elekta celebrates 6 60 Years of Stereotaxy

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1 news and advances in the management and treatment of serious disease vol. 13 no. 1 elekta celebrates 6 60 Years of Stereotaxy Also in this issue clinical use of 31 ELekta VMAT Monaco advanced treatment 40 planning system now VMAT-capable why data matters: 42 taking advantage of the data in your emr

2 Dear Friends WAVELENGTH VOL. 13 NO. 1 Contents In today s challenging economic environment, investments in technology must provide real solutions to real problems. These solutions must not only improve quality of care, but must simultaneously reduce the cost and burden on providers. Elekta is uniquely positioned to provide the leading-edge solutions that can provide these benefits, with best-of-breed applications across the continuum of patient care. 6 dear Friends 2 elekta Brings 4 a Message of Hope carlye s Story of Survival 5 Investments in technology must provide real solutions to real problems. This year, for example, we re celebrating 60 years of Stereotaxy. Since Professor Lars Leksell introduced the world s first stereotactic instrument in 1949, it has been setting the standard in stereotactic surgery worldwide. Today, Elekta s Leksell Stereotactic System is the most widely used frame system in the world, and forms the foundation for Stereotactic Neurosurgery innovations such as Leksell Gamma Knife and Elekta Axesse. Life with Lars Leksell on page 8, written from the perspective of his son, Dan Leksell, Executive Vice President and Senior Advisor at Elekta, gives you insight into what Elekta is built from. Elekta s MOSAIQ EMR solution has also set the bar by which all other radiation and medical oncology information systems are measured. Essential to optimizing clinical workflow, the simplicity and versatility of MOSAIQ also provides a flexible interface with any manufacturer s cancer treatment delivery system. It s another example of Elekta providing solutions to remedy very real workflow issues. On page 34, you can learn more about the benefits three centers have experienced using MOSAIQ. Costs can be significantly reduced when new systems integrate with current systems, regardless of manufacturer. Examples include the new Monaco treatment planning system, Volumetric Modulated Arc Therapy (VMAT) and other sophisticated radiation delivery plans. They can all be developed and optimized with simplicity and efficiency. As a vendor-independent solution, customers can streamline their treatment planning efforts within an all-elekta linear accelerator environment or existing multi-vendor infrastructures. On page 40, we go behind the scene for a glimpse of the development of Elekta s new Monaco treatment planning system with VMAT as well as the group behind its development. Whether the clinical need dictates stereotactic radiosurgery or radiotherapy, 3D conformal therapy, conventional IMRT, VMAT, or a powerful, comprehensive EMR, Elekta offers solutions that continue to provide real solutions to real problems. With intelligent and resource-efficient solutions Elekta will continue to provide confidence to both healthcare providers and patients worldwide. We hope you enjoy this issue of Elekta Wavelength. Mark Arnold Vice President, Global Marketing Elekta Wavelength is published by Elekta AB, All letters, suggestions for future articles, requests for reprints and permissions, and comments are welcome. Contact Michelle Lee Elekta Inc. Tel: Peachtree Industrial Boulevard Bldg. 300, Ste. 300 Norcross, GA Years of Stereotaxy elekta Celebrates 6 60 Years of Stereotaxy life with Lars Leksell 8 the First Leksell Gamma 13 knife in Japan Extending the Benefits 14 of Gamma Knife Surgery the Present and Future 18 of Functional Neurosurgery introducing the Leksell 20 centers of Radiosurgery Elekta Healthcare News from Your 22 worldwide Elekta Team 17-Year-Old Cancer Survivor 24 becomes Advocate for Teens associates in Radiation 28 Oncology is a Study in Efficiency Clinical Use of Elekta VMAT 31 astro and ESTRO Recap oncology Emr Users Find 34 Outstanding Benefits and Value partnering for Human Care: 39 bridging the Gap monaco Treatment Planning 40 system Now Vmat-Capable Why Data Matters: Taking Advantage 42 of the Data in Your Emr 2 wavelength vol. 13 no Elekta AB. All Rights Reserved.

