Gammaknife Managed....check!

[Lani]

As the last time I went to see Dr Adler with a friend's son t I was helping gather information/options for treatment of a benign brain tumor was 15 years ago I went on radiologyinfo.org a site cofounded by the Radiological Society of No American and the American College of Radiologists and got the following:

How does the equipment work?

The Gamma Knife® utilizes a technique called stereotactic radiosurgery, which uses multiple beams of radiation converging in three dimensions to focus precisely on a small volume, such as a tumor, permitting intense doses of radiation to be delivered to that volume safely. Current models of the Gamma Knife® use advanced robotic technology to move the patient in submillimeter increments during treatment, to focus radiation successfully on all parts of the target. In most cases, Gamma Knife® treatments are given in a single session.
Under local anesthesia, a special rigid head frame incorporating a three-dimensional coordinate system is attached to the patient's skull with four screws. Imaging studies, such as magnetic resonance imaging (MRI), computed tomography (CT), or angiography, are then obtained and the results are sent to the Gamma Knife®'s planning computer system. Together, physicians (radiation oncologists and neurosurgeons) and medical physicists delineate targets and normal anatomical structures. They use a planning computer program to determine the exact spatial relationship between the target, normal structures and the head frame to calculate Gamma Knife® treatment parameters. Targets often are best treated during the treatment session with combinations of several successive aimings, commonly known as "shots." The physicians and physicists routinely consider numerous fine-tuning adjustments of treatment parameters until an optimal plan and dose are determined.
Using the three-dimensional coordinates determined in the planning process, the frame is then precisely attached to the Gamma Knife® unit to guarantee that when the unit is activated, the target is placed exactly in the center of approximately 200 precision-aimed, converging beams of (Cobalt-60 generated) gamma radiation. Treatment takes anywhere from several minutes to a few hours to complete depending on the shape and size of the target, the number of "shots" and the dose required. Patients do not feel the radiation. Following treatment the head frame is removed and the patient may return to normal activity.


As I understand it he only way to attach something to the skull so there is no "wiggle room" eg for broken necks and after neck surgeries is for the teeth of the screw to enter through the outer table of the bone. I cannot imagine they don't need ti minimize :wiggle room" at least as much if not more for accurate aiming into the brain.

The pin holes are very shallow(there is little between the skin and the scalp in those positions, even if as kids we were called "fat heads!", but never the less it seems to require local anaesthetic if one is awake.

When done for broken necks and neck surgery the screws remain in longer, either for the duration of the surgery (hours) or until the fracture/surgery heals. In those cases the bumps where the screws were can remain slightly raised thereafter, possibly causing discomfort to those who wear headbands near the area.--that is usually the case when only two screws are used due to the screw placement positions.

All four screws should be behind the hairline so any residual bumpiness or tenderness should be known only to the person themselves (or their hairdresser!) I haven't heard of any complaints, but as I mostly read the literature and go to conferences, I am not likely to.

In the big picture of things, I would think any annoyance at the time this is done or after would be minimal (needing to postpone washing hair after the procedure, etc)

Haven't read any complaints on this site about post gamma knife scalp problems. Anyone?

Addendum--looks like they have been working on altering how the screws used:

Neurosurgery. 2007 Apr;60(4 Suppl 2):339-43; discussion 343-4.
Angled screw holes for anterior posts and a frame-positioning device for gamma knife radiosurgery: allowing for better targeting of intracranial lesions.
Quiñones-Hinojosa A, McDermott MW.
Source

Department of Neurological Surgery, Johns Hopkins University, Baltimore, Maryland 21231, USA. aquinon2@jhmi.edu
Abstract
OBJECTIVE:

Gamma knife radiosurgery requires frame positioning so that the treatment target is as close to the center of the frame and as low as possible to cover all of the posterior fossa contents. In this study, we report the use of two devices developed by the senior author (MWM) that facilitate these two crucial objectives in the treatment of intracranial targets using the gamma knife.
METHODS:

Custom front posts with threaded screw holes drilled at 5-, 10-, and 15-degree angles were created by the manufacturer at our request. A U-shaped metal device for frame positioning was designed in-house and fits into the holes at the 100-mm mark on the lateral sides of the Leksell stereotactic frame base. This allowed the positioning device to snap securely into the frame for use in positioning. The positioning device was constructed so that the lowest possible frame position would be achieved with each frame application, while avoiding collisions with the magnetic resonance imaging localizer box.
RESULTS:

