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Dawn of a New Era: Innovative Radiosurgical Strategies for Complex Diseases
Dr. Heron celebrates radiosurgery and its treatment applications in this UPMC CME presentation.
Upon completion of this activity, participants should be able to:
- List indications for radiosurgery for a variety of diseases
- Describe outcomes of radiosurgery for a variety of diseases
- Identify patients who may be eligible for primary and salvage radiosurgical options
- What the diagnostic radiologist needs to know about radiation oncology. Terezakis SA, Heron DE, Lavigne RF, Diehn M, Loo BW Jr. Radiology. 2011 Oct;261(1):30-44. Review.
- Stereotactic body radiation therapy for locally recurrent, previously irradiated nonsquamous cell cancers of the head and neck. Vargo JA, Wegner RE, Heron DE, Ferris RL, Rwigema JC, Quinn A, Gigliotti P, Ohr J, Kubicek GJ, Burton S. Head Neck. 2011 Nov 11. doi: 10.1002/hed.21889.
- Fractionated stereotactic radiosurgery for the treatment of meningiomas. Bria C, Wegner RE, Clump DA, Vargo JA, Mintz AH, Heron DE, Burton SA. J Cancer Res Ther. 2011 Jan-Mar;7(1):52-7.
Dr. Heron has no relationships with proprietary entities producing healthcare goods or services.
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Release Date: 3/20/2012 | Last Modified On: 3/20/2012 | Expires: 3/19/2013
Well welcome everyone, thank you for coming out today for a celebration of the new technology and new department at the Mary Hillman Jennings Cancer Center here at UPMC Shadyside. I’d like to just share with you my thoughts on some innovative technologies and techniques really done in a multidisciplinary fashion and some exciting work that’s been going on here at Shadyside that really is emanating across the world as well. So the title of my talk today is Dawn of a new Era: Innovative Radiosurgical Strategies for Complex Diseases. And to really understand where we are going and where we need to go, we need to understand really the scope of the problem. And cancer really is a growing problem, not just only in the United States, although to some extent we’ve made great progress here and our cancer incidence is actually decreasing. But if you look at this on a global scope or a global scale this a truly a world epidemic, and you can see the cancer mortality here from breast cancer, lung cancer continues to be, and this is actually a growing problem worldwide, I think I’m going to use the pointer here. It’s a growing problem worldwide, lung cancer, and this is the largest contributor of mortality. And this is a health crisis that we are clearly going to have to confront.
The expenses, the leading cause of death worldwide continues to be breast cancer as you can see here, it says incidence of mortality. You can see lung cancer, this is just another representation of what I just said, so the incidence of lung cancer is certainly less than breast and prostate, but the mortality is outweighed significantly by lung cancer. And again more and more folks around the world are continuing to smoke particularly in the Far East and so we expect that we are going to be facing this problem on an increasing scale.
Now when we talk about cancer we tend to think of it as one disease and the truth of the matter is it’s anything but. Cancer truly is a complex disease even in one individual, and so we’ve gotten to a point where we can start profiling tumors and a non-small cell lung cancer in one patient is generally not the same lung cancer in another patient and so that poses a major challenge for us. How do we come up with therapeutic strategies that is applicable across a population of patients if every patient’s tumor is likely different one to the next? What are some of the strategies that are out there? We use surgery, we use chemotherapy or now biological therapies, radiation therapy and those are the basically the three legs of the oncologic stool but we also need our colleagues in nutrition, in social services and so on if we are going to truly address the overall comprehensive care of our patients.
Cost of healthcare however is on the rise and although we have healthcare reform and it’s yet to fully hit, and it’s designed to really bend that curve when you look at the percentage of GDP the United States spends far more than any other country. You can see we are at 16% of our GDP and in fact it’s still growing. France is a close second at 11%, but you know places like Turkey, now you may make the argument that the standard of care, healthcare in those countries are very different but we have some modern countries here, first world countries that spend far less, nearly half of what we spend as a function of our gross domestic product. So we’ve got some issues here.
