A new approach to brain surgery
BY JIM HALL
Dianne Jennings and Susan Haley stood before their computers at the Regional Cancer Center, making final preparations to treat Dana Jacobs’ brain tumors.
Jacobs was on a table in the adjacent room. Cameras in that room allowed the two radiation therapists to see her.
“Beam 1, we’ve got 221 on 6x,” Jennings said.
“325 on Brainlab,” replied Haley.
Satisfied with the numbers, Jennings and Haley instructed the linear accelerator that hovered above Jacobs to radiate the cancerous growth in her brain.
“Beam on,” flashed Haley’s computer.
The invisible beam, about the width of an index finger, entered Jacobs’ head. Similar beams followed, all entering her brain from slightly different angles and all aimed at her unwelcome guest.
Each time, Jacobs, alone in the lead-and-concrete room, heard a clicking noise from the accelerator and then a buzzing sound when it released its radiation. She felt nothing.
Jacobs tried not to think about what was happening. Instead, she closed her eyes and prayed.
“I give God the glory,” she said. “I know that everything is well.”
EVOLUTION IN SURGERY
Jacobs is one of about 40 local residents to receive the region’s newest cancer treatment. Called stereotactic radiosurgery, or SRS, the procedure arrived in Fredericksburg in January.
Mary Washington Healthcare has teamed with the University of Virginia Health System to buy a $4.5 million Varian linear accelerator and do the procedure at Mary Washington Hospital.
With SRS, focused, high-dose beams of radiation are used to destroy cancerous growths. The goal is to treat the cancer but spare the healthy tissue around it. At Mary Washington, SRS has been used on patients with brain and lung cancers.
Groups such as the National Institutes of Health term radiosurgery a treatment rather than a surgical procedure.
But others argue that it represents an evolution in surgical technique. Previously, surgery was done through a single, large incision or, more recently, through a series of small incisions. Now it can be done with no incision.
“We’re killing the tumor just as surely as if I’m scooping it out during surgery,” said Dr. Jeffrey Poffenbarger, neurosurgeon at Mary Washington Hospital.
SRS also means that for patients like Jacobs, brain surgery has become an outpatient procedure. When one of her treatments finished last month, she rode home with her husband, Larry, to Remington in Fauquier County. Along the way she treated herself at Dairy Queen.
“I wanted some french fries,” she said.
STARTED IN HER BREAST
For Jacobs, the road to SRS began in 2010, when she learned that the mass in her left breast was cancerous.
She was 48 then, the mother of two adult daughters, Janelle and Stephanie, and an aide in the computer lab at Pierce Elementary in Remington. She had no family history of breast cancer.
Jacobs had chemotherapy to shrink the tumor, then a mastectomy, followed by radiation.
However, within six months, she learned that her right breast was similarly affected. She had chemo, a second mastectomy, followed by another round of radiation.
Then, in February 2011, she experienced bouts of dizziness, nausea and headaches. The cancer had spread to her brain.
An MRI test showed seven tumors in her brain. To treat them, Dr. John Chinault, radiation oncologist at Mary Washington, prescribed “whole brain” radiation. Jacobs underwent 10 consecutive days of radiation that bathed her entire brain.
The treatments shrank the tumors and relieved her symptoms, Jacobs said. Yet, the cancer was persistent.
During a six-month follow-up exam, two new tumors were discovered. They were troubling because they were growing.
Chinault and Poffenbarger agreed that Jacobs was a candidate for SRS. Her case was typical of SRS patients: Her tumors were small and located in hard-to-reach places. Both of them were in the cerebellum, at the left rear of her brain.
Poffenbarger could have done conventional surgery. If so, he would have opened Jacobs’ skull and parted several inches of healthy brain tissue to reach her tumors.
“She would spend 12 weeks recovering from all the effects of that surgery,” he said.
Instead, she underwent SRS.
BEAMS ARE NARROWER
“Are you ready?” asked Jennings, the radiation therapist.
Jacobs nodded yes and climbed onto the treatment table. She was at the cancer center for Day Two of her treatment.
She rested on her back, a pillow beneath her legs. Above her was the gantry or treatment head of the accelerator.
The machine is used for conventional radiation and for SRS. During SRS, the power is increased, and the X–ray beams are narrowed.
When Jacobs had whole brain radiation in 2011, no portion of her brain was untouched. This time the dosage was similar but concentrated. More than 99 percent of her brain was spared.
To treat the tumors, the team at the cancer center, including medical physicist Changan Xie, studied images of Jacobs’ tumors. With special computer software, he designed a four-part assault. The larger of the two tumors would be treated for three days. The smaller one would get one day.
The plan was to move the accelerator and the treatment table in combination to strike the tumor from different angles.
The X–ray beams would pass through her brain on their way to the tumor, but they would be lethal only in combination, when they met at the tumor.
The technique recalls a scene from an old Western where the townsfolk ambush the bad guys, firing at them from the rooftops. In Jacobs’ case, the tumors were the bad guys.
For this to work, however, Jacobs had to be immobilized, day after day, in the same spot on the treatment table.
To achieve this, the team molded a tight-fitting plastic mask for her face.
“You let us know if it feels too tight,” Jennings said, as she slipped the mask over Jacobs’ face and snapped it to the table.
Jacobs replied with a thumbs-up gesture.
Poffenbarger ran his finger beneath the mask to check the fit.
“It’s a little tight, but the tighter the better for accuracy,” he told Jacobs.
Poffenbarger asked Jacobs to wiggle her face, but she couldn’t.
“OK, we’re ready to go here,” he said.
ONE TUMOR GONE
In the control room, Chinault and Poffenbarger checked Jacobs’ positioning by examining X–rays of her brain. One of the X–rays was taken weeks earlier during preparations; the other was taken at the time of treatment.
The physicians placed one X–ray on top of the other on their computer screen. When the two X–rays lined up, Chinault told Haley, “We like what we saw.”
With that, Haley and Jennings loosed the radiation. They listened as their computer counted the 35-second exposure.
“Beam off,” the computer finally flashed.
Jennings and Haley repeated the process four more times. Finally, after about 45 minutes, they were done.
“That should be one tumor gone,” Chinault said.
After the four treatments, Jacobs was tired but otherwise in good shape.
“I have noticed that when evening comes, I am done for the day,” she said.
Side effects reported by other patients include nausea, headache, dizziness and, rarely, seizures.
Chinault said that since Jacobs’ cancer had already moved from her breasts to her brain, there is a chance it will reappear.
But he also said he is hopeful that the SRS procedure will result in a cure.
“If we can kill that tumor, then there’s a chance that this patient may go on for years,” he said.
Jacobs will return to see Chinault soon. She will have another MRI in two months to check on her tumors. She will continue to take two maintenance drugs, Herceptin and Tykerb, to limit tumor growth. And she has a year-old grandson, Jacob, to help care for.
“I have that peace in my heart that they did the job they needed to,” she said. “God has put me in the perfect place with the perfect people at the right time.”
Staff librarian Craig Schulin contributed to this story.
Jim Hall: 540/374-5433