3 Elekta brings a message of hope Elekta sponsors song project to sustain cancer awareness Rachel Farley and David Greer Shawn Mullins and six survivors of childhood cancer arlye Ketchum was a sophomore in college in 1997 when her father was diagnosed with a brain tumor. After two debulking surgeries, he was diagnosed with head, neck and face cancer. Carlye and her mother Linda, Senior Contract Administrator at Elekta, cared for him until his death in In 2007, Carlye herself was diagnosed with Stage Four tongue cancer. It was the same type of cancer her father had died from. Linda took Carlye to Shands Medical Center at the University of Florida because of their outstanding head, neck and face cancer facilities, and their recent installation of an Elekta Synergy. Carlye s case was reviewed by a multidisciplinary Tumor Board, which recommended a course of treatment that began with the removal of nine of Carlye s teeth. Then, in a 16-hour surgery, they removed Carlye s tongue and used tissue and muscle from the inside of her arm to create a flap where her tongue was. They told her she d never speak again, and wouldn t be able to swallow and have to use both a trachea tube and a feeding tube, says Linda. But we understand about 98 percent of what she says when she speaks, she can swallow liquids, she can breathe on her own, and feeds herself with the feeding tube. Carlye lost an eye to diabetic retinopathy, and has been completely blind five times in her lifetime. This year, she had open-heart surgery to replace her aortic valve. Still, Carlye is doing remarkably well. Though she can t eat solid food, she loves to cook. Top Chef is her favorite television show, and she cooks dinner for Linda every night. She s also working on a book, and hopes to inspire other survivors. When the challenges of Linda s job started to overwhelm her, she thinks back to the day she took Carlye to her first radiation treatment. We walked into the treatment room and I watched while they made the mask for her face, immobilized her on the table and lined up the lasers in preparation for her treatment. At one point, I looked up and my eyes caught the Elekta logo on the Synergy machine. Suddenly I realized, Oh my gosh, now I understand what it is I do, and why I do it. At Elekta, we help save lives every day, and make a difference in the lives of others. My daughter is still here because of that. Carlye s Story of Survival Linda and Carlye Ketchum Relay For Life is the American Cancer Society s signature fundraising activity, in which teams of people camp out at a local high school, park, or fairground and take turns walking or running around a track or path in relay style. The event begins with a Survivors Lap in which cancer survivors take a Carlye continues to amaze her victory lap around the track. physicians. She says every day is a gift it s Some are our family and Compelled by the events of Relay for Life, David Greer, a not a sprint, it s a marathon. She s so media and marketing entrepreneur from Atlanta, (Georgia, remarkable, says Linda. I m so grateful some are just memories. USA) wrote All Are Our Heroes, a song and video project in she s still here she has beaten the odds so But all are our heroes, support of all whose lives have been touched by cancer. Shortly many times. She s a survivor. afterward, David enlisted the talents of singer/songwriter Linda and Carlye are featured in the now let s find a cure. Rachel Farley and producer Shawn Mullins to record the song. All Are Our Heroes video (see page 4), Joining Farley and Mullins are some inspirational back-up which tells the stories of cancer survivors singers six young childhood cancer survivors who add their and their families. voices to the ending chorus. Backed by a team of corporate sponsors, including Elekta, the song has become a worldwide anthem. The All Are Our Heroes Facebook group has gathered over 7,500 fans, and the CD and download of the song have raised thousands of dollars for the Relay for Life and the American Cancer Society. Oh my gosh, now I understand what it is I do, Elekta is proud to embrace and support a project that brings a message of hope to those who know someone with and why I do it. At Elekta, we help save lives cancer, or who have cancer themselves, says Christine Oliver, every day, and make a difference in the lives of Vice President of Marketing Services for Elekta. We ve also identified our own heroes courageous individuals and families others. My daughter is still here because of that. who have overcome cancer with the aid of the equipment, technology and treatment Elekta pioneers and delivers and look forward to sharing their stories. To hear the song and read more about how you and your center can support this cause with your regional Relay for Life, 4 wavelength vol. 13 no. 1 visit wavelength vol. 13 no. 1 5

4 When Professor Lars Leksell developed the stereotactic frame in 1949, he probably didn t expect his small, family-run company to become the number one developer and manufacturer of stereotaxy solutions in the world. Professor Leksell s original stereotactic frame has evolved into a comprehensive portfolio of frames that use a system of three coordinates to locate and treat tumors with extreme precision, and his vision of a non-invasive method of neurosurgery has become the gold standard Leksell Gamma Knife. Invented in 1968, the ground-breaking Leksell Gamma Knife is a non-invasive system for treating brain disorders in just hours. More than 50,000 patients now benefit from Gamma Knife surgery every year. Most recently, Elekta introduced Leksell Gamma Knife Perfexion, the next-generation Leksell Gamma Knife, and Elekta Axesse, a leading-edge stereotactic treatment system that s suited for radiosurgery anywhere in the body. In keeping with a 60-year tradition of excellence in innovation, Elekta continues to develop and manufacture solutions that help prolong, improve and even save the lives of patients all around the world. Elekta Celebrates 60 Years of Stereotaxy World leader in stereotaxy looks to the past for its vision of the future 6 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 7

