With Novalis, knifeless surgery has arrived

January 29, 2009

A brain tumor can be as small as a pencil tip but can cause enormous problems.

The potential to remove these and other types of tumors without a scalpel arrived this fall at The Hospital of Central Connecticut with the Novalis® shaped beam surgery system. The hospital was the first in the state to use this Novalis system. Though called “radiosurgery,”the system actually uses precision radiation and speed to treat tumors without surgical incisions, pain or blood loss. It’s currently used to treat brain and spinal tumors, and lung, liver and prostate cancers. In the future, Novalis is expected to be used for pancreas and varied gynecological cancers.

Accuracy that spares normal tissue
Novalis is a form of knifeless surgery that uses a precalculated amount of radiation targeted to match a tumor’s shape. This helps spare healthy tissue from radiation and can eliminate side effects commonly associated with standard radiation therapy. Amazingly, within a few weeks of just one Novalis treatment — lasting only about 30 minutes — a brain or spinal tumor may be visibly smaller. Full effects of Novalis treatment can be gauged after three months of treatment. Shorter treatment is one of the most visible benefits of Novalis, with lung cancer care delivered in three to five consecutive days vs. treatment five days a week for seven weeks. “We chose Novalis because we feel that we are able to treat patients very accurately,”says Neal Goldberg, M.D., chief of Radiation Oncology.“We are able to verify that we’re hitting a tumor by confirming its position right before treatment using X-ray.”

Novalis, by BrainLab Inc., is the latest addition to the hospital’s comprehensive line of cancer services,which includes advanced radiation oncology technologies and procedures to treat many cancers. Says neurosurgeon Ahmed Khan, M.D. “The best thing about the Novalis technology is that it’s right here, in people’s back yard. They don’t have to travel.” Special focus on brain and spinal tumors Novalis is used primarily to treat brain and spinal tumors that have originated at those sites or spread to the brain or spine from cancer elsewhere in the body, such as a lung or breast. Potential Novalis candidates, Khan says, are patients with deep inoperable brain tumors; certain types of brain or spinal tumors or other medical conditions that make traditional surgery risky; or patients with benign tumors or other conditions,who want a less invasive option. Among the benign tumors and conditions Novalis can treat are acoustic neuroma, a tumor that affects hearing; trigeminal neuralgia, a condition that causes extreme facial pain; meningioma tumor, a benign growth that starts in the brain covering; and pituitary tumors.

With Novalis, recovery is shorter and there is less risk of complications than with surgery. “In some cases the goal is to avoid (traditional) surgery,in other cases to treat the lesion to extend life or the quality of life,” Khan says. He adds that Novalis offers a less invasive option for cancer proven difficult to operate on or inoperable. “We know that if we’re doing an operation and we don’t get the whole tumor out we have a back-up plan with radiosurgery.” Nearly 22,000 new cases of malignant brain and other nervous system tumors, including spinal cord tumors,were expected to be diagnosed in 2008, according to the National Cancer Institute. More than 215,000 new lung cancer cases were anticipated in 2008, says the American Cancer Society.

Pinpoint treatment planning
Pinpoint accuracy is a defining feature of Novalis. The technology uses care plans created or “mapped”using results of varied imaging studies that are merged with sophisticated computer applications. The result: an extremely detailed picture of the tumor and its exact location in the body. A tumor’s location and type determine which imaging studies are needed. An MRI provides clear, accurate pictures of organs and tissues. The hospital’s new 64-slice high-speed PET-CT scanner produces 3-D images with precise anatomic detail and detects cells’ metabolic (chemical)changes. In many cases, higher metabolic activity can indicate cancer. PET or CT studies may be conducted independently or combined. A patient with a brain or spinal tumor will have both MRI and CT studies; lung tumors are imaged using PET-CT. Prostate cancer patients receive a CT scan, with tiny gold seeds permanently implanted within the prostate before the scan to ensure radiation precision. PET-CT findings are particularly helpful in treating lung cancer patients, because breathing during treatment causes the tumor(s)to move. PET-CT results help determine how the Novalis beam will correlate to the tumor, so that surrounding tissue is not affected during treatment, even while the patient breathes, says Goldberg. This “respiratory gating”is achieved with the aid of small, gold seeds inserted permanently before the PET-CT scan, indicating the tumor’s precise location while the patient breathes.

Weeks before their initial visit, Radiation Oncology nurse coordinator Lisa Beckman, R.N., B.S.N., OCN, speaks with patients about the care process that begins with imaging studies, followed several days later by treatment. She tells patients receiving a brain CT scan that they’ll wear a mesh-like mask during the study to ensure that the head’s positioning during the scan is accurate. Instead of a mask, trigeminal neuralgia patients wear a head frame during the CT scan, also to ensure accuracy. Patients who may be anxious about the mask or head frame can request anti-anxiety medications, says Beckman.

‘Hundreds of thousands of computations’
How much radiation and how it will be delivered through Novalis is determined using results from the imaging studies and sophisticated computer software. “The computer does literally hundreds of thousands of computations to come up with the treatment plan,” says radiation oncology physicist George Pavlonnis, who works with Goldberg and Khan (for brain or spinal tumors) to develop plans. Once the plan is finalized, patients are escorted to the Novalis room, housed in the recently expanded American Savings Foundation Radiation Oncology Treatment Center, New Britain General campus. It’s here that Novalis’ advanced technological features work in unison to deliver a targeted, highly effective radiation treatment in about 30 minutes. The same results would probably require weeks of once weekly sessions using standard radiation therapy.

Novalis enables flexibility for single or multiple treatments, depending on the patient’s diagnosis as it relates to the brain or spine, says Khan. “Then patients are done and they go home and they don’t even need to stay in the hospital.” The session lasts 20 to 40 minutes, depending on the number of tumors. For prostate cancer patients,Novalis is a boost to traditional radiation therapy. Patients typically receive about four weeks of daily radiation therapy aimed at shrinking the tumor in preparation for about two weeks of Novalis treatment.

Novalis’ most distinguishing features come alive as the system engages. The patient lies on a robotic table that can move in six different directions up and down, left and right, in and out, and at three different angles — to best align the tumor. Patients with tumors or other conditions related to the brain lie within a head frame affixed to the table. Just before treatment, Novalis X-rays of the target area are taken to ensure accurate radiation positioning. The radiation then beams through a device that uses metal leaves to block unwanted radiation so that the beam conforms exactly to the tumor’s shape.A separate infrared camera ceases radiation delivery immediately if it senses patient movement that would shift radiation outside the target area.

High tech blends with personable staff
During the high tech treatment, personable staff from Radiation Oncology provide the human touch, speaking with and monitoring the patient during treatment from an adjacent room equipped with an intercom system and six cameras for constant viewing.Between dose deliveries, staff frequently goes to check on the patient whose comforting view above Novalis is a glass canopy of blue sky and autumn leaves. “We make sure they’re doing OK.We tell them what we’re doing next,” says radiation therapist Ann Allen, RTT. Most patients, says Beckman, are concerned about possible side effects, which through Novalis, are minimal. There may be slight hair loss from radiation to the brain and patients may feel slightly dizzy or have a headache after treatment. Beckman calls patients the next day to see how they are feeling and to answer questions. Patients see their referring physician within a few weeks and return to HCC in three months for an MRI to gauge Novalis effectiveness.

Beckman says patients are glad they can come to The Hospital of Central Connecticut for state-of-the-art tumor or cancer treatment.“When patients hear they have to go to a larger cancer center it’s often frightening for them. Now we can offer it in our community hospital here.”