Angled front posts allowed for pin contacts with the cranium anterior and/or superior to the superior temporal line despite a lateral or posterior position of the frame. This avoided penetration of the temporalis muscle and reduced discomfort for patients. The U-shaped metal device was used in place of the Velcro straps or ear bars routinely used for frame positioning in which the distance from the frame base to the top of the head must always be measured to avoid collisions with the localizer box. During the past 2 years, these devices have been used on a daily basis, achieving the desired results. In many cases, their use has avoided the need for frame repositioning and rescanning for targets that cannot be reached because of inexact frame positioning.
CONCLUSION:

A new design with angled screw holes in the front posts used for gamma knife radiosurgery allows surgeons to avoid penetration of the temporalis muscle and to maintain a perpendicular orientation of the fixation screw to the outer table of the cranium. They may also prevent mechanical creep caused by the obliquity of pin contact with the cranium and resulting loss of torque. We also present a simple device that may be useful in frame positioning. The device ensures a frame position as low as possible without the need for measurement at the time of frame positioning.

PMID:
17415172

[StephN]

When I had gamma knife the screws went in at each side of my forehead about an inch below my hairline in front. Of course the back two are placed in the solid bony area behind the top of the ears.

The person who numbed my scalp was a woman neurosurgery resident. She was very adept with the needle and hitting the right spot. The back areas of my scalp were numb for quite a while - maybe a couple of months to fully wear off.

I did not feel the screws, only the needle when she began the numbing - sort of like when the dentist is starting to numb your mouth.

My front places where the screws went left me with little scabs less than 1/4" in diameter. They barely bled when the headframe was removed.

For cyberknife you must have a mesh "mask" made that will fit extremely tightly over your face and bolt to the table so that there is NO movement.

The Gamma Knife is accurate to 1mm of the target area, so they can't have the patient able to move the head at all.

Just a few details from a patient's viewpoint.

[ElaineM]

I hope you are having a nice restful weekend.
Take care.

[7andcounting]

Denise, So happy for you that you have a Dr. that gets right onto things. Seems it wasn't all that long ago that you posted you had brain mets, and then here you are getting them treated. Way to go. Your picture inspires. Thanks for showing us that you can hit a bump, but then be right back into battle beating the snot out of cancer. Hope/pray your procedure was successful!

[Deb33]

BTW - your hair looks adorable.

[Mtngrl]

Denise,

I hope you're feeling better now. I'm so glad you were treated promptly. Brain mets fully resolved.....check!

I love your wit, spunk, and drive. God bless you.

[lkc Gumby]

Many many blessings to you Denise!

[Lani]

Steph thanks for the post of your personal experience.

Your descriptions should help others be realistic rather than imagining the worst

in trying to find the description of the screw/screw placement I googled
several patient's perceptions of what they had been through and they were quite "imaginative" it seemed. ie, that the screw went through the skull rather than into it.

In any case, there is no substitution for personal experience..Steph you have been there and done that and sharing your experience in a way others can quickly access it on this site is priceless.

Perhaps a thread should be started regarding: please describe your personal perceptions and experiences of the following procedures:

first dose of herceptin
first few doses of anthracycline
first few doses of taxane
first few doses of bisphosphonate
first few doses of navelbine
first few doss of vinorelbine, and other drugs commonly given
radiation therapy whole breast...describe how felt initially, two weeks into it, fourweeks into it, at the end, one month later

APBI upon iniiation, during it , at the end of it and one month later

SRS brain mets ditto

WBR brain mets ditto

embolization/spheres for liver mets

SRS of mets other than brain (Esther had liver I think)

lumbar puncture

IT herceptin

Then those facing these procedures could have instant information

Those with nursing backgrounds, eg Alaka Angel etc could state that --their descriptions might be less "imaginative" as they may have more background
knowledge about the whats and where fors

Fear of the unknown and loss of control seem to be the common theme
and posting a webpage with a medical description of the procedure, what to look out for, why and how it is done (usually on nih, nci website) would be well supplemented by personal experiences


Many of you have beem thrpigh so much

Making it easy for those who anxious about what is upcoming sould be leaving a valuable legacy


Thanks again, Steph

oops I forgot to list bone marrow aspiration

[NEDenise]

Yikes!
I certainly hope I didn't scare anyone with my description! The video link Jackie posted on the other thread shows exactly what to expect. It's the same one they showed me when they scheduled the procedure. And it's not scary at all!! Certainly not as scary as the phone call where the oncologist announces that you HAVE lesions on your brain. That, my friends is the scariest thing I've ever heard in my life.

