Radiosurgery, Neurosurgery Department, UF College of Medicine
Understanding Radiosurgery: A Guide for You and Your Family
You have been referred to the University of Florida Shands Neurological Center for evaluation and possible treatment with the LINAC Scalpel, also known as the stereotactic linear accelerator. Researchers at the University of Florida have been pioneers in the development and refinement of stereotactic radiosurgery and radiotherapy. UF neurosurgeons, radiation physicists, and radiation therapists established one of the first LINAC radiosurgical centers in the country at the UF Shands Neurological Center in 1988 and continue to seek ways to refine the LINAC system.
A team of health care professionals, specializing in the use of computer assisted stereo-tactic radiosurgery to treat certain brain disorders or tumors, will participate in your evaluation and plan an individualized course of treatment.
ABOUT THE UF SHANDS NEUROLOGICAL CENTER
The UF Shands Neurological Center is a "Center of Excellence" within Shands Hospital, a highly respected research and tertiary care facility serving the southeastern United States. Located in Gainesville on the campus of the University of Florida, Shands Hospital is the primary teaching facility for the Health Science Center, a major academic division of the university. UF faculty members in the Health Science Center's College of Medicine are members of the medical staff at Shands Hospital. Each faculty member pursues research, teaching, and patient care activities that support state of the art medical care for patients.
WHAT IS STEREOTACTIC RADIOSURGERY?
Stereotactic radiosurgery is the use of a computer guided radiation therapy system to aim highly focused beams of radiation directly into brain tumors and other abnormalities of the brain. This nonsurgical approach relies on the LINAC Scalpel, or stereotactic linear accelerator, a precision instrument that delivers high doses of radiation to specific areas within the head and brain. With this technique, all the radiation is focused directly to the area of the tumor or abnormality. Therefore, very little radiation reaches normal brain structures or tissue. Radiosurgery is ideal for treating arteriovenous malformations, acoustic neuromas, and tumors located deep within the brain.
During the procedure, neurosurgeons carefully program the LINAC Scalpel to focus multiple beams of x-rays on the lesion or tumor. Physicians are able to treat patients with brain disorders too difficult or dangerous to treat with traditional surgery. The procedure is typically performed on an outpatient basis under local anesthesia so recovery is very rapid. Patients are released to return home shortly after the procedure.
ARE YOU A CANDIDATE?
Initial evaluations are scheduled through a referral from your physician. Prior to an evaluation we may request that your physician send pertinent CT and MRI films, as well as any applicable hospital and office records. Once it has been determined that LINAC radiosurgery is an appropriate option for you, an appointment will be scheduled.
Generally, radiosurgery is the preferred choice when lesions or tumors are surgically inoperable, when they have recurred or remained after surgery, and when patients are either too weak for surgery or choose not to have a major procedure under general anesthesia. Some of the disorders most commonly treated with radiosurgery include arteriovenous malformations (AVMs), acoustic neuromas, meningiomas, and malignant brain tumors.
Arteriovenous malformations (AVMs) are the lesions most commonly treated with the LINAC Scalpel at the UF Shands Neurological Center.
One major consideration of the radiosurgery team when deciding whether your AVM is treatable with radiosurgery is the size of the AVM. Patients whose AVMs are less than 4 cm in diameter are candidates for LINAC treatment. UF neurosurgeons and radiation physicists perform radiosurgery for AVMs that have not ruptured and that are located deep within the brain. AVMs that have ruptured or that are in relatively "silent" brain areas are typically treated with open surgery.
Physicians worldwide have used radiosurgery to treat patients who have acoustic neuromas (ANs) or meningiomas, the leasions second most commonly treated with the LINAC Scalpel at the UF Shands Neurological Center
Size also is a major consideration in determining treatment options for these lesions. To be treated with radiosurgery, acoustic neuromas and meningiomas must be less than 3.5 cm in diameter. Radiosurgery also is used to treat those that have been partially removed or that have recurred after surgery.