And so what you’ve seen evolve over the last say 5 to 10 years are really multimodality approaches to cancer. And although that’s improved our local control rates and our overall survival rates in some instances, it’s also escalated the cost of care. And so what we are trying to do is this delicate balancing act between efficacy, toxicity and ultimately cost. I mean we as healthcare providers sometimes don’t think about that, but we are going to be forced to do it. So can we use these multimodality approaches and end up with kinder, gentler, perhaps more minimally invasive approaches? And so our surgical oncology colleagues have really gone down this path with a lot of their approaches that they are using now, and so the Da Vinci robot is a classical example of such an approach where our surgeons now are doing these very complex abdominal and thoracic and pelvic cases with minimal toxicity and with limited hospital stays. And so the question is can we as radiation oncologists and oncologists in general start implementing and using these targeted approaches and minimal invasive approaches to caring for our patients. And I would argue the answer is yes, and I’ll show you some of those strategies that we have implemented here at the Hillman Jennings Cancer Center.
So what are we doing for cancer? How are we able to effect this kinder, gentler, more precise, more targeted personalized medicine? Well we are going to start having to profile. And we are starting to do this. We are frankly in the very early stages of this. You know we can profile these tumors, but what does it mean and how to exploit the information here, this is truly a blueprint for these tumors. And I believe they hold the strategies if we can only exploit these molecular profiles of tumors. We are not there yet, however we’ve made some interesting initial steps.
Now I’m going to show you some, some strategies that are out there, most notably Perceptin, Cetuximab and perhaps Avastin are targeted agents, monoclonal antibodies even that help us really personalize to some extent and it’s probably not ultimately where we need to go, but it’s certainly moved us forward away from these more toxic nonspecific, I should say relatively nonspecific approaches. You know Taxol and Cisplatinum are one of the – are two of the most common agents that we use in a variety of different cancers. You know we are now exploiting the HER2 new genetic mutations that allow us to target both tumors in the GI tract and breast and clearly ultimately what we want to do here is improve and increase the response to these treatments. And of course some of these profiles may help us identify, I think that’s the greatest opportunity, identify patients who are going to be resistant to therapy. So yeah, so a fair number of patients will respond to our therapy, but what about those patients who are not going to respond? Can we identify them very, very early on and avoid perhaps expensive ineffective therapies? And I believe that this is the promise of profiling of these tumors.
So here is Herceptin. And it’s again a monoclonal antibody that against the HER2 expression, overexpression on the surface of the cell and how is this clinically important? Here is the example of gastric cancer, and these are patients who received Herceptin and chemotherapy versus chemotherapy alone and you can see there is a statistical improvement in overall survival in patients who received the Herceptin in conjunction with chemotherapy for gastric and gastroesophageal junction tumors. The same can be said for breast cancer. Another example, it’s nearly doubling. This is I believe time to progression, medium time to progression in patients with metastatic breast cancer who received Herceptin versus chemotherapy alone, a statistically significant prospective trial.
So can we intensify our therapies? Can we make them more potent, more focal and again minimally invasive? And so just like our medical oncology colleagues and our surgical oncology colleagues have adopted these techniques I think we as radiation oncologists must do the same. But to do that we must understand from whence we came. So to give you a historical perspective, radiation therapy has been around for a very, very long time. In fact the first radiation oncologists were not like you see us, today we are in fact dermatologists. But very, very early on back in 1917 we actually had physicians, not called radiation oncologists then, implanting radium needles into the breast and even then we recognized that we needed to treat the axilla. And you can see these radium rods, these needles being implanted into the axilla of the patients. A forerunner of our modern radiation therapy devices is this cathode ray tube. This is a patient with a breast mass and she has been treated with, this is what you can call teletherapy, external beam radiation therapy where the electrons shower from the cathode ray tube and is delivered to the tumor itself for the responses. So this is kind of a broad overview of where – from where we’ve come.
