow up.

A particularly complex technical challenge facing thoracic

radiosurgery is respiratory motion of the tumor. Tumor motion is

highly variable; Tumors at the apex of the lung typically remain

stationary, while diaphragmatic tumors can move as much as

4 cm (K. M. Langen., And D. T. L. Jones, “Organ motion and its

management,” Int. J. Radiation Oncology Biol. Phys., Vol. 50, No. 1,

pp. 265–278, 2001). At UAB, management of tumor motion begins

with the thoracic surgeon. Using navigational bronchoscopy, the

surgeon implants fiducial markers in the tumor. Conventional

bronchoscopic techniques cannot reach many tumors, for which

the only other option for implanting fiducial markers is trans-

thoracically. The trans-thoracic approach has a pneumothorax rate

as high as 30% ( Yousefi S, Collins BT, Reichner CA, Anderson ED,

Jamis-Dow C, Gagnon G, Malik S, Marshall B, Chang T, Banovac F.

Complications of thoracic computed tomography-guided fiducial

placement for the purpose of stereotactic body radiation therapy.

Clin Lung Cancer. 2007 Jan;8(4):252-6.), compared to less than

6% for navigational bronchoscopy (Schroeder C, Hejal R, Linden

PA. Coil spring fiducial markers placed safely using navigation

bronchoscopy in inoperable patients allows accurate delivery of

CyberKnife stereotactic radio surgery. J Thorac Cardiovasc Surg.

Triggered imaging Technique for Thoracic Radiosurgery

A message From the ChairsTriggered Imaging Technique for Thoracic Radiosurgery............... 2-3

Gamma Knife Radiosurgery for Pituitary Tumors .................... 4-5

Quality and Outcome Measures ..6-7

Publications ..............................8

Educational Site Visits ................9

Clinical Faculty ........................10

Contents

2

Merle M. Salter Professor and Chair

UAB Department of Radiation Oncology

Fay Fletcher Kerner Professor and Chair

UAB Department of Surgery

Robert Y. Kim Endowed Chair, Professor and Vice Chair


Interim Associate Director for Clinical Research

UAB Comprehensive Cancer Center

James Garber Galbraith Endowed Chair, Professor and Director

UAB Division of Neurosurgery Cover photo: Dr. Sharon Spencer, Dr. Barton Gurthrie, and Dr. Kristen Riley

Participating FacultyJames A. Bonner, MDKirby I. Bland, MDMichael C. Dobelbower,

MD, PhDJohn B. Fiveash, MDBarton L. Guthrie, MDDouglas J. Minnich, MDRichard A. Popple, PhDKristen Riley, MDSharon A. Spencer, MD

Editorial SupportJohn BrinkerhoffValeria Pacheco-RubiJoey SlatskyFresia Vega

Above: Dr. Richard Popple

2010 Nov;140(5):1137-42. Epub 2010 Sep 20.; Harley DP, Krimsky WS,

Sarkar S, Highfield D, Aygun C, Gurses B. Fiducial marker placement

using endobronchial ultrasound and navigational bronchoscopy for

stereotactic radiosurgery: an alternative strategy. Ann Thorac Surg.

2010 Feb;89(2):368-73; discussion 373-4). At UAB, we have had no

pneumothoraces with fiducial placement. The markers are typically

implanted during a diagnostic bronchoscopy, so the patient does not

need to undergo an additional procedure.

After bronchoscopy, the radiation oncologist and the thoracic

surgeon consult to determine the best treatment strategy. Once the

decision has been made to use radiosurgery, the patient receives a CT

scan to identify the tumor and nearby healthy structures that need

to be protected from the radiation. The CT scan is the next stage

in the management of tumor motion. During the scan, an optical

technique is used to measure the chest motion. The scan is a special

type, called a 4D CT, composed of 10 complete 3-dimensional CT

image sets. Each CT corresponds to a snapshot at a different point in

the respiratory cycle, which is correlated with the chest motion.

One method to ensure that the tumor remains within the radiation

beam is to simply treat the entire volume encompassed by tumor

motion. However, this approach results in a relatively large volume

of lung receiving a high radiation dose (Wu J, Li H, Shekhar R,

Suntharalingam M, D’Souza W., “An evaluation of planning techniques

for stereotactic body radiation therapy in lung tumors,” Radiother

Oncol. 2008 Apr;87(1):35-43. Epub 2008 Mar 24). This approach is

particularly undesirable in the context of the high, ablative radiation

dose delivered by radiosurgery. An alternative approach preferred

at UAB is to gate the radiation beam, turning it on only at the end

of expiration, when the lung is at rest and the tumor is relatively

stationary. The scans are evaluated for tumor motion by the medical

physicist, who determines the optimal point in breathing cycle

to turn the radiation beam on and off. The medical physicist also

locates the fiducial markers in the CT images. The radiosurgery team

then develops and tests an individualized treatment plan. The dose

distribution is sculpted to tightly conform to the tumor and limit

radiation dose to the lung, chest wall, and other healthy tissues.

The final and most critical step in motion management is treatment,

usually one to five treatments over one to two weeks. Prior to

starting radiation delivery, x-rays are taken to ensure that the tumor

is in the correct position. The fiducial markers are easily seen in the

x-rays and are compared with outlines of the expected position,

derived from the 4D CT scan and the preparation by the medical

physicist. If the outline and the image on the x-ray do not coincide,

the patient is shifted until they do. When the patient is in the correct

position and the tumor is centered in the radiation beam, the beam

is turned on. During treatment, the same optical technique used

during the CT scan is used to track the patient’s breathing. The

optical system instructs the radiation beam to turn on at the end of

expiration and to turn off as inspiration begins.

The newest development in motion

management at UAB is triggered

imaging. Using triggered imaging,

we observe the fiducial marker

during treatment delivery. At the

beginning of each expiratory cycle,

immediately before the radiation

beam comes on, an x-ray image is

taken. The image is displayed along

with a circle around the expected

position of the fiducial marker. The radiation oncologist and thoracic

surgeon are thus able to monitor the position of the tumor in

real time as the treatment progresses. If the patient moves or the

breathing pattern changes, treatment is suspended, the position

corrected, and treatment resumed.

Thoracic radiosurgery is a technically complex procedure requiring

advanced technologies and multidisciplinary care, which in Alabama

are available uniquely at UAB. The experienced team at UAB will

continue to remain at the forefront of innovation as the technologies

for thoracic radiosurgery continue to evolve.

Pituitary adenomas represent one of the most common intracranial neoplasms.

Found in 10-15% of the population, these benign tumors often pose complex

management situations. While the majority of pituitary tumors can be treated with

medication or surgery alone, a significant proportion require salvage treatment.

Pituitary tumors that generally require additional treatment include functional tumors

not controlled with surgery or medication and nonfunctional tumors that recur

following surgery.

Gamma Knife radiosurgery offers a precise, successful treatment modality for pituitary

adenomas. Tumor growth can be controlled in 90% of patients treated, frequently with

reduction in tumor volume. Radiosurgery effects on biochemical cure vary depending

on tumor type. (Sheehan et al 2011). Patient selection for radiosurgery depends on

endocrine evaluation, tumor size, location, growth pattern, and pathology.

Pituitary adenomas are classified according to size and endocrine profile.

Microadenomas, defined as smaller than 10mm in size, rarely cause clinical concern

due to size, but may require treatment if they are functionally active. Macroadenomas,

larger than 10mm, may cause visual difficulty if the optic pathways become

compressed by the tumor. Located at the base of the skull, pituitary tumors occur

adjacent to many critical structures such as the optic nerves, optic chiasm, cranial

nerves within the cavernous sinuses, carotid artery, and brainstem. The location of

these tumors requires specialized knowledge and techniques for management.

Additionally, pituitary adenomas often have either hormone overproduction

or deficiency. All management decisions regarding these tumors require a

multidisciplinary approach. While many tumors require only observation, a significant

number have endocrine and anatomical implications that must be addressed.