Frankly, I'm hoping this procedure saved my life...so what's a little discomfort for a few hours. The whole thing was easier than chemo (even Herceptin), and radiation! And...I don't have brain mets anymore!

Sorry if my description sounded scary...blame it on the drugs...or the swelling I guess. I was shooting for humor...and trying to put people at ease...guess that didn't come off so well.

Trust me when I say...it was virtually discomfort free...and 100% worth it.
Denise

[caya]

I am looking forward to an "all clear" report Denise!!

all the best
caya

[Cathya]

Denise;

Rest, relax and recover!! I too am looking forward to hearing an all clear from you. All the very best and many thanks to you and Steph for sharing your experiences.

Cathy

[StephN]

Denise -
Your photo is quite reassuring, since you say you have just had the headframe removed. You are NOT doubled over in pain and do not have blood gushing down your face. And the smile looks genuine.

LANI - glad you appreciate my experience. Hope others will see it.

The thing that goes on our head is called a HEAD FRAME - this is what is then attached to the HELMET that is already in place on the table in the machine.

The HELMET is like a big bowl with little holes in it where the beams come through to the area of treatment.

The head frame is VERY light weight (titanium, I think?), just a little awkward for trying to eat something (best to drink a shake through a straw), or lie back while waiting to go in the Gamma Knife machine. Being so light weight also means that the screws do not have to go on very tightly. Just enough to keep the frame in place while you wait and to attach in the helmet.

The pressure of the screws is a delicate procedure as the technicians would not want to cause a hairline fracture by too many turns of the screwdriver.

I did not have a headache and was out merrily driving around the next day.

Like Denise said - it is hearing the news that our brain has been invaded by the cancer which is the worst part. Next is the consults to see what are the possible treatments, and last nerve wracking is the MRI after the head frame is on and they are planning the treatment. That MRI will show if there are any new spots to treat. A big sigh of relief when they told me there was nothing new.

[StephN]

More on the HEAD FRAME:

This is exactly how mine looked:



I had posted a pic of me with mine on, but the post is still here and photo is not.

Just where the "pins" attach to the forehead is easy to see, and there are two more in the back. The stabilizers on the side do not have pins/screws. This is connected to the helmet, and the machine will make any positional adjustments itself. The patient is unable to move his head or neck on his own once in the machine.

[Mtngrl]

I appreciate getting this information.

[schoolteacher]

Glad this is over for you, Denise.

Amelia

[JillaryJill]

Denise,
You continue to amaze me. I am sure your students just adore you. Your full of personality and you effect many people in such a positive way. Your special!

[Lani]

Steph--thanks so much for your detailed descriptions of your experience

I do think it would be good to have a section on different procedures--
MRI
CT
Gamma Knife
Cyberknife
lumbar puncture
bone marrow aspirate
first few infusions of different chemos

so people have an idea of what they are in for (their imagination of what it might be like is probably worse than the reality)

If it all in one place, people will not have to use the search engine (which it seems people hate to do) and others with different experiences can easily chime in and add to the ongoing list of experiences

Anyone else think this might be useful?

Again, each thread could start with the website info on nih/nci about the procedure

Thanks again Steph

[Debbie L.]

I'm glad to hear you're past this hurdle, Denise.

I think Lani's idea is a great one. Would it be hard to set up a new forum just for treatment details? Someone would have to put together a thread for each procedure, with an intro message of the basic information. People do like to see the official information (NCI/NIH as Lani suggested) but then it always seems we are MORE interested in hearing personal experiences. We could help gather the opening info, if there's someone who could set up the forum.

As long as we have a good variety of experience, the stories from those who had harder times will be balanced out by those who sailed thru, so I don't think it would alarm people. As Lani said, for most of us our imagined version is worse than the reality turns out to be.

Plus, readers will see that the reason the "official" information sometimes seems so vague as to be no information at all is because each person reacts or responds differently -- so it's hard to say what the experience will be like for any one person.

In addition to describing the procedure and the personal experience of same, people could add helpful hints -- things that made it easier or helped with side effects (or didn't help), etc. And for the things that are hard to visualize (head frames and helmets!), photos are great.

Debbie Laxague

[Pray]

Denise, I'm so glad it all went well for you and you are doing fine. Have you been back to teach since this last bump in the road? If so I'm so glad you are keeping all of your eggs in a row.

Gods blessings Lil Girlfriend. I always keep you in my prayers.

[Sheila]

Denise...you not only amaze me but inspire me more than you will ever know! You photo looks like you just came back from a brisk walk in the park....

may you heal quickly and feel better each day...you are an inspiration of courage and strength to each and every one of us.