First treatment with radiation therapy, gastric tumor, 1896, successful treatment with external beam, this was for Sjögren. And actually about a year or so afterwards in 1999 basal cell carcinoma as I said radiation oncologists were dermatologists in fact. It was easy to see, you could apply the source and you could actually see a response. Then the concept of brachytherapy, this is radiation that is implanted or is in close proximity to the tumor and the concept purported by Becquerel & Curie really led to the radical treatment, that’s the definitive treatment of cervical cancer with radiation intracavitarily, putting these tumors in close proximity to radiation and in fact curing a lot of these patients. And then in the mid-1930s the concept of fractionation, so instead of giving radiation in one big dose we discovered that if you gave it in divided doses and gave it with inter – with a certain interval you can actually increase the efficacy of radiation. Then we really got into the era of teletherapy with cobalt. This is a radioactive source in the head of a machine, and again this was invented in the 1950s, the linear accelerators in the ‘60s and then some of the concepts of radiobiology, the true biological effects of radiation and oxygenation came in the 1960s, and that really formed the basis of our modern radiotherapeutic approaches.
And so this is the linear accelerator, electrically produced radiation comes in, electrons are accelerated, they hit a target, create photons and then the photons interact with atoms in the patient’s body and deposits the radiation dose. Photons themselves are nonionizing, they are not ionizing, it’s actually the electrons that result from the interaction with tissue that deposits the radiation dose or the concept that the nucleus, the DNA inside the nucleus is the primary target of radiation. That’s not to say that radiation cannot damage other cellular mechanisms, because they do, and that can actually affect lethal damage.
So defining the target is important and seeing truly is believing, we need to move beyond 2-D radiation therapy into 3-dimensional and in fact 4-dimensional radiation therapy. So what we’ve done over the years is used anatomic based imaging to design our radiation portals, and here you can see a radiation portal that really mimicked also a lymphangiogram, the patterns are spread in a patient who has a cervical cancer. And even then although we called this 2-dimensional conformal therapy 20 or 30 years ago, you can see there is not really much conformal about it. We’ve tried to minimize some normal tissues by blocking them outside the radiation field, but in this patient where they gave them what we gave them, oral contrast, you can see an awful lot of small bowel. Nearly half of the radiation field contains the small bowel, you can be sure that this is going to result in significant toxicity. So the field arrangements were fairly simple and we used these for rudimentary cases but clearly we needed to move beyond this rudimentary and fundamental approach to cancer care.
And another example is a patient who has a nasopharyngeal cancer. You can see the tumor is located here in the nasopharynx, and you can see the outline of the radiation field. And the problem is there is an awful lot of real estate here, and if you look at the x-ray itself you can see that the patient’s spinal cord is in the radiation field, a fair amount of the oral cavity, the mouth, the sinuses which don’t have tumor are in fact in the radiation field. The cochlea, the optic chiasm so lots of these areas including the parotid, which will result in xerostomia, dry mouth, and with patients who have dry mouth they can have significant trouble or difficulty with dentition, poor oral hygiene and so it is, it is really incumbent on us as oncologists to minimize the toxicity, these toxic cures as we sometimes call them.
And how do we do it? We do it through really the aid of diagnostic images, and we’ve done that for a long time with plain x-rays, with CT scans, with MRIs, invented really in the 1960s with CT, 1970s with CT I’m sorry, MRIs in the 1980s, but now we are into the era of functional imaging and PET imaging really has revolutionized what we do in cancer. So now not only can we couple anatomy we can now couple it with, with function, anatomy and function together. And so here is a perfect example of the use of multimodality imaging in cancer care. On the left is the image, the CT image of a brain tumor and if you look at it without the contour here you can see that it’s very hard to figure out where the brain tumor is. You could easily contour portions of the right lobe, anterial lobe or even posteriorly where there is a little bit more density here compared to the left hand side, right versus left. But when you have an MRI with contrast, and this scan, the CT scan is in fact given with contrast. But the MRI also given with contrast you can see very nicely this glioma.