At UF, patients with malignant brain tumors may undergo traditional radiation therapy, in which multiple small doses of radiation are administered. Patients are then treated with a radiosurgical "boost" dose. This treatment is available for patients who have small glioblastomas that are less than 3 cm in diameter. In addition, brain tumors that have resulted from the metastasis of other tumors from the lung, breast, colon, and from melanomas are often treatable with radiosurgery.
COURSE OF TREATMENT
For your radiosurgical treatment, you will usually be scheduled to arrive at Neurosurgical Specialties Clinic on a Monday. A special MRI scan is often done on Monday morning. That afternoon, you will consult with neurosurgeon Dr. William Friedman and a radiation oncologist who will review the radiosurgery procedure with you. The radiosurgery procedure will actually be performed on Tuesday.
Early on the morning of the procedure, you will be given an oral dose of Valium to relax you. Within the next 15 minutes, 4 spots on your head-2 on your forehead and 2 in the lower back part of your skull-will be numbed with a local anesthetic similar to Novocain. A metal head ring will be attached to your skull using plastic and aluminum set pins to hold your head still during treatment. You will feel a lot of pressure as the head ring is attached.
The head ring is fitted tightly to prevent movement during the procedure. This is necessary so physicians can locate the exact area of the brain or lesion they are targeting using complex measurements taken in relation to the head ring.
After the head ring is placed, you will be taken to the Shands Hospital Radiology Department for angiograms, and CT scans of your head. An attachment called a "CT localizer," is placed on the head ring before the CT scan is performed. The localizer will provide important information about the location of the lesion.
Some patients also will have an angiogram with an injection of contrast dye through a small plastic tube (IV catheter) that will help physicians pinpoint the lesion's location. During the angiogram, patients may feel a burning sensation from the contrast material. Markers attached to the head frame will appear on the angiogram and will be used by the radiosurgery team to calculate the lesion's location.
Information obtained from angiograms, CT scans, and/or MRI scans help physicians calculate the appropriate radiation dose. They use one of the most advanced radiosurgery computer planning systems in existence. Software developed by experts at UF simulates the effects of the radiation dose to be delivered by the LINAC Scalpel. This system quickly and efficiently allows for the planning and evaluation of treatment for each individual patient.
After these scans are completed, the radiosurgery team will plan your individual treatment. You will be served breakfast in a hospital waiting room. You and your family members will remain in the waiting room until your LINAC Scalpel treatment.
The radiation treatment takes about 30 to 60 minutes. During the procedure, you may see a red beam and hear a beep but you will not feel anything. After the treatment, the head ring is removed and you will be observed for a short time. After observation in the radiation therapy area, you will be released to go home.
FOLLOW-UP CARE
Depending on your diagnosis, you will be seen again in the clinic 3, 6, or 12 months after your radiosurgery procedure, at which time you may have another MRI scan.
Follow-up evaluation of AVM patients involves an MRI every 12 months after treatment and an angiogram 2 to 3 years after treatment to assess the size of the lesion.
If you had an acoustic neuroma, you will receive an MRI a year after treatment.
Follow-up assessment of malignant brain tumor patients involves an MRI every three months after treatment.
If travel to the UF Shands Neurological Center is difficult, you can arrange for follow-up scans to be taken at a medical facility in your area. You must arrange for your physician to send Dr. Friedman the updated scans for his review so that he can let you know how you are progressing.
RISKS OF LINAC TREATMENT
Dr. William Friedman will explain the radiosurgery risks that apply to your particular situation when he meets with you during your initial consultation.
There is no known immediate risk of radiosurgical therapy. In the case of AVMs, the goal is to create "thrombosis" or a depletion of blood supply to the AVM. It typically takes up to three years for an AVM's blood supply to completely shut down. A small number of AVM patients, about 3 percent per year, experience rebleeding, which may continue until the AVM is completely shut down. The risk of bleeding after radiosurgery is about the same as living with an untreated AVM.
There is a small incidence of delayed side effects from treatment related to the radiation. Radiation exposure sometimes causes brain tissue around the AVM to die, leading to a variety of neurological complications, depending on the location of the lesion. This occurs in less than 5 percent of AVM patients.