5 Early ideas sketched onto napkins by Lars Leksell Globetrotting on my father s behalf My father was frequently invited to give talks at meetings all over the world. I was fortunate in that he didn t like traveling. He preferred to stay at the Karolinska Hospital and work with his younger colleagues, engineers and physicists. When he realized that I was going into medicine, he started to increasingly make use of his doctor-to-be son, to go give his talks. He usually approached me only one or two days before I had to leave without having put together neither manuscript nor slides for his talk! One particularly memorable meeting was in India in We had just started using the prototype Gamma Knife in Stockholm, when my father was invited by Professor Ramamurthi to speak. Picture this: I was an 18-year-old hippie nerd in my final year of school and talking to the Indian Neurosurgical Society about treating brain tumors with the Gamma Knife, without opening the skull. Oh, this was also before we had published even a single paper on the subject, and I wasn t smart enough to be nervous during the 40-minute talk! The reaction of the Society members was harsh and understandable: Who is this charlatan? Throw him out! And that s just what they did. The next thing I knew, I was standing alone outside, feeling sorry for myself. With nothing else to do, I ate from a huge outdoor buffet next to a sacred zebu cow that was thoroughly enjoying it with me. [Life] with Lars Leksell Dan leksell recalls growing up with his father, the creator of leksell Gamma knife Until I was fifteen, when my mother died, life with my father was easy. Except for a few summer weekends in the countryside, we had very little interaction. However, one thing he managed to do during those early years was to infect me with his interest in stereotaxy, in the instrument, and, later on, in radiosurgery, among many other things. He often brought home the instrument in the evening to tinker and make improvements. Dan Leksell, MD, Executive Vice President and Senior Advisor at Elekta, speaks to attendees at the Leksell Gamma Knife Society meeting, Quebec, Canada wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 9

6 The Italian scandal My father often evaluated patients in Italy, mostly patients with Parkinson s disease, just as his predecessor Herbert Olivecrona had done before him. He selected patients who could be helped by a stereotactic thalamotomy and who would then travel to Stockholm for the procedure. It was usually a two-day affair, assessing about 25 cases per day. In 1971, just a couple of days before he was due to travel to Rome, he again claimed some kind of esoteric affliction and said that he needed my help. I was now in my third year at medical school, was done with my neurology exam and had sat with him through evaluations of many of these patients. So while I didn t hesitate much, I certainly wasn t certified to act as a doctor. I was sitting with a patient on my first day in Rome when a nurse came in and announced that the police were outside. They were waiting to talk to me. A doctor at the clinic had gotten wind of my unauthorized presence. I said goodbye to the patient and jumped out the window into the back garden of the clinic and took a taxi to the airport. I didn t bother to check out of my hotel. I got on the first flight out of Rome. When I landed in Stockholm I was surprised to see my father waiting for me at the gate. This was the first and only time ever that he met me at the airport. His conscience must have been darker than a Swedish night in the middle of winter! The next day the scandal was reported by all the major Italian newspapers: the medical-student son, impersonating Professor Lars Leksell, illegally seeing patients in a private clinic in Rome. The next day the scandal was reported by all the major Italian newspapers: the medical-student son, impersonating Professor Lars Leksell, illegally seeing patients in a private clinic in Rome. The news reached a newspaper in the south of Sweden, but luckily I managed to stop further spread in the Swedish press. My medical career could have ended right there! The last, most painful, presentation 1981 was the last time I was struck with my father s penchant for getting sick 24 hours before he was due to travel. He was invited to give the Sir Hugh Cairns Memorial Lecture, one of the most prestigious neurosurgical honors in the U.K. By now I had long since developed a routine for handling these emergencies. I collected my slides, flew to Manchester, and at midnight drove over the mountains to Sheffield. The weather was terrible and halfway there my rental car went off the road. When I came to, it was very dark and I had a big bump on my forehead. I was lucky to get a lift to Sheffield, I gave the talk and came home with his medal. Of course this habit of his caused a lot of grief and inconvenience. But in retrospect I have to say that, although I prefer to