We can do the same thing with functional imaging for the prostate. This is a patient with a prostate cancer, this is magnetic resonance spectroscopy and you can see we can see the prostate in the gland itself and so with this information we can target not only the entire prostate but the tumor inside the prostate and perhaps give it a larger more potent dose.
And this is an example of all of the diseases in which PET makes the difference, which it alters management. And you can see across the board in about a third of patients PET CT, functional imaging alters the management of care whether it’s lung or colorectal or lymphoma, melanoma, we can make this head/neck cancer, cervical cancer functional information will alter the management in nearly one-third of our patients. So we’ve taken this conformal radiation therapy approach and moved it down, moved the ball down the field with 3-dimensional conformal therapy. And in this instance you can see now the radiation is more tightly conformal around the tumor itself and there is a lot less dose to the lung compared to the 2-dimensional approach but nevertheless I think we could do better.
And along comes the fourth dimension, so we’ve beyond the 3-dimension, the third dimension which is an XYZ coordinate system into the fourth dimension. And what’s the fourth dimension? The fourth dimension is the dimension of time. So if you look at the scan here on the left it’s comparable to what we do now in general, it’s a snapshot, it’s a Polaroid, you can see the tumor in the lung but it’s not moving, and we now know in living patients it is actually a moving target. On the right is a 4-D CT scan and you can actually see the tumor as it moves in the chest of this patient. And with that information we can model turning the beam on and off and therefore minimizing the injury to the normal lung and surrounding tissue.
The next slide is another example of a tumor that predominantly moves in the superior to inferior direction and you can see that the tumor moves nearly 50% outside of its original contours. And because I have this information I can turn my radiation beam on and off to correspond to the motion of this target. So we are moving to a more conformal future beyond the 2-dimensional, beyond 3-dimensional, frankly beyond that into IMRT. So here is an example of the power of IMRT. This is our 3-dimensional approach and you can see the target looks like a boxcar. The portals themselves have uniform radiation fields, uniform radiation doses coming through each of these three fields. And unfortunately because we can’t vary the intensity with 3-dimensional radiation the outcome intensity map looks nothing like the target. One is a boxcar, the other is a box. However with intensity modulated radiotherapy because we can vary the intensity of the radiation beam through each of these portals you can see that the intensity map now very closely resembles the target itself and so that’s the wonderful thing when you are treating a lung cancer you can now have your conformal therapy around the target itself and you can see compared to the 3-D plan I showed you earlier there is very little dose to the lungs, so highly conformal.
And PET plays an important function here. As many of you know, PET CT was invented at the University of Pittsburgh. And in this model and in this machine we have the ability to acquire a spiral CT scan and a PET scan at the same time. And again this is adding anatomy to function and function to anatomy. And so in this example you can see there is something in the mediastinum, it’s very hard to tell whether – what’s the exact configuration, what it looks like. On the PET you can clearly see the uptake in the lower mediastinum, but you can see on the fused image anatomy with function. And as a result because you can see it clearly you can target this with a great degree of precision.
And so our department here at Shadyside, the Mary Hillman Jennings Cancer Center, was one of the first centers in the country to implement PET CT in the Department of Radiation Oncology for radiation treatment planning. So you can see we use a variety of our immobilization devices, having the patient comfortably laying on the table for our radiosurgical planning. Here is an example of intensity modulated radiation therapy, highly conformal with the low dose regions depicted here in yellow and blue and the high dose regions which contain the tumor here in red and black. We see it on the CT, you can see it the dose represented also on the PET. And so because we have these two pieces of information we can actually exploit function and anatomy in the radiotherapeutic management of our patients.
But we have taken this technology one step further, we’ve moved now beyond our conventional approaches to really something that was radically new, the cyber knife. And the cyber knife has a very fancy name and it really is space age technology, and remains space age technology. The original unit that was here at Shadyside had the serial number 002 because it was the second commercially available cyber knife that was ever produced. And it had sat dormant for quite some time, and my predecessor Dr. Shalom Kalnicki resurrected the cyber knife along with Dr. Burton and colleagues in neurosurgery including Dr. Gerson for the treatment of spine tumors.