The UAB Neurosurgical Pituitary Disorders Clinic offers comprehensive evaluation

and care for patients with pituitary tumors. Following diagnosis, whether for

an incidentally found tumor or a symptomatic pituitary adenoma, appropriate

evaluation includes imaging review, endocrine evaluation, and often ophthalmologic

evaluation. Observation, medical therapy, surgery, and radiation therapy comprise the

armamentarium of treatment options for pituitary tumors.

gamma Knife Radiosurgery for Pituitary Tumors

43

Above: Dr. Douglas Minnich and Dr. Michael Dobelbower

Above: Fiducial marker during

treatment delivery

Functional tumors, those that result in overproduction of hormones,

often require multi-modality treatment. Prolactinomas are the most

common functional pituitary tumors. For prolactinomas, medical

therapy with dopamine agonists is the standard of care for first line

treatment. However, for patients not controlled with medication

or who do not tolerate medication, surgery and radiation may be

utilized. Pituitary tumors resulting in acromegaly, from excess

growth hormone and Cushing’s disease from excess ACTH, require

treatment regardless of size. Surgery is the first line of treatment

for the majority of these tumors. In cases where a surgical cure is

not achieved, additional therapy is paramount due to the significant

increase in morbidity and mortality if hormone overproduction is not

controlled. For patients with Cushing’s disease, there is no available

medical treatment to suppress steroid production. Radiosurgery

offers a potential for cure.

In acromegaly, controversy exists regarding the timing of radiation

therapy related to medical therapy. Medical therapy is often

successful in normalizing growth hormone production, but at a

significant yearly financial cost. Without controversy, is the use of

radiation when patients are not controlled with medical therapy.

However, there may be utility in radiation treatment in an attempt to

shorten the length of time a patient requires medical therapy. Data

suggests radiosurgery offers a greater than 50% rate of cure for

growth hormone secreting pituitary tumors. (Sheehan et al 2011)

For residual nonfunctional adenomas following surgery, Gamma

Knife radiosurgery is considered if there is observed tumor growth

over time or if the pathology is atypical pituitary adenoma, indicating

a potentially higher chance of tumor recurrence. The recurrence rate

of pituitary adenomas following surgery is reported around 20%.

Recurrence is influenced by extent of resection and tumor pathology.

Patients with pituitary adenomas are followed postoperatively with

yearly imaging. The majority of tumor recurrence is seen in the first

five to seven years postoperatively, but can occur later.

Following any radiation to the sella, patients should have a yearly

endocrine evaluation. Secondary hypopituitarism is the most

common side effect of radiosurgery for pituitary adenomas. The

incidence of secondary hormone deficits increases with time, thus

necessitating long-term endocrine surveillance. Gamma Knife

radiosurgery may have a decreased rate of endocrine dysfunction

over fractionated radiation due to the ability to precisely deliver

radiation to the tumor and limit radiation to the normal gland in

some patients. (Taussky et al 2011) In addition to minimizing dose to

the normal pituitary gland, radiosurgery allows for treatment delivery

that minimizes radiation to adjacent normal brain cells. This precision

decreases the risk of neurocognitive impairment and secondary

malignancy from radiation.

Appropriate patient selection and experienced treatment planning

help to minimize the risks of radiosurgery. The anatomical location of

the pituitary tumor necessitates careful evaluation and planning to

limit toxicity to critical structures. Gamma Knife, with frame based

head fixation, offers the most precise method of radiation delivery.

In this area, millimeters matter. At UAB, we feel strongly that Gamma

Knife precision allows us to perform safe, successful radiosurgery for

pituitary tumors.

For more information or to refer a patient to the Multidisciplinary

Pituitary Clinic: Contact Michel Thomas, Office Assistant to Dr. Riley,

at 205-996-2461.

Gamma Knife Stereotactic Body Radiation Therapy

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1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

Timeline of our Success

Quality and Outcome measure

TIMElInE oF oUr SUccESS

SElEcTED DISEASE SITES

1992 First patient treated with stereotactic radiosurgery (linac)

1995 First CNS case treated with Gamma Knife

1999 First FDA-approved IMRT- delivering device

2001 First in Alabama to offer RPM Gating System

2005 First in Alabama to treat with stereotactic body radiation therapy

2008 First in the U.S. to treat with volumetric arc therapy (RapidArc™)

2010 One of the world’s first facilities to offer TrueBeam system (third in the United States)

2011 First in the world to use “Triggered Imaging” Technology from Varian Medical Systems to continually monitor tumor location during radiosurgery for lung cancer

The UAB Radiosurgery Program offers state-of-the-art treatment therapies

and technologies for a wide variety of body sites, including central nervous

system (CNS), lung, spine, and others. CNS tumors essentially are treated with the Gamma Knife. Tumors or

malformations of the liver, lung, spine, and other body sites are treated using

Stereotactic Body Radiation Therapy (SBRT). The following charts show the

outcome measures of selected body sites treated with cranial radiosurgery

and SBRT at UAB.

6

Sheehan JP, Pouratian N, Steiner L, Laws ER, Vance ML. Gamma Knife surgery for pituitary adenomas: factors related to radiological and endocrine outcomes. J Neurosurg. 2011 Feb: 114 (2) 303-9.

Taussky P, Kalra R, Coppens J, Mohebali J, Jensa R, Couldwell WT. Endocrinological outcome after pituitary transposition (hypophysopexy) and adjuvant radiotherapy for tumors involving the cavernous sinus. J Neurosurg. 2011 Jul; 115(1): 55-62.

Gamma Knife 2114Benign 432Malignant 1083Trigeminal Neuralgia 409Vascular 188Seizure 2

Stereotactic Body radiation Therapy 363Brain 36Lung 129Liver 24Other 53Spine 1215

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2012 Radiosurgery noteworthy Publications

Clark GM, Popple RA, Prendergast BM, Spencer SA, Thomas EM,

Stewart JG, Guthrie BL, Markert JM, Fiveash JB: Plan quality

and treatment planning technique for single isocenter cranial

radiosurgery with volumetric modulated arc therapy. Practical Radiation Oncology. Published online February 1, 2012. Citation

Pending.

Clark G, Popple R, Young PE, Fiveash J: Feasibility of single-

isocenter volumetric modulated arc radiosurgery for the treatment

of multiple brain metastases. Int J Radiat Oncol Biol Phys. 2010 Jan

1;76(1):296-302.

Fiveash J, Guthrie BG, Duan J, Markert JM, DeLosSantos JF, Keene

KS, Spencer SA, Dobelbower MC, Arafat W, Popple RA. A Phase II

Isotoxicity Study of Spinal Radiosurgery/SBRT. Int. J. Radiat. Oncol. Biol. Phys. 2010 November; 78(3) Suppl: S278.

Parker JN, Zheng X, Luckett W, Markert JM, Cassady KA. Strategies

for the rapid construction of conditionally-replicating HSV-1

vectors expressing foreign genes as anticancer therapeutic agents.

Mol Pharm. 2011 Feb 7;8(1):44-9. Epub 2010 Dec 17. Review. PMID:

21142023

Pearson BE, Markert JM, Fisher WS, Guthrie BL, Fiveash JB, Palmer

CA, Riley K. Hitting a moving target: evolution of a treatment

paradigm for atypical meningiomas amid changing diagnostic

criteria. Neurosurg Focus. 2008;24(5):E3. PMID: 18447742

Popple RA, Dieterich S, Duan J, Fiveash JB. Dependence of Dose-

volume Values on Calculation Method for Paraspinal Radiosurgery.

Int. J. Radiat. Oncol. Biol. Phys. 2010 November; 78(3) Suppl: S783.

Popple RA, Fiveash JB, Brezovich IA, Bonner JA: RapidArc radiation

therapy: first year experience at the University of Alabama at

Birmingham. Int J Radiat Oncol Biol Phys. 2010 Jul 1;77(3):932-41.

Prendergast BM, Bonner JA, Popple RA, Spencer SA, Fiveash JB,

Keene KS, Cerfolio RJ, Minnich DJ, Dobelbower MC. Dosimetric

analysis of imaging changes following pulmonary stereotactic

body radiation therapy. J Med Imagina Radiat Oncol 2011

Feb;55(1):90-6.