schedule my own trips and talks, traveling in my father s stead afforded me many opportunities to meet a host of wonderful people in all corners of the world. Times Together Between 1969 and the mid-1980s, my father and I developed a very close relationship based on mutual respect and an openness for sharing new ideas. At the time, my wife and I lived with our three children just a block from his apartment. As a result, he regularly ate dinner with us at least three times a week. Occasionally this became too much for my wife. We then solved this by simply going to the local restaurant together. During dinners we sketched our ideas on paper napkins and brainstormed around instrumentation and the potential clinical indications for radiosurgery. Curiosity, passion, patience My father had an innate curiosity in a wide variety of fields. When I worked on my thesis he would come to the lab to see any new findings, to listen and offer ideas. He had a good sense of esthetics, which often was useful to me and which manifested itself in his instrument designs. He was an avid reader and often, somewhat jokingly, scorned me for being illiterate. He loved classical music and ballet. Anything involving technical matters, such as cars, boats and motorcycles interested him greatly. He loved his Daimler, but not enough to get very upset when I, at 16 without a drivers license totaled it. He simply asked me to be a little more careful and to use my brain before I let my teenage impulses take over. During dinners we sketched our ideas on paper napkins and brainstormed around instrumentation and the potential clinical indications for radiosurgery. Professor Leksell, wife Ludmilla and Dan Rome, 1955 Professor Leksell on his boat 1975 Dan and Professor Lars Leksell Italy, 1953 Dan Leksell Rome, wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 11

7 Last days, fond memories In January 1986 my father was spending a few weeks at a ski resort in Switzerland. He was writing a new book when his dictating machine broke. I was on call and in the OR with an emergency, when he called me at five in the morning asking me to buy a new Dictaphone and send it to him in Switzerland. Stressed and tired, I didn t control my words and gave him a rude tirade about how improper it was of him to call about such a trivial matter at such an inopportune hour. Later that day I got the machine and sent it to him. Many of us likely regret something we did to our parents that weighs heavily on our conscience. This episode became mine. That same day he had a cardiac arrest and died. To this day, I wish I had been more thoughtful when I took his call in that operating room! A couple of days after his passing was announced on Swedish radio and TV, the 60-year-old concierge of his apartment building rang at my door. He told me that of all the people who lived in the building, about thirty families, my father had been the only one who, when they met, always stopped to talk to him as an equal. On the day of his funeral the church was completely filled and the mood was somber; everyone was sad and quiet. As people filed past his casket, there were two who very loudly and uncontrollably wept they were the two wonderful servers who had fed us during all of our dinners at the local restaurant. So, how was life with Lars Leksell? Sure, it was demanding when I had to do things for which I was neither prepared nor competent. It was hard to strike a balance between being less than competent and not losing face. On the other side of the coin, there was tremendous stimulation and many, many sweet memories, from serious and less serious times spent together. Today, after 24 years, I still miss him very much! Against the odds: the first Leksell Gamma Knife in Japan Opening a new market for Leksell Gamma Knife is challenging. When facing restrictive conditions, reconsiderations and a national scandal, it becomes even much more challenging. In 1988, the Japanese Ministry of Health and Welfare told Elekta that a precondition for approval of the Gamma Knife in Japan was the submission of results in 30 patients, all of whom had to be treated in Japan. Installing a Gamma Knife in Japan on a speculative basis was more than the tiny company could afford. At Dan Leksell s insistence, the Ministry eventually reconsidered and would accept a submission based on 30 Japanese subjects treated outside of Japan. It took months to retrieve patient files of Japanese patients treated in other countries. After organizing the heavy, analog celluloids, Leksell sent the boxes to the Ministry in Tokyo. The Ministry reconsidered. They again insisted on trials conducted on Japanese subjects in Japan. We were left no other choice than to bite the bullet, manufacture the equipment and ship it to Tokyo, Leksell says. As the instrument was on its way to Tokyo University Hospital the Japanese media unearthed a radioactive dumping ground. It reported that for years the department of radiology at Tokyo University had buried spent nuclear material just beneath the grass in the hospital gardens. Likely as a result of the incriminating news, the chairman of the radiology department committed hara-kiri. Prospects for Leksell Gamma Knife looked more doomed than ever. Then, for some unknown reason even after the negative press Leksell Gamma Knife was allowed into Japan. Together with physicist Jürgen Arndt, Leksell went to Japan in June 1990 to supervise the treatment of the first 30 Japanese Gamma Knife surgery patients. Every case had to be a success, recalls Leksell, who spent at least 12 hours every day for two months at Tokyo University Hospital to make sure each patient was properly selected and each surgery went as planned. We couldn t afford anything to go wrong. Follow-ups were completed, and the materials were collected and submitted to the Ministry. A year later, Leksell Gamma Knife was approved for sale on the Japanese market. Today, the installed base per capita matches that of the United States. With 270 Gamma Knife systems worldwide as of December 2009, 53 are clinical in Japan. Professor Lars Leksell believed that form and balance were essential to good design 12 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 13