This cyber knife, this here at Shadyside is the busiest cyber knife in the country, in the United States. It is the busiest cyber knife for cranial cases and I think I saw Dr. Mince in the audience someplace, there he is, Dr. Mince, and it is quite busy for lung actually Dr. Christy in the back as well. So we’ve adopted a multimodality, multidisciplinary approach for using this technology. Sehad is our lead physicist in the audience here. So you can see that this machine has the ability while the patient is on the table of acquiring real time images, delivering the dose and updating the images and then again delivering more dose from multiple different angles and this is something that has allowed us to deliver pinpoint accurate treatment for tumors outside the cranium, much like the gamma knife did in the past but now we have the ability to do it for tumors frankly anywhere in the body, this is the quintessential prototype machine, you are going to see the most advanced machine in just a moment. And so we can create this really complex and elegant radiosurgical plan for the head/neck. This is a patient who has had treatment before that has failed that would not have been a candidate for retreatment with radiation therapy, and we now basically have gone – done away with the concept that once you’ve received radiation once you can’t ever get it again. But we’ve treated patients 3 and 4 and maybe even 5 times because we have the capability and the collaboration and intellectual knowhow to do this. So here is this tumor, you can see the radiation dose is highly conformal to the target and so things like the spinal cord in the old day would have been a rate limiting toxicity, a rate limiting organ we can now actually treat patients with relative impunity clearly we have to pay attention to those organs but we can do this fairly routinely.
And how is this important? Here is an example of functional imaging being used with stereotactic body radiotherapy to really help us manage a very complex case. Here is a patient who has a recurrent mass that is not a surgical candidate because it clearly surrounds the carotid in this location and you can see the benefit or the power of the PET because you know you look at this and you said well where exactly is the edge of the tumor? Does it cross midline, is the tumor here? And clearly the PET is telling you it’s not – it doesn’t cross the midline, here a zone 2 node but it does encase the carotid. This is the post-treatment PET scan that happened 8 weeks after treatment and the important thing here is if you look at the CT you would be tempted to say this patient didn’t have a complete response, they had a partial response. You still see an abnormality here, it’s not completely like the other side. If you look at the PET you can see that it’s relatively cold, it is a very lukewarm area but that’s a residual radiation change. And so the important part and the reason why this helps us so much is that it allowed us to avoid an unnecessary intervention, more chemotherapy or potentially other intervention or basically say you know you didn’t respond, and game over. We can actually confidently say to that patient that we’ve treated your tumor, we’ve treated it effectively and you don’t need any more therapy right now, that’s exactly what happened to this patient who is now 23 months out and remains controlled in this area. Basically a radiosurgical salvage of a patient that was not a surgical candidate.
So the concept here is once may not be enough in fact, and we are now challenging this conventional paradigm with these highly conformal techniques. We are saying you know, Mrs. Jones, we can treat you a second and third time and clearly if there is a tumor that’s resectable we ought to take it out, but if it’s resectable and there are positive margins, or if it’s unresectable we have an opportunity to offer you salvage or palliation in a way that’s going to minimize your toxicity. And so we’ve actually looked at our outcomes and we now have a nomogram, it’s the only one in the literature where we’ve taken our head/neck cancer cases, our recurrent squamous cell carcinomas, head/neck, almost 100 patients and we’ve actually subjected them over the last 5 or 6 years to reradiation strategies in a very systematic fashion. And what we’ve been able to show is that if you give these patients a fairly aggressive dose of radiation 8, 8.8 grade to 10 grade refraction over a week and a half so, Monday, Wednesday, Friday, Monday, Wednesday approach that the higher dose of radiation results in an improvement in the 1, 2 and 3 year survival for these patients, this is local control and here is survival. So take a look at the local control at 3 years. These are patients that usually have a medium survival of only about 6 to 9 months and we are looking at 3 years out with the smallest tumors getting the highest dose, sorry, smallest tumors getting the highest dose of having nearly half of those patients around, surviving. That’s quite remarkable.
