Spanish hospital boosts intracranial SRS precision and scope with Gamma Knife radiosurgery
Neurosurgery, radiation oncology departments and many other specialists team up for a streamlined, cooperative service
For 26 years, clinicians at Hospital de las Nieves (Granada, Spain) amassed considerable experience using their linear accelerator for intra- and extracranial stereotactic radiosurgery (SRS) for a wide spectrum of indications. In 2018, the center was ready to go to the next level and began exploring options for a dedicated intracranial SRS system. In 2022, Hospital de las Nieves started treating patients with Elekta’s Leksell Gamma Knife® Icon™ radiosurgery system. Nearing their second year with Icon, neurosurgeons, radiation oncologists and other specialists approach cranial SRS in a highly collaborative way, ensuring that patients receive world-class care.
Acquiring an SRS system devoted to intracranial pathologies offered the hospital numerous advantages, according to Gonzalo Olivares Granados, MD, head of the center’s neurosurgery service and José Expósito Hernández, MD, head of the radiation oncology service and coordinator of the multidisciplinary Gamma Knife radiosurgery unit.
“In 2018, we aspired to have a dedicated SRS service for brain indications, one that would not compete with extracranial treatments and one that would be the ideal complement to the neurosurgical techniques we already used,” Dr. Olivares says. “We based our selection of Icon on the extensive published literature on Gamma Knife that gave us a perspective on long-term patient outcomes.1-7
“Patients with movement disorders, epilepsy and complex pituitary adenomas now come to us from all over Spain for radiosurgery.”
“Gamma Knife would provide us the precision and steep dose fall-off to treat intracranial targets that are too close to organs-at-risk,” he continues. “That is something we couldn’t safely do even with our micro-MLC equipped linac – we had to refer these patients elsewhere. And importantly, we could use Icon to treat functional pathologies. Patients with movement disorders, epilepsy and complex pituitary adenomas now come to us from all over Spain for radiosurgery.”
Dr. Expósito agrees that the accuracy of Gamma Knife radiosurgery – its sharp dose gradients, target conformity and exceptional target coverage – has greatly expanded the range of indications.
“We are treating patients with multiple metastases, as many as 17 brain lesions in a single session,” he says. “We have treated patients with recurrent glioblastoma and astrocytoma, in addition to benign pathologies, such as neuromas, skull base meningiomas, AVMs, hamartomas, and trigeminal neuralgia. Our goal this year is to start treating patients with obsessive-compulsive disorders or those with chronic pain.”
With Icon, Hospital de las Nieves treats an average of three patients each day, five days a week and most patients are treated in a single session.
Multidisciplinary approach a hallmark of the Gamma Knife unit
Dr. Olivares notes that Hospital de las Nieves has a long tradition of teamwork, which – since the clinical opening in November 2022 – has extended to this service as well.
“The work is multidisciplinary,” he observes. “When a patient arrives, each of us is able to contribute the best of our experience and knowledge. The neurosurgeon has knowledge in cranial pathology, not only anatomically, but also regarding what other treatment alternatives might be suitable, such as surgery.”
He adds that the oncologists and radiation oncologists can bring their experience, especially in malignant tumor pathology that requires other types of complementary therapy. The physicist has a fundamental role in dosimetric planning and the team also includes neuroradiologists, who are important not only in planning, but also in monitoring patients because, increasingly, malignant tumor pathology can involve immunological treatment, and the response observed in imaging during follow-up can sometimes be equivocal.
Dr. Olivares says that the Gamma Knife team is not only multidisciplinary, but interdisciplinary as well.
“The work is almost interchangeable between different specialties,” he explains. “When we work as a team here, the notion of individual roles is blurred, meaning that what ultimately matters is a specialist in radiosurgery, more than the specialty he or she comes from.
“We also have significant experience in the multidisciplinary evaluation of patients with other types of pathology,” Dr. Olivares adds. “For example, when patients come to be treated for epilepsy, they have already been through a committee that includes neurologists, neurophysiologists, neuroradiologists, psychologists and neurosurgeons. So, pouring all of that information into the radiosurgery treatment is also complementary. In the end, the treatment is highly individualized for each patient, rather than a standard treatment.”
Patients appreciate “one-and-done” Gamma Knife radiosurgery
The potent, highly focused doses of Gamma Knife radiosurgery mean that a single, minimally invasive treatment session is sufficient for virtually all patients. This has been a significant improvement versus pre-Gamma Knife days, when patients would have to accept either linac-based, hypofractionated radiotherapy or open surgery, both options requiring hospital stays and/or increased discomfort.
“We receive patients from all over Andalusia and elsewhere, so we have placed great emphasis on treating patients in one day, including an MRI scan,” Dr. Expósito says. “The patient arrives in the morning, the MRI is performed, and the frame is fixed. Interestingly, the latest frame – Vantage – is lightweight and is quite comfortable. Patients are extremely grateful to be treated in a single session.
“With radiosurgery, patients are quite content and leave with a feeling of having been treated in a radical way in just one morning.”