8 Extending the benefits of Gamma Knife surgery First centers gear up and start treating with Extend program, a new solution for non-invasive, hypofractionated radiosurgery with Leksell Gamma Knife Perfexion The Extend program harnesses the proven precision of Gamma Knife surgery for new tasks in a dramatic broadening of the types of cases for which clinicians can employ Leksell Gamma Knife. Designed for use with Leksell Gamma Knife Perfexion, Extend combines innovative, patient-friendly head immobilization technology and stereotactic localization methods, enabling clinicians to spread the patient s Gamma Knife treatments over two to five fractions. The first centers to acquire Extend San Raffaele Hospital (Milan, Italy), the University of Virginia (Charlottesville, Virginia, USA), The Brain Centre (Hong Kong) are preparing to use or have begun using Extend in specific cases, including large benign skull base tumors, lesions too close to critical anatomy and single or multiple brain metastases. 14 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 15

9 San Raffaele Hospital Begins Hypofractionated Radiosurgery with Extend San Raffaele Hospital has been performing Gamma Knife surgery since 1993, when it acquired its first Leksell Gamma Knife. Over the next 14 years, clinicians built their case volume, and by 2006 were conducting 500 treatments annually. By 2007, San Raffaele was averaging 15 patient treatments per week for classical Gamma Knife indications, including metastases, benign gliomas, meningiomas, pituitary adenomas and AVMs. San Raffaele Hospital, Milan, Italy The 2007 acquisition of Leksell Gamma Knife Perfexion enabled San Raffaele to refine its Gamma Knife surgery practice. The advanced collimator system allowed clinicians to improve planning by allowing composite shots and sector shielding. With the Perfexion system, it s easier to treat multiple metastases, because we can use more shots and conform more closely to complex tumor shapes, said Antonella del Vecchio, PhD, Physicist at San Raffaele Hospital. The collimator also facilitates treatment for lesions in peripheral regions and in the upper spine. In addition, setting up the patient in the treatment position is easier, because Perfexion doesn t require us to use a tool to fix the G-frame to the patient s head. San Raffaele acquired the Extend program in 2009, permitting physicians to evaluate the efficacy of hypofractionated Gamma Knife treatments. Hypofractionated Gamma Knife treatment is advantageous to treat lesions located near organs-at-risk, such as perioptic meningiomas and brainstem lesions, Dr. del Vecchio notes. Fractionating the treatment allows us to use a lower dose per fraction to protect critical healthy tissues near the tumor target and to take advantage of radiobiological differences between normal and cancerous tissues; normal cells recover more quickly between fractions. The Extend program s unique patient fixation technology improves patient comfort considerably and provides more flexibility to develop fractionation plans, she explains. San Raffaele s first treatment using Extend was in September 2009 and has now completed its fourth treatment. Indications have included a perioptic lesion, neuroma, nasopharynx carcinoma and pituitary adenoma. So far, we have used a maximum of five fractions, Dr. del Vecchio says. Theoretically, there isn t a limit on the number of fractions we could use. We could deliver a number of fractions comparable to conventional radiation therapy. The choice depends on the risk to critical organs as the number of fractions increases, the risk to nearby tissues decreases. We decide based on what we think will provide the optimal clinical result. Patient set up with Extend is somewhat more meticulous due to the customization for each patient s vacuum-assisted bite block and the requirement to perform accuracy and reproducibility checks, she observes. However, our phantom tests show that the accuracy difference between the G-frame and Extend is negligible. First Extend Cases at the Brain Centre are Successful Clinicians led by Robert Ting Kwok Ho, MD, Medical Director and Chief Executive of The Brain Centre (Hong Kong), have successfully conducted their first two hypofractionated Gamma Knife treatments using the Extend program. The first case was a patient with a solitary metastasis who had undergone five radiosurgery treatments over time to control the tumor s growth. During each session, physicians used the standard G-frame head fixation for stereotactic immobilization. In October 2009, Extend was employed for the sixth Gamma Knife treatment. The patient was very pleased with the enhanced comfort that Extend offered, Dr. Ho says. The patient comfort features of Extend were as important to Dr. Ho as the ability to fractionate Gamma Knife surgery for key indications. I was very much involved in the acquisition of Extend, recalls