In fact we’ve developed a nomogram, it’s the only one in the literature that basically allows clinicians anywhere around the country or the world that wants to use this approach to say to their patients that if you have a tumor that’s 40 cc and if I give you 44 gy that I can tell you that your 1 year probability of local control is going to be 80%, and I can project this to 2 and 3 year. And this is really powerful data. And again yet to be entirely validated in a prospective randomized trial where we are now running the Phase 2 with Cetuximab and the Phase 3 has been designed and is now off, is about to be submitted to the IRB in the next month or so. Clearly not, we’ve moved the ball down the field, it’s not an entire home run because we do have those patients that fail.
Lung cancer is another clinical challenge for us. We have patients who are not great surgical candidates, have Stage I and Stage II lung cancers and frequently we’ve been asked to offer them external beam radiotherapy, but because of their pulmonary reserve we do this fairly gingerly. Well we now have a technique radiosurgery that allows us to deliver very potent doses of radiation you saw there, 18 gy, 18 to 20 gy in times 3 fractions or 4 fractions over about a week or so with high success rates. But to do that it clearly needs functional imaging. And again in this case here you see a tumor and without the PET information you see this area of atelectasis and it’s pretty hard to figure out where this tumor is. But with PET you can clearly see where the tumor is and so if you are going to do a radiosurgical plan on a tumor like this you know where it is, you can target this area instead of a much larger area, or where you’d say you would not be a candidate for radiosurgery because your tumor is too big, so the importance of PET.
And so we’ve looked at our outcomes. Here is an example of a patient who has a small tumor, here it is CT, here it is on PET. This is a pretreatment scan. And 8 weeks after treatment what you can see there is a little infiltrate here, a little bit of a scaring, you can see it’s cold on the PET scan and so this patient had a complete response. And when you put all of these patients together we are able to really document the likelihood of complete response long term based on your PET change. So those patients who had a complete response and was controlled long term had a 90% reduction in their SUV. Those patients who had a partial response 54%, stable disease 30% and clearly those that had a progression or increase in their SUV of 34% or likely to progress. And so it’s clear that pre and post-PET CT scans are valuable not only for target destination but predicting ultimately long term response to radiosurgery. So we do this fairly routinely now for our lung cancer patients who undergo radiosurgery.
And I have just a couple of other examples. Here is pretreatment, this scan is I think obtained at 1 month, which is a little early for us now. This is at 3 months and I think this is at 8 months. You can see the study improvement in SUV which sometimes can be fairly prolonged. So the benefits of radiosurgery for lung cancer, 3 to 4 fractions over about a week or so, preservation of normal lung function, so very few patients run into complications from these treatments, particularly if you don’t use fiducial. A much higher dose and local control rates actually better, very, very good, 80 to 95% and that’s compared to a 7 week course of radiation, obviously lots of fibrosis to the lung. We typically give a lower dose just because of the lung tolerance and our local control rates even for Stage I and II lung cancers aren’t the greatest. You know they are anywhere – they average around 50% or so.
So we’ve looked at lung cancers, we’ve talked a little bit about recurrent head/neck cancers, but liver radiosurgery is another novel thing that we’ve been doing here. Those – we have two clinical trials, one for hepatocellular carcinoma and one for metastatic disease. And we use liver radiosurgery as either potent palliation, I’m going to present you a case or as a bridge, bridge to transplant. So here is a close-up image and an animation of this approach you are going to see the machine and I’m going to invite all of you to come to the department right after this lecture to see the equipment and see all of the innovative things that we are doing here.