Prendergast Brendan M, Popple Richard A., Clark Grant M., Spencer

Sharon A., Guthrie Bart, Markert James, Fiveash John B: Improved

clinical efficacy in CNS stereotactic radiosurgery using a flattening

filter free linear accelerator. Journal of Radiosurgery and SBRT.

Accepted for publication Journal of Radiosurgery and SBRT, August

9, 2011. Citation Pending.

Sawrie SM, Fiveash JB. Caudell, JJ: Stereotactic Body Radiation

Therapy for Liver Metastases and Primary Hepatocellular

Carcinoma: Normal Tissue Tolerances and Toxicity. Cancer Control April 2010, Vol. 17, No. 2:111-119

Spencer S, Swaid N, Barton G, Young P, Wong W, Meredith RF,

Markert J, Fisher W, Wu X, Nordal R, Fiveash J. Impact of Dose Rate

on Outcomes of Gamma Knife Radiosurgery in Patients with Face

Pain. Radiosurgery 2010 7:360-5.

Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, Sneed

PK, Chao ST, Weil RJ, Suh J, Bhatt A, Jensen AW, Brown PD, Shih

HA, Kirkpatrick J, Gaspar LE, Fiveash JB, Chiang V, Knisely JPS,

Sperduo CM, Lin N, Mehta M: Summary Report on The Graded

Prognostic Assessment: An Accurate and Facile Diagnosis-Specific

Tool to Estimate Survival for Patients with Brain Metastases. J Clin Oncol, 29, 2011.

Sperduto PW, Kased N, Roberge D, Xu Z, Shanley R, Luo X, Sneed

PK, Chao ST, Weil RJ, Suh J, Bhatt A, Jensen AW, Brown PD, Shih

HA, Kirkpatrick J, Gasper LE, Fiveash JB, Chiang V, Knisely JP,

Sperduto CM, Lin N, Mehta M: Effect of Tumor Subtype on Survival

and the Graded Prognostic Assessment for Patients with Breast

Cancer and Brain Metastases. Int J Radiat Oncol Biol Phys 2011,

April 14.

Stewart JG, Sawrie SM, Bag A, Han X, Fiveash JB: Management of

Brain Metastases. Current Treatment Options in Neurology. 2010

Jul;12(4):334-46.

Vaphiades MS, Spencer SA, Riley K, Francis C, Deitz L, Kline LB.

Radiation-induced ocular motor cranial nerve palsies in patients

with pituitary tumor. J Neuroophthalmol. 2011 Sep;31(3):210-3.

The Leksell Gamma Knife is a highly advanced

technology that delivers 201 tightly focused cobalt

radiation beams to one point in the brain. The

radiation beams and doses are so precise they affect only the targeted

tissue and generally spare the surrounding healthy

tissue.

Stereotactic Body Radiation Therapy (SBRT) uses a high

dose of radiation shaped to conform to the patient’s tumor. It delivers radiation

to the intended target and avoids healthy tissue.

Small tumors are accurately identified and located with

precise coordinates.


crAnIAl rADIoSUrGErY ProcEDUrES

SBrT ProcEDUrES

87

visiTing insTiTUTiOn dATe OF visiT

Gulfport Memorial Hospital – Gulfport, MS 1/31/2011

Rush University – Chicago, IL 2/17/2011

Torrance Memorial Medical Center – Torrance, CA 2/18/2011

University of Kentucky – Lexington, KY 3/24/2011

Memorial Hospital – Chattanooga, TN 4/29/2011

Hospital Israelita Albert Einstein – São Paulo, Brasil 4/12/2011

West Michigan Cancer Center – Kalamazoo, MI 5/6/2011

Corpus Christi Cancer Center – Corpus Christi, TX 5/20/2011

Medical Center at Bowling Green – Bowling Green, KY 6/3/2011

Memorial Hospital – Gulfport, MS 6/9/2011

Eastern Health-Cancer Care Program Dr. H. Bliss Murphy Cancer Centre – NL, Canada 6/16/2011

Baptist Hospital – Miami, FL 7/1/2011

University of Puerto Rico Cancer Center – San Juan, Puerto Rico 8/4/2011 8/5/2011

Vanderbilt University Medical Center – Nashville, TN 8/26/2011

Jackson-Madison County General Hospital – Jackson, TN 9/8/2011 9/9/2011

University of Tennessee Hospital – Knoxville, TN 9/23/2011

Cancer Treatment Centers of America – Tulsa, OK 10/28/2011

Renown Medical Center – Reno, NV 11/11/2011

Radiological Associates of Sacramento – Sacramento, CA 11/18/2011

Hospital Médica Sur – Mexico City, D.F., Mexico 12/9/2011

Tours of excellenceUAB SITE VISITS 2011

UAB Radiosurgical Clinical Faculty

James A. Bonner, MDRadiation OncologySpecialties: lung, head and neck

Ivan Brezovich, PhDMedical PhysicistSpecialty: physics

O.L. Burnett III, MDRadiation OncologySpecialties: GU, gynecological, lymphoma, pediatrics, breast, sarcoma, GI

Rex A. Cardan, PhDMedical PhysicistSpecialty: physics

Robert Cerfolio, MDThoracic SurgerySpecialty: thorax

Melissa Chambers, MD Neurosurgery Specialties: brain tumors

Jennifer De Los Santos, MDRadiation OncologySpecialties: breast, gynecological, lung, lymphoma, sarcoma, skin

Michael Dobelbower, MD, PhDRadiation OncologySpecialties: benign disease, CNS, GI, GU, head and neck

Juan Duan, PhDMedical PhysicistSpecialty: physics

Winfield S. Fisher, MDNeurosurgerySpecialties: brain tumors, face pain, vascular

John Fiveash, MDRadiation OncologySpecialties: CNS, GU, gynecological, ocular melanoma, pediatrics, sarcoma

Barton L. Guthrie, MDNeurosurgerySpecialties: brain tumors, face pain

Rojymon Jacob, MDRadiation OncologySpecialties: CNS, GI, GU, sarcoma, benign disease

Kimberly Keene, MDRadiation OncologySpecialties: breast, GI, head and neck, pediatrics, skin

Robert Kim, MDRadiation OncologySpecialties: GU, gynecololgical, ocular melanoma, orbital tumors

James A. Markert, MDNeurosurgerySpecialties: brain tumors, spinal radiosurgery, trigeminal neuralgia

Ruby Meredith, MD, PhDRadiation OncologySpecialties: benign disease, breast, CNS, GI, head and neck, lung, lymphoma, orbital tumors, skin

Douglas J. Minnich, MDThoracic OncologySpecialty: thorax

Richard Popple, PhDMedical PhysicistSpecialty: physics

Prem Pareek, PhDMedical PhysicistSpecialty: physics

Kristen Riley, MDNeurosurgerySpecialties: brain tumors, epilepsy, spine

Sui Shen, PhDMedical PhysicistSpecialty: physics

Sharon Spencer, MDRadiation OncologySpecialties: breast, CNS, GI, gynecological, head and neck, lung, lymphoma, orbital tumors, ocular melanoma, pediatrics, sarcoma, skin

Christopher Willey, MD, PhDRadiation OncologySpecialties: breast, CNS, head and neck, lung, pancreas

Xingen Wu, PhDMedical PhysicistSpecialty: physics

Eddy Yang, MDRadiation OncologySpecialties: lung, GU, breast, head and neck

109 Partial listing of programs visiting the University of Alabama at Birmingham to learn about treatment techniques on the TrueBeam linear accelerator

2011 UAB Radiosurgery Program Outcomes

UAB RAdiOsURgeRy PROgRAmHazelrig-salter Radiation Oncology CenterHSROC 2248 • 1700 6th Avenue South619 19TH ST SBIRMINGHAM AL 35249-6832

Non-Profit Org.U.S. Postage

PAIDPermit No. 1256Birmingham, AL

THe UAB COmPReHensive CAnCeR CenTeR

To refer a patient to the UAB Radiosurgery Program or schedule

appointments, contact UAB MIST at 1.800.822.6478.