The goal in patients with an acoustic neuroma (AN) or meningioma is shrinking of the tumor or stopping the growth of the tumor. About half the patients with an acoustic neuroma (AN) or meningioma show a shrinkage of the tumor after radiosurgery, while about 40 percent of tumors remain the same. Less than 10 percent of these tumors continue to grow. Facial nerve and/or trigeminal nerve problems develop in about 3 per-cent of AN patients
MEET THE LINAC EXPERTS
During your medical screening and the subsequent radiosurgical procedure, you will be cared for by a multidisciplinary team that includes UF neurosurgeons, radiation physicists, radiation oncologists, and computer programmers, as well as Shands Hospital radiation therapy technicians, nurses, and social workers. This comprehensive, collaborative effort ensures you receive the optimal level of care during your visit.
Among the UF LINAC specialists you will meet are:
Dr. William Alan Friedman, A.L. Rhoton Professor and Chairman of the Department of Neurosurgery, was born in Dayton, Ohio on April 25, 1953. He attended high school in Cincinnati, Ohio. He graduated in 1970 as a National Merit Scholar and attended Oberlin College. There he was elected to Phi Beta Kappa before moving on to the Ohio State University College of Medicine. Before graduating summa cum laude from medical school in 1976, he was elected to the Alpha Omega Alpha honor society and received the Maurice B. Rusoff Award for excellence in medicine. In 1976, Dr. Friedman moved to the University of Florida in Gainesville, Florida. He performed a surgical internship and a neurosurgical residency, from which he graduated in 1982. During residency training he did basic neurophysiology research as an NIH postdoctoral fellow (1 F32 NS0682-02). In 1982, he joined the faculty of the Department of Neurosurgery, as an Assistant Professor. He received an NIH Teacher Investigator Award (NS 00682-02), from July, 1982 - July, 1987, which funded further research into the basic neurophysiology of spinal cord injuries. In addition, this award supported the development of one of the first intraoperative neurophysiology monitoring laboratories, subsequently used to monitor thousands of neurosurgical and orthopedic surgical cases. Dr. Friedman served as Medical Director of the Intraoperative Neurophysiology Service from 1982-1992.
Dr. Friedman was promoted to Associate Professor and received tenure in August, 1987. In August, 1991 he was promoted to Professor. He currently serves as Chairman of the Department of Neurosurgery and the A. L. Rhoton Professor of Neurosurgery. He is the author of more than 160 articles and book chapters and has written a book on radiosurgery. He is a member of numerous professional organizations. Most notably, he serves as President of the Congress of Neurological Surgeons, and is the Past President of the Florida Neurosurgical Society. He is Vice-President (and President-Elect) of the International Stereotactic Radiosurgery Society. He is the Past Editor of Neurosurgery On Call, the Internet homepage of organized neurosurgery. He is on the editorial board of Neurosurgery, Contemporary Neurosurgery, and the Journal of Stereotactic Surgery.
In 1986, Dr. Friedman began collaborative work with Dr. Frank Bova, which led to the development of the University of Florida radiosurgery system. This system was subsequently patented by the University of Florida and licensed to Philips. The Philips commercial version of the system has become one of the most popular radiosurgical systems worldwide. Drs. Friedman and Bova received the 1990 UF College of Medicine Clinical Research Prize in recognition of this accomplishment. Dr. Friedman is the leader of a multidisciplinary radiosurgery team which has treated over 1000 patients, published more than 70 papers and chapters, produced many international meetings, and educated hundreds of visiting physicians. This team is engaged in many ongoing research projects in the new radiosurgery/radiobiology laboratory in the UF Brain Institute.