But here is a lesion, a tumor in the liver, let’s call it a metastasis in this case, or it may even be a primary hepatocellular carcinoma, a little bit on the small side but the concept is still the same. Patient is breathing freely on the table, you have the imaging system that is acquiring and localizing the tumor in real time and you can see the beam going on and off. The patient is breathing in and out, the tumor is in the liver and you can see when it enters the radiation portal the beam is on, and as soon as it goes out of the portal the beam goes off and we reduce the toxicity and reduce the dose to the normal tissues when we use this approach, a remarkable ability to deliver highly potent doses of radiation with pinpoint accuracy and minimal toxicity.
So here is the example of a patient that I met about 2 years ago, 40 year old female with breast cancer, metastatic in nature and when I met her, her pain was essentially 10 out of 10. She was on high doses of narcotics, had nausea and so she was referred to me for a palliation of a liver mass. And when we saw her we had a discussion about the options that were available to her and we offered her stereotactic radiosurgery with 4-D PET CT stimulation. And when we did the scan you can see the dominant lesion here in the liver, we’ve actually placed the fiducial. You can see that she had 2 other areas but these were not likely the cause and source of her pain. It was this tumor that was right up against the capsule, and that was the main cause and you can see how you can see very, very clearly here on the PET CT scan. We created a radiosurgical plan for her, you see how highly conformal this radiation is. And this is her post-treatment PET CT scan after giving her, I think we treated her 40 gy, 20 gy in 3 fractions, 45 gy I’m sorry in 3 fractions, so 15 gy times 3. And what you see if you look at the CT alone you would say well she really didn’t respond to treatment. Well, functionally she actually did, she had a complete metabolic response. What you are still seeing here are just changes in the liver, unfortunately she progressed in the other 2 areas, but she had a complete metabolic response. CT did show a partial response, a slight reduction in size. She had nearly complete relief of her pain, so that’s the efficacy. This is potent palliation. So we got her completely off her narcotics medication, was just on a minimal amount and she was very quickly then able to start her systemic therapy. So a 3 fraction approach over a week and then she quickly went on to chemotherapy, but came very quickly off her narcotic therapy. And so PET CT scan in 4-D, PET CT scan really made a difference in this case in this patient.
This is a patient who has a tumor in the abdomen. Looking at this it’s kind of hard to tell where it is, but if I show you the PET you can see where it is. It’s like mobilized, it would make it a 40 PET now you can see what’s going on, you can see the gastric bubble there, here is her liver, you can see the tumor is there and it’s clearly moving. We don’t know what this is, but when you do a 4-D PET CT you can see a lot more than you can just see, than you saw even in the PET CT. You can see that there are actually two nodes that weren’t apparent before, and more importantly if you look at the dominant pancreatic masses, the pancreatic tumor you can see this is an FDG PET, that the center of it is hypometabolic, which probably means it’s more radio-resistant toward therapy. And so we designed a radiosurgical plan for this patient on the cyber knife and this is the response, acquired 8 weeks after the completion of radiosurgery. And what you see here if you look at the CT alone there is a residual mass, and you’d be tempted to say this patient didn’t have a complete response, but in fact she had a complete metabolic response and she remained controlled in this area and unfortunately went on to develop metastatic disease in the liver and lungs, but remained controlled in this area for the duration of her life. And so again a very potent approach, and again the combination of the two is well worth it.
So what we’ve brought together here at Shadyside are really remarkable technologies, technologies that allow us to noninvasively or minimally invasively image, localize and target tumors in the body and in the brain. You are going to see this new machine called the True Beam powered by Novalis Radiosurgery. And so at the center of what we do, I’ve shown you a lot of technology, but at the center of what we do is the patient. We bring to bear image guided technologies, functional imaging, 4-D, PET CT, gated therapies in a multidisciplinary fashion that really service a complex network, and you all know what our network looks like. But I want to remind you that what we have is not a regional network but in fact it’s an international model for care where we are exploiting a lot of what we are doing here at Shadyside and in Western Pennsylvania to Ireland, we were just to Italy and other parts of the world and actually there is a complex interchange of ideas that’s happening that I think is really enriching the processes that we have here in Western Pennsylvania.
