Gamma Knife®- Cutting Edge Technology in the Treatment of

Brain Metastases

CNSA Annual Congress 2016

ANGELA McBEAN

Gamma Knife® CNC State-wide Care Coordinator

Gamma Knife® Centre of QLD

Princess Alexandra Hospital

• Overview of Gamma Knife® Radiosurgery

• Advantages & Limitations

• Brain metastases & Gamma Knife®

• Gamma Knife® Centre of QLD service

detail

• Brain metastases & Gamma Knife®

• State-wide Telehealth service

• Advantages of Gamma Knife® to the

health system

•Advantages of Gamma Knife® to the patient

OVERVIEW

Radiosurgery is surgery using radiation, that is, the

destruction of precisely selected areas of tissue using

ionizing radiation rather than excision with a blade.

Stereotactic = Precision

- 3D co-ordinate system

- Enables precise localisation

- Particularly useful in brain

• Small lesions

• Adjacent critical structures

Radiosurgery- Destruction/ablation of

tissue- Single high dose 15-24 Gy- Fundamentally different

from radiotherapy

Stereotactic Radiosurgery

Stereotactic Machines

Linac based SRS

Cyber Knife

Gamma Knife Intracranial Radiosurgery unit

ADVANTAGES:

•Accuracy to ‘hit the target’0.2mm

•Rapid dose fall offLess dose to adjacent normal/critical tissue

•Ability to treat more intracranial conditions

•EfficiencySame day service

•Requires multidisciplinary inputNeurosurgeonRadiation Oncologist

Why Gamma Knife Perfexion??

LIMITATIONS:

•Intracranial disease only•Small lesions ≤4cm

Clinical indications for Gamma Knife Radiosurgery

Significance of Brain Metastases (BMs)

• 20-40% of cancer population – Lung, breast, melanoma

• Improved systemic treatments & control of extracranial disease

• Improved detection (MRI – resolution)– Access to MRI

• Morbidity and mortality

• OS remains poor (6 months)

• Approx 50% have ‘limited BMs’

• Historically – few options for intracranialPD > Surgery (+/- PORT) vs WBRT

METASTATIC DISEASE:

Who is referred?•New patients

•Patients with recurrence

•Patients who have had surgery for consideration of cavity boost

•Complex cases – surgery not recommended

Inclusion criteria:•Solid malignancy confirmed histologically or radiologically

•All patients with a single brain metastasis

•New patients with 2-5 brain metastases for consideration of local therapy

•ECOG 0-2

•Controlled or controllable extra-cranial disease, prognosis >6/12

•Complex cases requiring advice regarding sequencing or selection of treatment modalities

•Old patients for consideration of further local therapy at recurrence

Patient Selection Criteria

Service Detail• State-wide service

– Based at PAH– Only Public Service provider in Australia

• Multidisciplinary team approach– Neurosurgeons, Radiation Oncologists, Radiation Therapists, Medical Physicists, Nursing and

Allied Health staff.

• Weekly Multidisciplinary Meeting (10:00 – 11:00 Thursday)– Dial in facilities (regional)– Welcome attendance (metropolitan)

• Weekly MDT Clinic (Wednesday 10:00-12:00)– Held on site PAH– Telehealth service for regional and remote patients (UQ Centre for Online Health)

• Treatment Day- Single treatment delivered in Outpatient setting- Frame attachment → Planning CT →Planning MRI → Treatment Plan → Treatment

Gamma Knife Centre of QLD @ PA HOSPITAL

Malignant

1 GLIOMA

12 MELANOMA

18 LUNG

4 BREAST

2 CRC

3 RCC

2 OVARIAN

Benign55 TUMOUR

6 FUNCTIONAL

5 VASCULAR

TOTAL 108

Service to Date: 26/10/15 – 06/05/16

100th Patient Treatment: 26th April 2016

• Cost saving through:- reduced bed days (median LOS 8 days)

- reduced theatre schedules and associated costs

- reduced ICU / High Dependency Unit admissions

- reduction in number of Radiation Therapy external beam / Stereotactic

treatments

- reduction in Medical, Nursing, Radiation Therapist staff costs

- assists in reduction of hospital / Radiation Therapy waiting periods

• Cost saving to Metro South Health Service (average)

- 45 / 108 patients were surgical candidates

- Cost of surgical procedure: $32,316pp Total = $1,454,220

- Cost of Gamma Knife treatment: $7,000pp Total = $ 315,000

- Cost saving to MSHS Total = $1,139,220

ADAVANTAGES OF GAMMA KNIFE®: Health Service Perspective

- no lengthy treatment episodes

- no hospital admission / open surgery / anaesthetic

- minimal discomfort / downtime and early resumption of normal activities

- increased precision of treatment with minimal side effects

- availability of service to regional patients

ADAVANTAGES OF GAMMA KNIFE®: Patient Perspective

State-wide Telehealth Service

GEOGRAPHIC DISTRIBUTION: QUEENSLAND

- Largest proportion of people who live in outer regional, remote, and very remote areas compared to other Australian jurisdictions.

- Non-Indigenous population is largely centred in major city areas (60%), with only 2.8% living in remote or very remote areas

- In contrast, 22% of Indigenous Queenslanders live in remote or very remote areas, with only 28% in major cities.

2010 Report of the Chief Health Officerhttps://www.health.qld.gov.au/cho_report/2010/2profile.asp

State-wide Telehealth Service

• QLD Health comprehensive Tele-health network• ≥ 100km from Brisbane – eligible for Tele-health service• New & Review appointment types• Ease of collaboration with referring Dr if required• No travel to Brisbane for pre and post clinic review• Reduced time off work ( benign )• Improved quality of life ( malignant )• 38 (19%) of total patients seen via tele-health service

Case Study

• 79 yo female, lives w/ husband (81 yo) • Lives in remote area of South West QLD - 385km from Brisbane• Nearest hospital: Roma (82km)• Cannot drive, husband limited driving• Relies on Daughter to attend medical appointments• Hx: Metastatic Melanoma

- 2006: R) WLE & SLNBx of Melanoma R) foot- 2013: Solitary brain met L) insular region treated w/ LINAC SRS28Gy/2#

- 2014: Recurrence in brain treated w/ LINAC SRS- 2015: further recurrence in brain treated w/ LINAC SRS- Gamma Knife to 2 x lesions

Pre & Post Treatment MRI

QUESTIONS/COMMENTS???

Gamma Knife® Surgery. [online] Irsa.org. Available at: <http://www.irsa.org/gamma_knife.html> [Accessed 13 January 2016].

Lippitz, B., 2008. Treatment of Brain Metastases Using Gamma Knife Radiosurgery — The Gold Standard. European Neurological Review, 3(1), p.81.

Lee, C., Lee, S., Cho, J., Yang, K. and Kim, S., 2011. Therapeutic Effect of Gamma Knife Radiosurgery for Multiple Brain Metastases. J Korean Neurosurg Soc, 50(3), p.179.

Team, E., 2016. Leksell Gamma Knife® Perfexion™. [online] Elekta AB. Available at: <https://www.elekta.com/radiosurgery/leksell-gamma-knife-perfexion.html> [Accessed 13 January 2016].

REFERENCES

Chin, L. & Regine, W., 2008. Principles and Practice of Stereotactic Radiosurgery. Springer: Boston

ANGELA MCBEANGAMMA KNIFE CNC STATE-WIDE CARE COORDINATOR

(07) 3176 1908

angela.mcbean@health.qld.gov.au