Dr. Friedman has been very active in the committee structure of the University of Florida College of Medicine. He has served on the Faculty Council and on the UF Faculty Senate. He was the first Chairman of the Institutional Graduate Medical Education Committee and guided the development and submission of our first Institutional Policy Review Document to the ACGME. He has served on the Council for Resource Management, the Physician Incentive Subcommittee, the Professorial Promotion and Tenure Committee, and multiple Chair Search committees. More recently, he has chaired the Level 1 Trauma Center Task Force, has served as the Medical Director of DPII, and is a member of the Clinical Practice Committee.
Dr. Friedman has been cited, since 1992, in the book, "The Best Doctors in America," and was listed in Good Housekeeping (10/92) as one of the "400 best cancer specialists in America."
Frank Joseph Bova, Ph.D. was born in New York City on March 19, 1950. He attended Sawanhaka High School in Elmont, New York graduating in 1968. He attended Renesslear Polytechnic Institute and in 1972 graduated with a Bachelor in Biomedical Engineering and in 1973 a Masters in Biomedical Engineering. He went on to receive a Ph.D. in Nuclear Engineering Sciences with a specialization in Medical Physics from the University of Florida in 1977.
In 1978 Dr. Bova joined the Department of Radiation Oncology at the University of Florida. He was promoted to Associate Professor in Radiation Oncology in 1989. In 1991 he was appointed as the Einstein Fund Professor of Computer-Assisted Stereotactic Neurosurgery within the Department of Neurosurgery. In 1994 he was promoted to Professor of Radiation Oncology. In January of 1999 he joined the faculty of Neurosurgery at the University of Florida and was appointed Professor of Neurosurgery.
Since 1979 Dr. Bova has been a member of the Graduate research Faculty at the University of Florida and was appointed to the Doctoral Research faculty in 1987. He holds appointments in the Departments of Nuclear and Radiological Sciences and the Department of Neuroscience. In 1990 Dr. Bova and Dr. William Friedman received the University of Florida College of Medicine's Faculty Research Prize in Clinical Science for their work in the development of the University of Florida's Stereotactic Radiosurgery system. Their work has resulted in 5 patents dealing with both mechanical and computer system associated with radiosurgery and image guided procedures.
Dr. Bova has been very active in the Florida Chapter of the American Association of Physicist in Medicine, holding the office of President for 1997-8. He had previously served as the President of the Southeast Chapter of the AAPM from 1985-86. He is also active in the American Association of Physicist in Medicine serving as a Board member in 1998-2000. He is also a Board member of the International Society of Radiosurgery. Dr. Bova has served on committees for the State of Florida's Department of Radiation Control, the American Cancer Society, American College of Radiology, the Florida Radiological Society, the American Society of Therapeutic Oncologist, the American Association of Physicist in Medicine. He has also serves as a Delegate to the International Electrotechnical Commission. He has been active in the American Board of Radiology, chairing the Physics section of the written examination for Therapeutic Oncologist since 1994.
In 1985 Dr. Bova and Dr. William Friedman began a collaborative project that was responsible for establishing the University of Florida's radiosurgery program. Since its inception this program had treated over 1300 radiosurgery patients and 0ver 200 stereotactic radiotherapy patients. Over 80 papers and chapters as well as numerous presentations at national and international meeting. In 1998 the Radiosurgery/Biology Laboratory at the University of Florida Brain Institute was established. Dr. Bova along with Dr. Friedman and Dr. Dietmar Siemann are co-directors of this facility.
We hope this information is helpful to you and your family. If you have any questions about the treatment described, please call the University of Florida Consultation Center at 1-800-633-2122 and ask for extension 39000 or write to the Department of Neurological Surgery, University of Florida College of Medicine, PO Box 100265, Gainesville, FL 32610-0265.
ACKNOWLEDGEMENT
The information contained here is furnished to you by the University of Florida Shands Neurological Center in cooperation with the University of Florida College of Medicine, Department of Neurological Surgery. This material is selective and does not cover all the information about this topic. If you have any questions or need clarification of this material, consult your doctor. This information is not a substitute for the recommendations of your doctor.
For questions about Radiosurgery at the University of Florida or to make an appointment send e-mail to Fran Anderson or call (352) 273-9000, Fax (352) 392-8413