So we have adopted this multidisciplinary approach which in integrated, we believe efficient point of care service. And so as an example I’m going to hold up our new oncology multidisciplinary clinic that we hold every week in our department with Dr. Minn and a Discovery Channel piece that we did.
Hello, I’m Dr. John White, Chief Medical Expert for Discovery Channel. Radiation oncologists and neurosurgeons at UPMC believe the best care for patients diagnosed with tumors of the brain and spine is care that is delivered in a multidisciplinary setting in which physicians work as partners. Treatment often involved stereotactic radiosurgery, using technologies such as the Gamma Knife and Line at Base Platforms such as the Cyber Knife, Trilogy and True Beam. Let’s find out how UPMC’s technology and multidisciplinary approach helps patients achieve the best possible outcome.
At UPMC we feel that the best way to diagnose and treat a patient is with a number of different specialists looking at the patient at the same time, so we’ve developed a multidisciplinary clinic for many disease sites. For brain tumors, especially those that we are considering doing radiation or radiosurgery on patients are seen in conjunction with radiation oncology and neurosurgery at the same time.
At the core of what we do in our radiosurgical program at UPMC is really the patient, it’s really patient focused. And so everything that has evolved including our multidisciplinary program really is focused on the patient, and so it was very easy for us to bring the neurosurgeon along with the radiation oncologist along with our neuroradiologists and all our supporting staff including the nurses to bear in the treatment of these patients.
I think UPMC is unique in a number of ways. Number one, the very high volume of patients that we treat on a daily basis in our facilities, and two, we have a lot of advanced technology.
I think those centers and the facilities that we have at UPMC is remarkably unique in the country, and frankly perhaps in the world. It’s probably one of the only sites where we’ve brought together really advanced technologies such as Cyber Knife, Trilogy and our newest addition the True Beam which really brings together a series of technologies along with our multidisciplinary approach to these oncologic, new oncologic imaging.
We are involved in currently a study here using a ______ called ML10 which is a marker of apoptosis. And the goal of this trial is to be able to very early within 48 hours see what’s happening with a tumor after it has been treated with radiosurgery so we can have an idea of has this treatment been effective. You know this is an early stage trial and hopefully it will give us information as to what next has to be done for the patient if the tumor is not undergoing apoptosis as we expect.
We also have a number of other clinical trials including a cooperative group trial that’s looking at radiosurgery for spine tumors, so these patients we want to really critically evaluate the benefit or lack thereof if it doesn’t exist of these very innovative kind of treatment for patients. And so our program not only is it multidisciplinary and it’s clinically oriented, but we believe there is an opportunity given our expertise, our worldwide expertise to really advance the field to better understand the use of these technologies for a variety of these tumors.
The multidisciplinary approach allows patients the opportunity to consult with radiation oncologists and neurosurgeons in the same setting. This combined with state of the art radiosurgical tools assures patients of innovative, comprehensive care.
So what I’ve shown you is a model of care bringing together all these technologies in Western Pennsylvania in a fashion that really is bar none. And I think our patients here are the better and benefit very much from what we’ve put together in the commitment of our multidisciplinary team. To get where we are today wasn’t one large leap and in fact as you can see here and this is a – this was my fortune cookie during one of my recent trips to China actually, kind of funny in China they give you a fortune cookie, but it said two small jumps are sometimes better than one big leap. And I would make an argument that we’ve made several small jumps that are perceptually small jumps but the total effect of that have been remarkable large leaps. And so we are excited and very proud of the efforts of our team here, we believe that our future is very strong. We’ve certainly acquired the technology, we have acquired the expertise and then the multidisciplinary approach. And so I offer you the opportunity to come to the department right after this session to see a lot of the equipment, to meet a lot of our staff that care for a lot of our patients and a lot of your patients and ask you to see what this technology, see, touch and feel really the future of this personalized, highly conformal future that awaits us. And with that I’ll take any questions and thank you for your attention.