Dr. Ho, a neurologist. The prospect of Gamma Knife surgery becoming totally non-invasive was a major factor. Since October, The Brain Centre has used Extend to complete a patient s treatment course for a skull base chordoma. We have only begun to ascertain the capabilities of Extend, Dr. Ho explains. It certainly has potential to facilitate treatment for a wide range of large benign and malignant lesions, including large metastases and gliomas, in addition to benign skull base lesions such as meningiomas and chordomas as well as complex AVMs. For more information check out YouTube.com/WeAreFightingCancer The Brain Centre has been performing Gamma Knife surgery since 1995, its main indications including acoustic neuromas, pituitary tumors, skull base meningiomas and AVMs. Ten percent of the site s workload are metastases. Today, The Brain Centre treats an average of five patients per week. To remain at the forefront of Gamma Knife surgery, the center acquired Leksell Gamma Knife Perfexion in October Perfexion significantly improved our work flow, enabling us to easily treat three patients a day and finish in the early afternoon, Dr. Ho observes. With the system s advanced collimator system, we can treat extrinsic lesions much more easily and treat multiple metastases in a single session. Patient comfort and treatment times also significantly improved. Radiation safety is exceptional, which is very important for patients with benign lesions, who have long expected survivals. Robert Ting Kwok Ho, MD The Brain Centre, Hong Kong University of Virginia Health System set for January 2010 Start with Extend The University of Virginia (UVA) Health System is among the first U.S. centers to acquire the Extend program, which was delivered in December UVA clinicians, whose Leksell Gamma Knife experience dates back to 1989, have performed nearly 7,000 Gamma Knife surgery treatments over the last 20 years. In 2007, UVA was the sixth U.S. medical center to install Leksell Gamma Knife Perfexion. Patients with overly large benign skull base tumors, lesions too close to critical anatomy and those with multiple metastases will be the first cases that UVA clinicians treat using Extend, said Jason Sheehan, MD, PhD, Associate Professor in Neurosurgery and Radiation Oncology at UVA and Co-director of UVA s Gamma Knife Center. Team members from both the neurosurgery and radiation oncology departments made the decision to acquire Extend, Dr. Sheehan says. We wanted to expand the versatility of the Perfexion system to allow hypofractionated Gamma Knife treatment. This will enable us to treat lesions immediately adjacent to critical structures, such as the optic apparatus, in addition to targets that are simply too large for single fraction radiosurgery. It also creates the potential to treat brain metastases, which in many cases might not require the precision provided by a very rigid frame. There s no question that Extend broadens the potential for Gamma Knife Perfexion, adds James Larner, MD, Professor and Chair, Radiation Oncology at UVA. First, fractionating therapy under certain circumstances cases in which a small tumor abuts a critical structure, for example provides a greater anti-tumor effect for a given level of normal tissue toxicity. Second, Extend is a non-invasive fixation alternative for Gamma Knife. Jason Sheehan, MD, PhD University of Virginia Health System Charlottesville, Virginia, USA James Larner, MD University of Virginia Health System Charlottesville, Virginia, USA 16 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 17

10 The present and future of functional neurosurgery University of Toronto using innovative techniques to treat neurologic disorders Andres M. Lozano, MD, PhD, FRCSC is Professor of Surgery and R.R. Tasker Chair in Functional Neurosurgery at the University of Toronto. He is also Senior Scientist at Toronto Western Research Institute and Past President of the World Society for Stereotactic and Functional Neurosurgery. Functional neurosurgery is used to treat conditions such as Parkinson s disease, epilepsy and chronic intractable pain. Functional neurosurgery might involve making a lesion, in which miniscule parts of the brain are destroyed in order to disrupt an abnormal neural pathway, or changing or stimulating the activity of a neural pathway with electricity. By destroying, changing or stimulating the appropriate pathway, the symptoms of movement disorders and chronic pain may be dramatically improved. Andres M. Lozano, MD, PhD, FRCSC is Professor of Surgery and R.R. Tasker Chair in Functional Neurosurgery at the University of Toronto. He performs about 100 functional neurosurgeries a year, using Elekta s Leksell Stereotactic System. The Leksell Stereotactic System is the most commonly used system in functional neurosurgery worldwide, It may be possible to activate intrinsic brain stem cells so that they start dividing and repairing an area of the brain that is damaged. he says. It s easy to use, robust and reliable, and has enabled neurosurgeons to reach any part of the brain to treat patients with significant neurologic illnesses. The arc frame has really been a workhorse for functional neurosurgery. There are two advantages to using DBS, Professor Lozano says. One is that the surgery is considered to be reversible. The brain tissue is not being destroyed so if you are in the wrong place, you can turn the stimulators off or remove them. The second advantage is that they are adjustable; you can increase or decrease the dose of current, and possibly help the