For more information about the UAB Radiosurgery Program,

visit uabmedicine.org/radiosurgery or uab.edu/radonc.

The 2011 UAB Radiosurgery Program Outcomes booklet

continues our effort to provide our friends and colleagues

an informative picture of how we are handling our mission

to provide care to the citizens of Alabama and the region.

In UAB’s culture of collaboration, the Department of

Radiation Oncology and the Department of Surgery

developed the UAB Radiosurgery Program. This special

approach to patient care provides every patient requiring

stereotactic radiation surgery with a reasoned and thorough

evaluation of their situation, resulting in a recommended

treatment plan. Treatment outcomes are completed as

patients are treated and followed. The goal is to optimize

treatments and add to the body of knowledge of the field.

As this interspecialty relationship has flourished, the

program has maintained growth and the outstanding score

in patient satisfaction you will see in this report.

As an update, we are pleased to report that the linear

accelerator based radiosurgery program moved into a new

building, the Hazelrig-Salter Radiation Oncology Center, in

March 2010, providing our patients and their families with a more comfortable, attractive

setting. Included in the new space is one of the first TrueBeam radiation devices in the

world. TrueBeam is living up to its promise of delivering precise radiosurgical treatments

in significantly less time than previously possible with other machines. For our patients,

reduced treatment time means more accurate delivery and increased comfort. The

improvement in delivery accuracy reduces the potential for collateral damage to nearby

healthy tissue.

This type of continually updated technology, a faculty with more than 253 total years

of experience in radiosurgery, and a clinical team that understands and supports our

patients’ individual needs all combine to pursue our goal of eventually curing cancer.

We invite your questions and comments. If you wish to learn more about the

progress of our program, you may contact the Department of Radiation Oncology at

205.934.5670.

Kirby I. Bland, MD Lung cancer is a disease that is too well known by too many people. Only 100

years ago, lung cancer was considered a rare and uncommon entity [1]. Medical

literature at that time regarding lung cancer was limited to small studies and

individual reports of an uncommon disease [2-5]. Now, scarcely three generations

later, it is a leading cause of death and morbidity in the United States, with

approximately 196,000 cases diagnosed each year. Of those, 158,000 will die from

their disease.

Surgical resection of lung cancer has long been considered the standard of care

when attempting to cure patients when the disease is diagnosed early and in a well-

localized fashion. Unfortunately, many patients present with advanced disease that

is not amenable to operative resection. Other patients, who otherwise would have

resectable disease, are not candidates for surgery because of comorbidities such as

heart disease. For patients who are unable to undergo surgical resection, high-dose

radiation that is delivered daily for several weeks has been used in an effort to cure.

This approach has produced less than satisfying results [6, 7]. Now, with the advent

of thoracic radiosurgery, outcomes that are more comparable to surgery are possible

[8].

Radiosurgery is not a new technology. It has been used for many years to treat

cancers in the central nervous system [9]; however, its use in the lung has been

Thoracic Radiosurgery

A message From the Chairs

1. Witschi H. A Short History of Lung Cancer. Toxicological Sciences. 2001;64:4-6.

2. Ryn TC, Meyer FW. Bronchogenic Carcinoma. U.S. Naval Bulletin. 1949;49(5):863-867.

3. Hirsch EF. Bronchogenic Carcinoma of the Lung. Illinois Med J. 1949;95(4):241-243.

4. Corsello JN, O’Brien WB. Primary Bronchogenic Carcinoma, a report of 47 cases. Rhode Island Med J. 1947;30(1):15-20.

5. Eagan JC. Bronchgenic Carcinoma of the Lung; report of a case. Nebraska State Med J. 1948;31:94-98.

6. Haffty B, et al. Results of radical radiation therapy in clinical stage 1, technically operable non-small cell lung cancer. Int J Radiat Oncol Biol Phys. 1998;69-73.

7. Dosoretz D, et al. Radiation therapy in the management of medically inoperable carcinoma of the lung: Results and implications for future treatment strategies. Int J Radiat Oncol Biol Phys. 1992;24:3.

8. Palma D, Visser O, Lagerwaard F, Slotman B, Belderbos J, Senan S. A Population-Based Matched-Pair Comparison of Stereotactic Radiotherapy vs. Surgery for the Treatment of Stage I NSCLC in Elderly Patients. Chicago Multidiciplinary Symposium in Thoracic Oncology, Chicago, Dec 2010.

9. Leksell L. The Steroetaxic Method and Radiosurgery of the Brain. Acta chir Scand. 1951;102:316.

Thoracic Radiosurgery ............ 2-3

Truebeam: Image Guided Radiotherapy and Radiosurgery .. 4-5

Locations ..................................5

Quality and Outcome Measures ..6-7

Publications ..............................8

Faculty Presentations .................9

Educational Site Visits ................9

Clinical Faculty ........................10

Contents

2

Merle M. Salter Professor and Chair


Fay Fletcher Kerner Professor and Chair


Cover photo: Depicts a patient on UAB’s new Truebeam with Dr. Douglas Minnich, Dept of Surgery, and Dr. Chris Dobelbower, Dept of Radiation Oncology

James A. Bonner, MD

Participating Faculty

James A. Bonner, M.D.

Kirby I. Bland, M.D.

Michael C. Dobelbower, M.D., Ph.D.

John B. Fiveash, M.D.

Barton L. Guthrie, M.D.

Douglas J. Minnich, M.D.

Richard A. Popple, Ph.D.

Christopher D. Willey, M.D., Ph.D.

Editorial Team

John C. Brinkerhoff

Catina M. Diggs

Valeria Pacheco-Rubi

Fresia Vega-Thompson

Data Collection Support

Ginna Blaylock

Kathy Bowman

Joey P. Slatsky

a far more challenging problem for numerous reasons. The first among these is

that the lung is in motion. Thus, the challenge is to hit a moving target with great

precision. Other challenges include visualizing small tumors with great accuracy

and dose calculation challenges in the lungs that are unique from other sites in

the body. Technological advances in radiation treatment machines, such as the

Varian TrueBeam™ STx radiosurgical machine and the superDimension® navigational

bronchoscopy system, have solved many of the problems associated with thoracic

radiosurgery. In fact, numerous currently ongoing clinical trials are testing the

safety and efficacy of expanding the use of thoracic radiosurgery. Early results from

several institutions have shown that this approach is not only safe, but also can

produce similar cancer-free survivals to surgery at 3 years and have less morbidity

in the short term [8,10-13]. In fact, control rates for thoracic tumors treated with

radiosurgery now range from 80 percent to more than 90 percent [14].

Thoracic radiosurgery at UAB is performed by a multidisciplinary team including

thoracic surgeons, radiation oncologists, dosimetrists, and medical physicists. The

process begins with the diagnosis of malignancy. New tools for the diagnosis of

cancer with minimally invasive approaches, such as navigational bronchoscopy are

used at UAB to diagnose the malignancy and to place markers into the tumor for

targeting by the radiation machine. Once a diagnosis is made, patients undergo a

specialized planning CT scan to identify the tumor and nearby structures that need

to be protected from the radiation. The radiosurgery team then develops and tests

an individualized treatment plan. Radiation is subsequently delivered, usually in one

to five treatments over the next 1 to 2 weeks, with each treatment generally lasting

less than 30 minutes. The treatments are performed on an outpatient basis, are

painless, and only require that the patient lie still during treatment.

Thoracic radiosurgery is an exciting and promising new therapy for patients with

medically inoperable early-stage lung cancer. The ultimate role that thoracic

radiosurgery will have in the treatment of lung cancer is yet to be defined.

Large clinical trials evaluating its efficacy are exploring new indications for this

treatment, and the long-term effects remain unknown. What is clear is that thoracic

radiosurgery does offer a chance for cure in patients who previously would have had

limited treatment options.

10. Rusthoven KE, Kavanagh BD, Burri SH, Chen C, Cardenes H, Chidel MA, Pugh TJ, Kane M, Gaspar LE, Schefter TE. Multi-Institutional Phase I/II Trial of Stereotactic Body Radiation Therapy for Lung Metastases. Journal of Clin Oncol. 2009;27(10).

