Gamma Knife : Brain Without A Scalpel

Presenter: Kathryn Sweeney-Ewing, MSN, RN, CMSRN Disclosure Statement:

I have no financial or non-financial relationships to disclose regarding the content of this presentation. Learning Objectives

1) The learner will be able to define gamma knife stereotactic radiosurgery ( GK SRS) 2) The learner will be able to list conditions treated with GK SRS 3) The learner will able to discuss the benefits of GK SRS 4) The learner will be able to list risks post GK SRS 5) The learner will be able to list medications to help prevent complications 6) The learner will be able to describe the procedural flow during GK SRS 7) The learner will be able to list skills needed to be a GK RN Lars Leksell - inventor of radiosurgery

▶ Swedish physician and considered the father of radiosurgery ▶ Developed his first arc-centered stereotactic frame in 1948 ▶ He introduced radiosurgery in the 1950’s ▶ He treated the first patient with “gamma knife” in 1960. ▶ In 1968, the first Leksell gamma knife unit was installed in , ▶ Gold-standard in radiosurgery What is Gamma Knife Anyways????

▶ Gamma Knife (GK) is a clinically proven, precise, and powerful surgical procedure for the treatment of brain disorders

▶ There is no actual “Knife” involved in this surgical procedure

▶ GK delivers extremely focused beams of cobalt radiation to precise targets in the brain using 3D imaging

▶ You may hear or see it termed as a type of Stereotactic Radiosurgery (SRS)

▶ SRS refers to directing radiation to a specific focal point using an external, three-dimensional frame of reference What can be treated with GK SRS????

▶ Brain and Skull Base Tumors ▶ Metastases, , glomus jugulare tumors, , chordomas ▶ Pituitary Tumors ▶ Acoustic Neuromas ▶ Functional Disorders ▶ Trigeminal Neuralgia, Essential Tremor ▶ Arteriovascular Malformations (AVM’s) ▶ Hemangioblastomas ▶ GK only treats disorders and tumors of the brain How does GK SRS treat these conditions??? ▶ Tumors - Focused radiation to the targeted tumor cells causes DNA disruption. The radiation interferes with the ability of the cells to reproduce, causing shrinking of the tumor over time ▶ Benign tumors - can take up to 2 years to shrink ▶ Malignant tumors - can take weeks to months to shrink ▶ AVM’s (tangled veins/arteries) - Focused radiation damages the AVM. Over time, the affected veins/arteries will close. ▶ This can take 1-3 years ▶ Functional Disorders (Trigeminal neuralgia & Essential tremor) - Focused radiation targets the area of the brain producing symptoms associated TN or ET. Radiation damages these areas, thereby, stopping the transmission of facial pain or tremor ▶ This can take months for symptoms to resolve - not a quick fix From an oncology perspective who is a good candidate for GK SRS???

▶ A patient who has malignant disease in the brain ▶ A patient who is not end-of-life or on hospice services ▶ Ideally a patient with 10 or less metastatic brain lesions ▶ Ideally a patient who has an ECOG score of 0, 1, or 2 ▶ A patient who, from a respiratory standpoint, can tolerate conscious sedation and laying flat for an extended period Frequently asked questions

▶ Do you shave my head? No ▶ Will I be staying in the hospital? No (unless acute complication) ▶ How long will the procedure take? Length of stay is approx. 6 hours ▶ How long is the recovery period? This is individualized - some people are back to their normal routine the next day while other can be fatigued for several weeks ▶ Can I have GK SRS more than once? Yes ▶ Do I have to stop my blood thinners? No Frequently asked questions cont.

▶ Can I eat the morning of GK SRS? No ▶ Can I drive myself home from GK SRS? No ▶ After GK SRS, will my tumor immediately be gone? No ▶ After GK SRS, can I immediately stop my TN medications and be pain free? No ▶ Do I have to see both radiation oncology and for consult prior to GK SRS? Yes ▶ Can GK SRS treat tumors outside the brain? No Procedural Flow on the day of GK

▶ Patients arrive at 5:45 am in the morning to register ▶ Patients then are brought into the procedural suite and meet their treatment team for the day (nurses, neurosurgeon, radiation oncologist, and medical physicist) ▶ IV access is obtained for conscious sedation and MRI contrast ▶ For metastases patients, these patient have an MRI with 1mm thin slices and are given a double dose of the contrast agent ▶ Often, additional metastases are found on the date of GK due to this special study Procedural Flow Continued

▶ Patients are given a mixture of versed and fentanyl for the framing process ▶ A local anesthetic is also given at the pin sites ▶ Patients then go to MRI for the planning images ▶ Once the images are back, the neurosurgeon and radiation oncologist use the images to map where the radiation will be focused ▶ The medical physicist obtains 24 skull measurements. This creates a model of the patients head that is critical for the planning stage. Procedural Flow Continued

▶ Once the plan is created, the neurosurgeon, radiation oncologist, and medical physicist all agree on the plan ▶ This treatment plan and length is then discussed with the patients and their families ▶ The patients then get locked into the machine for the treatment phase ▶ Post treatment, the frame is taken off and patients are given food/drink ▶ Discharge instructions are then discussed with patients and their families ▶ Patients are finally discharged home with family/friends For GK, our three dimensional frame of reference is a titanium halo, as seen below.