“You have to remember that for these patients, the alternative could have been surgery, for example, and that requires a hospital stay of four or five days,” he adds. “With radiosurgery, patients are quite content and leave with a feeling of having been treated in a radical way in just one morning. Then, we simply call them after a week or two weeks to check that everything is well and schedule a follow-up appointment. The experience is very good – in fact we measure it through a survey and the satisfaction level is great.”
Dr. Olivares agrees, stressing that their patients prioritize a treatment that involves the least discomfort and one that is the least invasive in terms of side effects.
“That means preserving brain function,” he says. “For this, radiosurgery is perhaps the treatment that best allows these aspects to be combined with greater ease. Patients tell us that Gamma Knife radiosurgery is a comfortable treatment, especially when we treat tumor recurrences after a previous open surgery. Comparing what surgery entails with leaving the same day and being able to resume their usual tasks a few days later, or even after a few hours, is a really significant qualitative change.”
Clinic also benefits from radiosurgery efficiency
Having a dedicated SRS unit that enables single-session therapy has advantages not only for the patient, but also for the center’s workflow, Dr. Olivares observes.
“For some time now, there have been major demographic changes – the population is aging, and from an epidemiological perspective there is an increasing prevalence and frequency of neurological diseases,” he says. “Addressing both of these factors would be impossible today without a radiosurgery option. If we had to surgically treat acoustic neuromas, for example, the workload would be unsustainable.
“Additionally, we are diagnosing intracranial lesions more frequently before they show symptoms, but we observe growth that requires treatment,” Dr. Olivares continues. “We treat these lesions before they cause problems, with a system that poses practically zero risk to the patient. The advantage is indeed fundamental. Thus, not just from the standpoint of treatment safety, but also from an efficiency viewpoint, cost control, and the ability to meet the growing demand for treatment, I believe radiosurgery is essential today. It would be unimaginable to handle everything we currently treat using only traditional surgical techniques.”
Leksell Gamma Knife has made the clinic’s workload much more reasonable, Dr. Expósito adds. Pre-Gamma Knife, the clinic had to treat intracranial indications on Saturday and Sunday, from eight o’clock in the morning to eight o'clock at night.
“By treating many more of these patients with Gamma Knife, we don’t have to compete with the resources of other units.”
“By treating many more of these patients with Gamma Knife, we don’t have to compete with the resources of other units,” he notes. “Our waiting list management is substantially easier and more focused on the patient. They can come from Huelva, Seville or Murcia – all several hours drives from Granada – and receive the treatment on a weekday morning and return home at noon. Overall, we avoid surgery with ward stays, hours in the operating room and a lot of other personnel.”
The perfect complement for intracranial indications
Both Drs. Expósito and Olivares view Gamma Knife radiosurgery as a critical addition to their treatment arsenal.
“As a neurosurgeon, radiosurgery is an exceptionally powerful modality that complements the treatment options we have,” Dr. Olivares says. “It’s a very valid alternative that presents less risk for the patient. I believe that today, neurosurgery cannot be considered without radiosurgical therapy, because in many cases it constitutes the best option for the patient.
“There are certain types of tumors in which it is safe to perform a partial resection to preserve function, and in which a radical treatment can be completed with radiosurgery,” he adds. “This avoids patient suffering and preservation of cognitive function. Conversely, for many pathologies, radiosurgery has become the frontline therapy. The fact that neurosurgeons are involved and use it as another weapon in the arsenal opens up tremendous possibilities for patients.”
From Dr. Expósito’s perspective as a radiation oncologist, Hospital de las Nieves’ addition of Gamma Knife Icon is the ideal intracranial counterpart to high-dose, hypofractionated, linac-based SRS for extracranial targets.
“The availability of a technological instrument that enables us to confidently administer radical doses for intracranial indications has greatly facilitated our work,” he observes. “This treatment is comfortable and safe for us. I insist on the importance of careful patient selection, ensuring that the disease volume is appropriate and that organs-at-risk are at a safe distance. However, even when the organs are closer, we have been able to treat pathologies with Icon that were previously untreatable with the linac. The system has fundamentally transformed our practice.”
Learn more about Leksell Gamma Knife.
References
- https://www.elekta.com/medical-affairs/bibliographies/gamma-knife-srs-for-brain-metastases/
- https://www.elekta.com/medical-affairs/bibliographies/gamma-knife-srs-for-trigeminal-neuralgia/
- https://www.elekta.com/medical-affairs/bibliographies/LGKS%20Review%20of%20epidemiology.pdf
- https://www.elekta.com/medical-affairs/bibliographies/LGK%20Bibliography_%20AVM_2012-2020.pdf
- https://www.elekta.com/medical-affairs/bibliographies/LGK%20Bibliography_%20Meningioma_2012-2020.pdf
- https://www.elekta.com/medical-affairs/bibliographies/LGK%20Bibliography_%20Pituitary%20Adenoma_2012-2020.pdf
- https://www.elekta.com/medical-affairs/bibliographies/LGK%20Bibliography_%20Vestibular%20Schwannoma_2012-2020.pdf
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