11. Timmerman R, Papiez L, McGarry R, Likes L, DesRosiers C, Frost S, Williams M. Extracranial Stereotactic Radioablation Results of a Phase I Study in Medically Inoperable Stage I Non-small Cell Lung. Chest. 2003;124:1946-1955.

12. Fakiris AJ, McGarry RC, Yiannoutsos CT, Papiez L, Williams M, Henderson MA, Timmerman R. Steroetactic Body Radiation Therapy for Early-Stage Non-Small-Cell Lung Carcinoma: Four-Year Results of a Prospective Phase II Study. Int J Radiat Oncol Biol Phys. 2009;75(3):677-682.

13. Louie AV, Rodrigues G, Hannouf M, Palma DA, Cao JQ, Yaremko BP, Malthaner R, Mocanu JD, Zaric GS. Is Stereotactic Body Radiotherapy Warranted in Medically Operable Stage I NSCLC? A Markov Model Based Decision Analysis. Chicago Multidisciplinary Symposium in Thoracic Oncology, Chicago, Dec 2010.

14. Timmerman RD, Park C, Kavanagh BD. The North American Experience with Stereotactic Body Radiation Therapy in Non-small Cell Lung Cancer. J Thorac Oncol. 2007;2(7) Supplement 3.

Last year, the UAB Department of Radiation Oncology was among the first institutions

in the world to deploy a TrueBeam™ system for image-guided radiotherapy and

radiosurgery. Designed to treat a moving target with unprecedented speed and

accuracy, TrueBeam incorporates numerous technical innovations that dynamically

synchronize imaging, patient positioning, motion management, and treatment

delivery during a radiotherapy or radiosurgery procedure.

One important feature of the TrueBeam system is its high-intensity mode, which

makes it possible to deliver doses up to four times faster than can be accomplished

with other radiosurgery machines, significantly shortening treatment times. Cutting

down treatment time by a factor of two to four makes a big difference to patients

and can enhance treatment accuracy by leaving less time for tumor motion during

dose delivery. Using the TrueBeam system, a standard intensity-modulated treatment

that would typically take 10 minutes can be completed in less than two minutes.

Simple RapidArc treatments, which used to be done in 2 minutes, can now be

completed in 1 minute.

UAB clinicians have used the TrueBeam system to deliver fast, highly precise

treatment for tumors of the brain, spine, lung, liver, prostate, head and neck, and

pancreas. The system is extremely flexible, allowing for selection of an optimal

treatment approach in each case, from intensity-modulated radiotherapy (IMRT)

to stereotactic radiosurgery (SRS), from stereotactic body radiotherapy (SBRT) to

volumetric arc (RapidArc®) therapy. In addition, a new gated RapidArc capability

allows it to be used with tumors that are subject to respiratory motion, such as many

tumors of the lung or liver.

“Intelligent” automation further speeds treatments with an up to fivefold reduction

in the number of steps needed for imaging, positioning, and treating patients. A

nine-field IMRT treatment that would have required 52 separate steps or mouse-

clicks using earlier generations of technology can now be completed in less than ten

TrueBeam: state-of-the-Art image-guided Radiotherapy and Radiosurgery

43

steps. As a result, UAB radiation therapists can focus more of their attention on the

patient and on the progress of the treatment.

The precision of a TrueBeam system is measured in increments of less than a

millimeter. This accuracy is made possible by the system’s sophisticated architecture,

which establishes a new level of synchronization between imaging, patient

positioning, motion management, beam shaping, and dose delivery technologies.

Accuracy checks are performed every 10 milliseconds throughout the treatment.

More than 100,000 data points are monitored continually as a treatment progresses,

ensuring that the system maintains a true isocenter, or focal point of treatment.

The TrueBeam imager, which is used to localize a tumor just prior to treatment, can

generate 3-D anatomical images in 60 percent less time, with a 25 percent reduction

in X-ray dose to the patient, when compared with earlier generations of technology.

We are excited about this powerful and fully integrated high-end system and regard

it as a significant step forward in our ongoing commitment to providing patients

with access to the best of available contemporary radiosurgical technology.

LOCATIONS

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Stereotactic Radiosurgery Special Procedures

2005 20062007 20082009 2010

S p e c i a l P r o c e d u r e s o n S e l e c t e d D i s e a s e S i t e s

Gamma KnifeBenignMalignantTrigeminal NeuralgiaVascular

1883393981352157

Stereotactic Body Radiation TherapyBrainLungLiverSpineOther

2651394198950

UAB HighlandsCranial radiosurgery with the Leksell Gamma Knife® 1201 11th Avenue South Birmingham, AL 35205

The Kirklin Clinic® at Acton RoadSBRT with TomoTherapy® and with the Varian EX® linear accelerator 2145 Bonner Way Birmingham, AL 35243

Hazelrig-Salter Radiation Oncology CenterSBRT with the Varian iX linear accelerator and TrueBeam accelerator1700 6th Avenue SouthBirmingham, AL 35233

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1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 2010

Timeline of Our Success

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TIMeLINe OF Our SuCCeSS

SeLeCTeD DISeASe SITeS







2010 One of the world’s first facilities to offer TrueBeam system (third in the United States)

The UAB Radiosurgery Program offers state-of-the-art treatment therapies

and technologies for a wide variety of body sites, including central nervous

system (CNS), lung, spine, and others. CNS tumors essentially are treated with the Gamma Knife. Tumors or

malformations of the liver, lung, spine, and other body sites are treated using

SBRT. The following charts show the outcome measures of selected body

sites treated with cranial radiosurgery and SBRT at UAB.

65

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2005 2006 2007 2008 2009 2010

2011 Radiosurgery noteworthy Publications

Brown PD, Kee AY, Eshleman JS, Fiveash JB. Adjuvant whole brain radiotherapy: strong emotions decide but

rationale studies are needed: in regard to Brown et al. (Int J Radiat Oncol Biol Phys. 2008;70:1305-1309). In

reply to Drs. Larson and Sahgal. Int J Radiat Oncol Biol Phys. 2009 Sep;75(1):316-7.

Clark GM, Popple RA, Young PE, Fiveash JB. Feasibility of single-isocenter volumetric modulated arc

radiosurgery for treatment of multiple brain metastases. Int J Radiat Oncol Biol Phys. 2010;76(1):296-302.

Dobelbower MC, Nabell L, Markert J, Carroll W, Said-Al-Naief N, Meredith RF. Cancer of the Tonsil presenting

as Central Nervous System Metastasis: A Case Report. Head & Neck. 2009;31:127-30.

Prendergast BM, Bonner JA, Popple RA, Spencer SA, Fiveash JB, Keene KS, Cerfolio RJ, Minnich DJ,

Dobelbower MC. Dosimetric analysis of imaging changes following pulmonary stereotactic body radiation

therapy. J Med Imaging Radiat Oncol. 2011;55(1):90-6.

Prendergast BM, Popple RA, Spencer SA, Minnich DJ, Dobelbower MC. Flattening filter-free mode improves

clinical efficiency for pulmonary and hepatic SBRT in American College of Radiation Oncology Annual

Meeting. San Diego, Feb 2011.

Sawrie SM, Fiveash JB, Caudell JJ. Stereotactic body radiation therapy for liver metastases and primary

hepatocellular carcinoma: normal tissue tolerances and toxicity. Cancer Control. 2010;17(2):111-119.

Spencer SA, Swaid S, Guthrie B, Young P, Wond W, Meredith RF, Markert J, Fisher W, Wu J, Nordal R, Fiveash

JB. Impact of Dose Rate on Outcomes of Gamma Knife Radiosurgery in Patients with Face Pain. McDermott

MW (ed): Radiosurgery. Basel, Garger, 2010, 7: 360-365.

Stewart JG, Sawrie SM, Bag A, Han X, Fiveash JB. Management of Brain Metastases. Curr Treat Options Neurol.

2010;12(4):334-346.