What are the benefits of GK SRS??? ▶ The precision technology saves normal brain tissue from being affected ▶ GK SRS is generally one fraction of radiation - meaning the patient gets their radiation treatment in 1 setting ▶ Sometimes two sessions approx. 6-12 months apart is needed for certain tumors or AVMs. ▶ It is minimally invasive and does not involve general anesthesia - outpatient procedure ▶ This intervention can reach tumors or AVMs that are inaccessible or undesirable for open surgery. ▶ It is a highly effective treatment and clinically proven ▶ The recovery process is minimal, if any ▶ There is no head shaving or hair cutting What are the minor risks of GK SRS???

▶ Fatigue lasting several weeks ▶ Possible hair loss if the area being treated is close to the skull bone - this hair will grow back starting at about 3-4 months post GK SRS ▶ Many people experience headaches post GK SRS - moderate headaches that are alleviated with time, rest, and OTC meds ▶ Scalp numbness/tingling for several weeks post GK SRS ▶ Nausea/vomiting ▶ Infection at pin site locations ▶ Mild pain/tenderness at the pin site locations ▶ Swelling around the eyes for several days What are the, rare but real, major risks of GK SRS???

▶ Seizure activity (tumor swelling/radiation treatment effect/location of treated tumor - temporal lobe) ▶ Intracranial hemorrhage (calvarial fracture/ displacement of crani flap/tumor or AVM bleeds) ▶ Facial paralysis or numbness (tumor swelling or risk associated with treating TN) ▶ Language and cognitive difficulty/paralysis (treating ET) ▶ Also depending on the location of treated tumors, patient can experience motor weakness, double/blurred vision, or aphasia (generally temporary) What can be done to prevent post GK SRS complications???

▶ A majority of our patients go home on a dexamethasone taper to decrease swelling, in hopes of complication prevention. ▶ Many of our patients are already on Keppra for seizure prevention prior to GK SRS. ▶ On rare occasions, we do start Keppra for a short period post GK SRS if we feel the patient is acutely at high risk for seizure activity The best-laid plans of mice and men often go awry. --- adapted from Robert Burns’ poem “To A Mouse” Who are the Penn Medicine GK MDs??? We have a specialized team of CNS radiation oncologists neurosurgeons and ENT’s that have been through a specific training course in GK SRS .

Radiation oncologists - Drs. James Kolker and Suneel Nagda (PAH) Drs. Michelle Alonso-Basanta, Goldie Kurtz, Robert Lustig, and Jacob Shabason (UPenn) Neurosurgeons - Drs. John Y. K. Lee and Zarina Ali (PAH) Drs. Donald ORourke, Steven Brem, Eric Zager, and Omar Choudhri (UPenn) ENT’s - Drs. Michael Ruckenstein and Douglas Bigelow (UPenn) Dr. Jason Brant (PAH) What special skills are needed to be a GK nurse???

▶ Our nurses provide 100% HEART Bundle care ALL THE WAY (Holistic, Evidence-Based, Advocating, Resources, Teamwork) ▶ Our nurses are skilled in IV insertion and assessing Port-a- caths ▶ Our nurses are competent in administering moderate sedation ▶ This requires 1:1 nursing care for each patient ▶ Our nurses are BSLC and ACLS certified How can I refer a patient to the Penn Gamma Knife Center???

Direct physician referral is always welcomed - especially for benign cases (AN, TN, ET, Glomus, , ) ▶ The majority of the oncology referrals are directed to me for triage ▶ This referral pattern facilitates the quickest pathway for treatment of oncology patients. If you think a patient of yours could benefit from GK SRS, please send the referral to my email at [email protected] Other little tidbits and statistics about Penn’s Gamma Knife Center

▶ We are located at 801 Spruce St.; Philadelpha, PA ▶ We do not treat everyday. We treat every Tuesday & Friday and the 2nd, 4th, & 5th Wednesdays of the month. ▶ We have 1 treatment machine. ▶ Our program has shown 20% growth in the last year. ▶ Currently about 70,000 patients undergo GK SRS yearly - here at Penn our current course is approximately 415 patients treated yearly ▶ Currently about 70% of the Penn patient population are those with metastatic brain lesions Statistics cont. Resources

International Parkinson and Movement Disorder Society. (2018). Pioneer Lars Leksell. Retrieved from https://www.movementdisorders.org/MDS/ About/Committees--Other-Groups/Special-Interest-Groups/Neurosurgery- Special-Interest-Group/Pioneer-Surgeon-Lars-Leksell.htm

International RadioSurgery Association. (2018). Stereotactic Radiosurgery Overview. Retrieved from http://www.irsa.org/radiosurgery.html

Memorial Sloan Kettering Center. (2018). What is Stereotactic Radiosurgery?. Retrieved from https://www.mskcc.org/cancer-care/ diagnosis-treatment/cancer-treatments/radiation-therapy/what-stereotactic- radiosurgery#which-patients-are-good-candidates-for-srs-

Mayo Clinic. (March 21, 2018). Stereotactic Radiosurgery: Overview. Retrieved from https://www.mayoclinic.org/tests-procedures/stereotactic- radiosurgery/about/pac-20384526 Resources cont.

Health Quality Ontario. (2002). Gamma Knife: An Evidence-Based Analysis. Ontario Health Technology Assessment Series, 2(2), pp. 1–22. Retrieved from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3387771/

Penn Medicine. (2018). What is Gamma Knife?. Retrieved from https://www. pennmedicine.org/for-patients-and-visitors/find-a-program-or- service/neurosurgery/skull-base-surgery/treatments-and- procedures/gamma-knife

University of California, San Francisco. (September 12, 2018). Trigeminal Neuralgia Treatment. Retrieved from http://neurosurgery.ucsf.edu/index. php/pain_treatment_trigeminal_neuralgia.html