patient just by changing the settings on the device. Clinical trials are underway to test whether DBS might be effective in patients with psychiatric disorders such as depression, obsessive-compulsive disorder, and Tourette s syndrome. This would open up treatment to thousands of patients struggling with psychiatric disorders despite currently available medical treatment. Future holds the promise of new treatments In addition to developing new surgical options for treating Parkinson s disease, epilepsy, chronic pain and psychiatric disorders, researchers are studying the Deep Brain Stimulation is reversible, adjustable possibility of stem cell implantation. Professor Lozano says one of the most exciting It may be possible to activate intrinsic brain stem cells so that they procedures in functional neurosurgery today is deep start dividing and repairing an area of the brain that is damaged, explains brain stimulation (DBS), which involves placing Professor Lozano. There are also exogenous, or external, stem cells that could be electrodes on specific areas of the brain and connecting transplanted from another source to replace missing neurons. There are several them to an internal pulse generator, or pacemaker. issues, though, in that it is hard to make enough of these neurons to transplant, The pacemaker can be programmed percutaneously and it is not yet clear how the neurons will behave. So there are still many issues using an external programmer, explains Professor to overcome with stem cells and their use for treating humans. Lozano. We are able to program the settings to deliver Professor Lozano is seeing an increase of interest in functional a very tiny and specific current to one area of the brain neurosurgery. I think that we re in a phase of tremendous growth and to see whether it improves the symptoms of the illness. excitement. We santicipate that functional neurosurgery will play an even The surgery is often done with the patient awake to help more important role in the future. find the right target. He says approximately 60,000 people have received DBS worldwide with an additional 18 wavelength vol. 13 no. 1 8,000 to 10,000 new patients each year. wavelength vol. 13 no. 1 19

11 Elekta s long tradition of innovation and collaboration has culminated in the creation of four new Leksell Centers of Radiosurgery (LCR). The Centers are regionally renowned and highly preferred facilities that use the world s most advanced radiosurgery and radiotherapy systems within a rigorous, multidisciplinary program of research, education and outreach. Benefits of Leksell Centers of Radiosurgery Leksell Centers Introducing the Leksell Centers of Radiosurgery Pioneering centers combine Leksell Gamma Knife Perfexion and Elekta Axesse for clinical research, education and outreach Each of the four Leksell Centers of Radiosurgery utilizes both Leksell Gamma Knife Perfexion and Elekta Axesse. Each participates in clinical studies conducted by the Leksell Center of Radiosurgery Consortium, provides user training on Leksell Gamma Knife Perfexion and Elekta Axesse, and supports community education of both referring physicians and patients through case studies and seminars. Headed up by a program director, medical director, neurosurgeon, radiation oncologist, physicist and an Elekta representative, each LCR team develops a program plan that establishes measurable goals for the Center. Wake Forest University Baptist Medical Center (Winston-Salem, North Carolina, USA) is one of the first sites in the world to become a Leksell Center of Radiosurgery (LCR). Research Clinical and translational research is conceived and evaluated by the LCR Consortium, and involves the application of Leksell Gamma Knife Perfexion and Elekta Axesse technology for specific cases. Results of LCR research may be presented at Leksell Gamma Knife Society meetings and regional symposia. Outreach After an open house and comprehensive site promotion, each LCR becomes an Elekta show site for potential Elekta customers. The Centers also may participate in the Elekta Speakers Bureau, in which recognized experts on Elekta technology are available to the media for interviews and profiles. These industry experts are also featured speakers at Elekta events, and provide quotes and comments in Elekta articles and press releases. Education Each LCR site is designated as a Leksell Gamma Knife Perfexion and/or Elekta Axesse training facility, with annual or semi-annual sessions for new users and Elekta staff. Centers may also be chosen to participate in Elekta educational events or be featured in papers or case studies. Advantages and Benefits Each Center is featured in LCR promotional materials and, with full access to Elekta marketing materials, participates in detailed market segmentation to target its growth opportunities. LCRs invariably show improved productivity, revenue, profit and ROI with the combined investment in SRS and SRT. More importantly, the LCR designation strengthens each site s reputation as a leader in the field, and promises patients the most advanced head-to-toe treatment technology available today. Stephen B. Tatter, MD, PhD, is a Neurosurgeon at Wake Forest. He says one advantage of becoming a Leksell Center of Radiosurgery is the opportunity to share experiences and ideas. We are interacting with other users through our courses. It has also opened up an ongoing dialog between Wake Forest and Elekta. James J. Urbanic, MD, Radiation Oncologist at Wake Forest, says, The LCR designation highlights the team approach to both our neurosurgical and body radiosurgery programs; we focus on integrating multiple specialties and disciplines. The program s benefits to patients are tremendous. We offer our patients the best equipment for intracranial applications Leksell Gamma Knife Perfexion and for body radiosurgery Elekta Axesse, says Dr. Urbanic. We effectively treat all parts of the anatomy, as opposed to having one machine that s pretty good at both applications but not the best at either. Dr. Tatter says this means fewer limitations to both planning and treatment. We can optimize treatment for each patient, and the Elekta software makes our plans much more conformal, faster and easier to execute. We are excited to be the first Leksell Center of Radiosurgery, says Dr. Urbanic. It s going to add to what we ve been doing here for many years. 