2010 Radiosurgery publication mistake: The following publication is not from our Dr. Sharon Spencer-UAB.

Spencer SS. Gamma knife radiosurgery for refractory medial temporal lobe epilepsy: Too little, too late? Neurology.

2008;70(19):1654-5. No abstract available. PMID: 18458224 [PubMed - indexed for MEDLINE]

The Leksell Gamma Knife is a highly advanced technology that delivers 201 tightly fo-

cused cobalt radiation beams to one point in the brain. The

radiation beams and doses are so precise they affect

only the targeted tissue and relatively spare the surround-

ing healthy tissue.

Stereotactic Body Radiation Therapy (SBRT) uses a high

dose of radiation shaped to conform to the patient’s tumor. It delivers radiation to the intended target and

avoids healthy tissue. Small tumors are accurately identi-fied and located with precise

coordinates.


CrANIAL rADIOSurGerY PrOCeDureS

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MIChAeL DOBeLBOwer, MD, PhD Thoracic radiosurgery, how we got here (and what we think we know)8th Annual Simon Kramer Institute Oncologic Symposium, Simon Kramer Institute of

Therapeutic Oncology, New Philadelphia, PA

Audience: Physicians with practices related to oncology

May 22, 2010

JOhN B. FIveASh, MDInitial Clinical experience with TrueBeamASTRO Convention, UCSD, San Diego, CA

October 30, 2010

eclipse/TrueBeam Clinical Demonstration University of Florida Radiosurgery Course, Orlando, FL

December 10, 2010

Advancing Technology for Therapeutic Gain (Clinical Forums CMe)Denver, CO

January 26, 2011

ChrISTOPher D. wILLeY, MD, PhDSBrT and Clinical Applications in radiation TherapyEastern Shore Oncology Conference, Salisbury, MD

November 12, 2009

4D IGrT – Certain Phase of respirationAmerican Association of Medical Dosimetrists Region IV Dosimetry Conference, Burlington, VT

October 24, 2009

Adaptive radiotherapy: New Technologies & New Applications for IG-IMrT, SBrT, and SrS Varian Clinical Solutions Forum, Old Greenwich, CT

March 12, 2009

Faculty Presentations

UAB Radiosurgical Clinical Faculty

James A. Bonner, MDRadiation OncologySpecialties: lung, head and neck

Ivan Brezovich, PhDMedical PhysicistSpecialty: physics

O.L. Burnett III, MDRadiation OncologySpecialties: GU, gynecological, lymphoma, pediatrics, breast, sarcoma, GI

Robert Cerfolio, MDThoracic SurgerySpecialty: thorax

Jennifer De Los Santos, MDRadiation OncologySpecialties: breast, gynecological, lung, lymphoma, sarcoma, skin

Michael Dobelbower, MD, PhDRadiation OncologySpecialties: benign disease, CNS, GI, GU, head and neck

Juan Duan, PhDMedical PhysicistSpecialty: physics

Winfield S. Fisher, MDNeurosurgerySpecialties: brain tumors, face pain, vascular

John Fiveash, MDRadiation OncologySpecialties: CNS, GU, gynecological, ocular melanoma, pediatrics, sarcoma

Barton L. Guthrie, MDNeurosurgerySpecialties: brain tumors, face pain

Rojymon Jacob, MDRadiation OncologySpecialties: CNS, GI, GU, sarcoma, benign disease

Kimberly Keene, MDRadiation OncologySpecialties: breast, GI, head and neck, pediatrics, skin

Robert Kim, MDRadiation OncologySpecialties: GU, gynecololgical, ocular melanoma, orbital tumors

James A. Markert, MDNeurosurgerySpecialties: brain tumors, spinal radiosurgery, trigeminal neuralgia

Ruby Meredith, MD, PhDRadiation OncologySpecialties: benign disease, breast, CNS, GI, head and neck, lung, lymphoma, orbital tumors, skin

Douglass J. Minnich, MDThoracic OncologySpecialty: thorax

Richard Popple, PhDMedical PhysicistSpecialty: physics

Prem Pareek, PhDMedical PhysicistSpecialty: physics

Kristen Riley, MDNeurosurgerySpecialties: brain tumors, epilepsy, spine

Sui Shen, PhDMedical PhysicistSpecialty: physics

Sharon Spencer, MDRadiation OncologySpecialties: breast, CNS, GI, gynecological, head and neck, lung, lymphoma, orbital tumors, ocular melanoma, pediatrics, sarcoma, skin

Christopher Willey, MD, PhDRadiation OncologySpecialties: breast, CNS, head and neck, lung, pancreas

Xingen Wu, PhDMedical PhysicistSpecialty: physics

Eddy Yang, MDRadiation OncologySpecialties: lung, GU, breast, head and neck

eDuCATIONAL SITe vISITS TO uAB

• McLeod Medical Center, August 2010

• Renown Medical Center, Reno, NV,

September 2010

• Exeter Hospital Manchester, NH,

October 2010

• Mayo Clinic, Jacksonville, FL, October

2010

• Baptist Memorial Hospital-DeSoto,

Southaven, MS, November 2010

• Landenau Hospital, Wynnewood, PA,

November 2010

• Memorial Medical Center, Modesto, CA,

November 2010

• University of Arkansas For Medical

Sciences, Little Rock, AR, December

2010

• Florida Hospital, Orlando, FL, December

2010

109

T h e U A B C o m p r e h e n s i v e C A n C e r C e n T e r

To refer a patient to the UAB Radiosurgery

Program or schedule appointments,

contact UAB MIST at 1.800.822.6478.

For more information about the

UAB Radiosurgery Program,

visit uabmedicine.org/radiosurgery.

outcomes2010

UAB RAdiosURgeRy PRogRAm

A M

eS

SA

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nts c ha i r le t ter s 2-3

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qual i t y and outcome

measures 5-6

program over v iew 7

pat ient ex per ience/

loc at ions 8

research/publ ic at ions 9

cl in ic a l f acul t y 10

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1642350861301130


1722

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pArTiCipATing FACUlTy

Ivan A. Brezovich, Ph.D.

Michael C. Dobelbower, M.D., Ph.D.

John B. fiveash, M.D.

Barton L. guthrie, M.D.

Richard A. Popple, Ph.D.

Sui Shen, Ph.D.

ediToriAl TeAm

John C. Brinkerhoff

Linda f. gunter

Valeria M. Pacheco-Rubi

fresia W. Vega

dATA ColleCTionsUpporT

Mark e. Bassett

Jordan M. DeMoss

Ronnie A. Hathorne

Teresa L. Honeycutt

Joey P. Slatsky

Co

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THe UAB RADIoSURgeRy PRogRAM is proud to introduce the first of its Outcomes

book series. The Outcomes book contains a thorough description of the program and

provides valuable data on patient volume and outcome measures on selected treatment

procedures and disease sites. for more information about the UAB Radiosurgery Program,

visit uabmedicine.org/radiosurgery.

Radiosurgery outcomes 2010

2

James A. Bonner, M.D.Chair, Department of Radiation OncologyThe University of Alabama at Birmingham

This is our inaugural UAB Radiosurgery Program Outcomes book. I am hopeful that our 2010 edition provides you with some valuable insights into the clinical progress occurring in the fields of stereotactic radiosurgery (SRS) and stereotactic body radiation therapy (SBRT).

Patients who place their trust in our care are our greatest priority. It is our mission to combine excellence in clinical care, research, and education toward the pursuit of curing cancer for our patients. As an institution, we have chosen to develop a multidisciplinary approach to the treatment of patients with complicated tumors requiring stereotactic radiation therapy. This program, as part of the UAB Comprehensive Cancer Center, has successfully integrated sub-specialized faculty and staff from both the Department of Radiation Oncology and the Department of Surgery. This structure will lead to further innovations, revolutionizing the diagnosis and treatment of patients with complicated cancer processes. Tumors that were untreatable just a few years ago now can be treated successfully with SRS or SBRT.

Furthermore, our faculty and staff understand that the diagnosis of cancer is a life-altering event for both the patient and their loved ones. Having the most advanced technology available with a highly experienced faculty is not enough. Our team of associates makes a point to understand our patients’ specific needs and subsequently provides compassionate care and social support services to ease these trying times.

As you explore this Outcomes book, I hope you find it to be a valuable tool as you learn more about the progress in SRS and SBRT and how it can help you and your patients. For further information, you may contact the Department of Radiation Oncology at (205)934-5670.

Sincerely,

James A. Bonner, M.D.Merle M. Salter Professor and ChairUAB Department of Radiation Oncology

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IIn April 1992 the first patient in Alabama was treated at UAB with stereotactic radiosurgery for a primary brain tumor. Physics team members modified a standard linear accelerator to provide the extra precision required for this exacting procedure. Because radiosurgery was in its early stages and commercial turnkey equipment was not available, many of the instruments and devices were designed and manufactured in the laboratory. The institution-designed equipment provided for submillimeter precision—the most accurate delivery reported at that time.1 The 1992 multidisciplinary team included neurosurgeons, radiation oncologists, and medical physicists.

With the expansion of this modality to arteriovenous malformations and brain metastases, the number of patients benefiting from radiosurgery increased rapidly to the point that a system dedicated to central nervous system treatments became necessary. The UAB Radiosurgery Program added a Leksell Gamma Knife® (model B) in 1995. The first Gamma Knife was replaced in 2004 with a more advanced system that included automatic positioning (model C). With more than 4,300 patient treatments performed by the end of 2009, the UAB Radiosurgery program is one of the most experienced programs in the nation.

Further progress in linac technology and image guidance made it possible to extend stereotactic radiosurgery to areas beyond the brain. In 1999 UAB placed the Nomos Peacock® system into operation and initiated its stereotactic body radiation therapy (SBRT) program. This device was the first FDA-cleared, intensity-modulated radiation therapy (IMRT) device available. UAB was the first program in Alabama to treat a patient with IMRT and 32nd in the world. In 2001 a system based on a multileaf collimator with sliding window technology replaced the Nomos Peacock system, substantially shortening treatment delivery time. This technology allowed UAB faculty to treat tumors located near critical structures such as the spinal cord, heart, and gastrointestinal tract. Additionally, in 2001 UAB was the first center in Alabama to offer the Real-time Position Management™ (RPM) system, a noninvasive, video-based system that allows for clean imaging and treatment of lung, breast, and upper abdominal sites. RPM works by measuring the patient’s breathing patterns (their gate) and aligning their respiratory cycle to the tumor’s position. Only when alignment is correct is the linear accelerator allowed to emit a beam of radiation.

UAB’s installation of the 14th TomoTherapy® unit in the world in 2004 was another first in Alabama. The TomoTherapy unit was the first clinically viable CT-based image guidance platform for radiation therapy. With the ability to image a tumor immediately before the application of the therapy beam, targeting precision was greatly enhanced increasing the physician’s ability to treat complicated tumors with radiation.

Building on its longstanding experience with radiosurgery and SBRT, in May 2008 UAB became the first institution in the United States to treat patients with the newly developed volumetric arc therapy (RapidArc). The system provides high-quality CT images with greatly shortened treatment times, reducing the possibility of patient movement between imaging and radiation delivery. UAB physicists were instrumental in the final research stages of development and testing of RapidArc before its FDA approval.

In June 2010, UAB added the TrueBeam STx, the most advanced tool in our radiosurgery armamentarium. The TrueBeam STx was designed from the ground up to provide state-of-the-art radiotherapy techniques and to develop the techniques of the future. Flattening filter-free radiosurgical beams deliver the highest dose rates available on any radiation delivery system, up to four times faster than standard linear accelerators. In combination with RapidArc delivery technology, the TrueBeam STx can complete radiosurgery in minutes rather than hours.

Currently UAB offers a variety of advanced technologies for frame-based or frameless radiosurgery and SBRT for tumors. UAB brings together a multidisciplinary team of radiation oncologists, neurosurgeons, and physicists with decades of experience in radiosurgery to design and evaluate each treatment plan. The radiosurgery team at UAB continues to evaluate, pursue, and develop the most advanced technology available for cancer treatment in the world.

Historyo U R

Kirby I. Bland, M.D.Chair, Department of SurgeryThe University of Alabama at Birmingham

We are delighted to introduce our first UAB Radiosurgery Program Outcomes book. The UAB Radiosurgery Program began in 1992, and since then we have successfully treated thousands of patients. We remain one of the busiest radiosurgical centers in the world.

Our goal is to offer every patient compassionate, superior care by maximizing the value of our encounter with each patient. The UAB Radiosurgery Program accomplishes this in a number of ways. First and foremost is the unique collaborative effort among surgeons and radiation oncologists who are members of the UAB Comprehensive Cancer

Center. This unique approach provides every patient with a thoughtful and thorough evaluation of their situation and therapeutic options. Second is the broad array

of contemporary radiosurgical technology that is available to best carry out the treatment plan. Finally, we follow up with each patient and focus on outcomes such that treatments can be optimized, as we understand more about the value of our approach to the spectrum of disorders you will see in this report.

The results of our attention to patient needs and maximizing our value to the patient is evidenced by our growth and consistently high patient satisfaction depicted in this report. We take this as an indication of excellent service to our

patients and the community. It is our mission to continue along this path of optimal patient care.

Sincerely,

Kirby I. Bland, M.D.Fay Fletcher Kerner Professor and Chair


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1Brezovich, Ivan, Prem Pareek, Eugene Plott, and Richard Jennelle. “Quality Assurance System to Correct for Errors Arising from Couch Rotation in LINAC-Based Stereotactic Radiosurgery.” Int. J. Radiation Oncology Biol. Phys Vol. 38 (1997): 883-890.

The Leksell Gamma Knife is a highly advanced technology that delivers 201 tightly focused cobalt radiation beams to one point in the brain. The radiation beams and doses are so precise they affect only the targeted tissue and relatively spare the surrounding healthy tissue.

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Cranial Radiosurgery Procedures

Cranial Radiosurgery Procedures

Stereotactic Body Radiation Therapy (SBRT) uses a high dose of radiation shaped to conform to the patient’s tumor. It delivers radiation to the intended target and avoids healthy tissue. Small tumors are accurately identified and located with precise coordinates.

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The UAB Radiosurgery Program offers state-of-the-art treatment therapies and technologies for a wide variety of body sites including central nervous system (CNS), lung, spine, and others. CNS tumors essentially are treated with the Gamma Knife. Tumors or malformations of the liver, lung, spine, and other body sites are treated using SBRT. The following charts show the outcome measures of selected body sites treated with cranial radiosurgery and SBRT at UAB.0

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SBRT Procedures

AexperiencePAt i e n t

The UAB Radiosurgery Program strives to provide high quality health care with compassion. To track our success and to measure our patient satisfaction we ask our patients about their experience with our clinical services, personnel, and facilities. We attend to every detail, from parking issues to checkout services. Even though we have consistently been highly rated by our patients as an outstanding health care provider, we are dedicated to improving our services.

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94.2 92.3 98.6 93.1 95.2 96.8 93.3 91.6 92.0 86.7 90.5 85.8

Note: The patient satisfaction chart for Hazelrig-Salter Radiation Oncology Center includes overall performance for Stereotactic Body Radiation Therapy (SBRT).

At UAB a team of sub-specialists from multiple disciplines—radiation oncology, surgery, medical oncology, GYN oncology, radiology, and pathology—evaluate multiple parameters related to an individual patient’s cancer and derive a treatment plan based on UAB expertise and current protocols. If radiosurgery is indicated, the patient will be referred to the UAB Radiosurgery Program. Relying on their 18 years of experience treating patients with complicated tumors, the radiation oncologists and surgeons will design a patient-specific plan and implement it with the most advanced technology available.

The UAB Radiosurgery Program is a recognized national leader in providing quality comprehensive care and using state-of-the-art technology. Starting in 1992 with a linear accelerator, the program added the Leksell Gamma Knife in 1995. Soon thereafter the program expanded its treatment procedures by introducing stereotactic body radiation therapy (SBRT). SBRT enabled physicians to treat spinal and lung tumors with high precision. Technological leadership on treatment therapies contributes to the program’s success, but the UAB Radiosurgery Program also offers an extensive, highly qualified group of neurosurgeons and radiation oncologists with many years of experience in this field that sub-specialize in the full range of tumor types.

Cranial radiosurgery at UAB offers patients with certain disorders a safe, effective alternative to conventional neurosurgery. The program offers cranial radiosurgery on the Leksell Gamma Knife at UAB Highlands. The highly advanced technology allows UAB specialists to treat

arteriovenous malformations, benign and malignant brain tumors, select vascular malformations, and other functional brain disorders without an incision and without damage to healthy tissue.

The UAB Radiosurgery Program offers SBRT on the TomoTherapy unit at The Kirklin Clinic at Acton Road and also on the Varian iX linear accelerator with RapidArc at the Hazelrig-Salter Radiation Oncology Center. In addition, in June 2010, TrueBeam Technology became available at the Hazelrig-Salter Radiation Oncology Center. This highly advanced radiation therapy allows physicians to deliver high-energy X-ray beams precisely to tumor targets throughout the body. Physicians can use higher doses of radiation and reduce toxicity, resulting in fewer side effects and shorter treatment times as compared with other treatment modalities. Lungs are the most common SBRT treatment site, but spine, liver, and other sites also can be treated.

UAB offers cranial radiosurgery and SBRT as part of its comprehensive cancer program recognized for its excellent care, innovative research, specialists, and advanced technology.

Stereotactic RadiosurgeryA t U A B

Top left: Leksell Gamma Knife®

Bottom left: Varian TrueBeam™ STxBottom right: TomoTherapy Hi·Art®

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Locations

U A B H i g h l a n d sCranial radiosurgery with the Leksell Gamma Knife® 1201 11th Avenue South Birmingham, AL 35205

T h e K i r k l i n C l i n i c ® a t A c t o n R o a dSBRT with TomoTherapy® and with the Varian EX® linear accelerator 2145 Bonner Way Birmingham, AL 35243

H a z e l r i g - S a l t e r R a d i a t i o n o n c o l o g y C e n t e rSBRT with the Varian iX linear accelerator and TrueBeam accelerator1700 6th Avenue SouthBirmingham, AL 35233

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hitting a moving target: evolution of a treatment paradigm

for atypical meningiomas amid changing diagnostic criteria

Pearson BE, Markert JM, Fisher WS, Guthrie BL, Fiveash JB, Palmer CA, Riley K. Neurosurgy Focus. 2008; 24(5):E3. PMID: 18447742 [PubMed - indexed for MEDLINE]

predictors of distant brain recurrence for patients with newly

diagnosed brain metastases treated with stereotactic

radiosurgery alone

Sawrie SM, Guthrie BL, Spencer SA, Nordal RA, Meredith RF, Markert JM, Cloud GA, Fiveash JB. Int. J Radiat Oncol Biol Phys. 2008 Jan 1; 70(1):181-6. Epub 2007 Sep 4. PMID: 17768015 [PubMed - indexed for MEDLINE] gamma knife radiosurgery for refractory medial temporal

lobe epilepsy: Too little, too late?

Spencer SS. Neurology. 2008 May 6;70(19):1654-5. No abstract available. PMID: 18458224 [PubMed - indexed for MEDLINE]

Treatment of adults with recurrent malignant glioma

Nabors LB, Fiveash J. Expert Rev Neurother. 2005 Jul;5(4):509-14. Review.PMID: 16026234 [PubMed - indexed for MEDLINE] Brain metastases

Shaffrey ME, Mut M, Asher AL, Burri SH, Chahlavi A, Chang SM, Farace E, Fiveash JB, Lang FF, Lopes MB, Markert JM, Schiff D, Siomin V, Tatter SB, Vogelbaum MA. Curr Probl Surg. 2004 Aug;41(8):665-741. Review. No abstract available. PMID: 15354117 [PubMed - indexed for MEDLINE]

radionecrosis of the inferior occipital lobes with altitudinal visual

field loss after gamma knife radiosurgery

Monheit BE, Fiveash JB, Girkin CA. J Neuroophthalmol. 2004 Sep;24(3):195-9. PMID: 15348983 [PubMed - indexed for MEDLINE]

initial treatment of melanoma brain metastases using gamma knife

radiosurgery: An evaluation of efficacy and toxicity

Radbill AE, Fiveash JF, Falkenberg ET, Guthrie BL, Young PE, Meleth S, Markert JM. Cancer. 2004 Aug 15;101(4):825-33. PMID: 15305416 [PubMed - indexed for MEDLINE]

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faculty U A B R a d i o s u r g i c a l c l i n i c a l

James A. Bonner, m.d.Radiation OncologySpecialties: lung, head and neck

ivan Brezovich, ph.d.Medical PhysicistSpecialties: physics

o.l. Burnett iii, m.d.Radiation OncologySpecialties: G.U., gynecological, lymphoma, pediatrics, breast, sarcoma, G.I.

Jennifer de los santos, m.d.Radiation OncologySpecialties: breast, gynecological, lung, lymphoma, sarcoma, skin

michael dobelbower, m.d., ph.d.Radiation OncologySpecialties: benign disease, CNS, G.I., G.U., head and neck

Juan duan, ph.d.Medical PhysicistSpecialties: physics

Winfield s. Fisher, m.d.NeurosurgerySpecialties: brain tumors, face pain, vascular

advancementsR e s e A R c h

UAB is one of America’s premier research universities, with a world-renowned academic medical center and 80 interdisciplinary research centers. UAB consistently ranks among the top 20 academic medical centers in funding from the National Institutes of Health. The UAB Radiosurgery Program contributes to this success by exploring new research methods and performing studies and clinical trials in an effort to bring new solutions and hope for our patients and their families. Two prospective clinical trials of radiosurgery have been conducted at UAB. Four others are planned and may be potentially performed. Active or completed studies include:

• A phase 2 trial of temozolomide and radiosurgery in patients with 1 to 4 brain metastases. In this trial systemic chemotherapy was utilized in an attempt to decrease the risk of new brain tumors after radiosurgery alone.

• A phase 2 trial of spinal radiosurgery. In this study the quality assurance procedures for spinal stereotactic radiation were defined. Patients were treated with a single large dose of focused radiation instead of 2 to 6 weeks of treatment.

John Fiveash, m.d.Radiation OncologySpecialties: CNS, G.U., gynecological, ocular melanoma, pediatrics, sarcoma

Barton l. guthrie, m.d.NeurosurgerySpecialties: brain tumors, face pain

rojymon Jacob, m.d.Radiation OncologySpecialties: CNS, G.I., GU, sarcoma, benign disease

Kimberly Keene, m.d.Radiation OncologySpecialties: breast, G.I., head and neck, pediatrics, skin

robert Kim, m.d.Radiation OncologySpecialties: G.U., gynecololgical, ocular melanoma, orbital tumors

James A. markert, m.d.NeurosurgerySpecialties: brain tumors, spinal radiosurgery, trigeminal neuralgia

ruby meredith, m.d., ph.d.Radiation OncologySpecialties: benign disease, breast, CNS, G.I., head and neck, lung, lymphoma, orbital tumors, skin

richard popple, ph.d.Medical PhysicistSpecialties: physics

prem pareek, ph.d.Medical PhysicistSpecialties: physics

Kristen riley, m.d.NeurosurgerySpecialties: brain tumors, epilepsy,spine

sui shen, ph.d.Medical PhysicistSpecialties: physics

sharon spencer, m.d.Radiation OncologySpecialties: breast, CNS, G.I., gynecological, head and neck, lung, lymphoma, orbital tumors, ocular melanoma, pediatrics, sarcoma, skin

Christopher Willey, m.d., ph.d.Radiation OncologySpecialties: breast, CNS, head and neck, lung, pancreas

Xingen Wu, ph.d.Medical PhysicistSpecialties: physics

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publicationsn o t e w o R t h y

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