20 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 21

12 Mexico Canada OCA Hospital in Monterrey, Mexico becomes the first Elekta VMAT and Monaco system in Mexico and Latin America. They were the first Elekta Synergy IGRT in Mexico and Latin America five years ago and now they become the first center to offer VMAT treatments. Jose A. Lopez, Sales Manager, Elekta North America Several Canadian oncology centers undertaking major expansions and Elekta Canada are forging long-term strategic partnership agreements. The collaborations combine Elekta technologies and clinical resources to increase access to and quality of cancer management for patients. Gerry Hogue, Vice President and General Manager Elekta Canada USA Elekta Strategic Marketing and Referral Techniques (SMART) Program is designed to help centers market to referring physicians, the community and the patent population. This industry-leading program combines market analysis with marketing materials to offset customer spending and optimize marketing resources. Erin E. Evans, Marketing Manager, Customer Development, Elekta North America The Elekta Lung Consortium, a multi-national group investigating the use of SBRT in the treatment of non-small cell lung cancer, presented its first report of aggregated treatment outcome data using volumetric image guidance at ASTRO in November To read about the Consortium, visit: com/acover.wcs?entryid= Joel W. Goldwein, MD, Vice President, Medical Affairs, Elekta The world-class Elekta training center at Preston Ridge (Georgia, USA) houses the most up-to-date Elekta equipment available for system-oriented training. Elekta employees, as well as customer employees, physicists, and engineers from all over the world, get extensive, hands-on experience in the most efficient methods for repairing Elekta linear accelerators and the advanced peripheral technology associated with them. John Joyce, Technical Training Manager, Elekta North America UK Elekta is honored to have won the 2009 World-Class Manufacturer of the Year award from The Manufacturer magazine. The award was given for Elekta s commitment to Lean manufacturing practices, which led to dramatic gains in productivity and efficiency. Elekta will continue to deliver improved performance and, more importantly, improved quality. Brian Edwards, Senior Manufacturing Manager, Elekta Crawley Elekta is proud to launch its first Radiation Oncology Information Systems Advisory Board for European users. With an increasing demand for Elekta products globally, our customers are keen to get involved, as well as excited to help shape the future of Elekta s software system, MOSAIQ. Nicky Wilson, International Business Development, Director for Oncology Information Systems, Elekta Crawley Italy The 4th Elekta European Users Conference was held in Stresa, Italy in June A total of 370 persons from 32 countries were on hand for plenary sessions and hands-on workshops on Elekta treatment and workflow solutions for small clinics and universities alike. Information on the June 2011 meeting will soon be posted on Elekta.com. Lotta Särnman, Manager Sales & Marketing Coordination, Elekta International Neuroscience India India is seeing a tremendous growth in high-quality cancer care, as Elekta expands its presence at a large number of sites all across the country. Leksell Gamma Knife Perfexion units are now treating patients at the Postgraduate Institute of Medical Education and Research, (Chandigarh) and Ojjus Goodwill Hospital (Noida, Uttar Pradesh). Narayana Hrudayalaya Hospital in Bangalore, Karnataka is treating patients on Elekta Synergy S and Elekta Synergy Platform. Indo-American Cancer Institute and Research Center (Hyderabad, Andhra Pradesh) added an Elekta Compact to the lineup of treatment units that includes Elekta Synergy and Elekta Synergy Platform. Medanta - The Medicity Hospital (Gurgaon, Harayana) has placed an order for Elekta Infinity, the first in the country; and Elekta Synergy S. Gustaf Piehl, Director, Marketing and Business Development, Elekta Medical Systems India Pvt. Ltd., Elekta India Taiwan China Participants in the Elekta Compact meeting in Beijing discussed, formally and informally, the newest member of the Elekta Delivery Systems portfolio. With its smaller footprint and streamlined design, it s an ideal replacement for existing Cobalt units, as well as for new clinical facilities in new markets. Elekta is proud to see its products in so many emerging world markets. Peter J. Gaccione, Vice President, Global Sales Initiatives, Elekta Oncology The first Elekta Axesse center in Asia Pacific opened in October 2009 at the Changhua Christian Hospital. Elekta thanks guest speakers Dr. Kuo Shou Jen, Superintendent, and Dr. Liu Mu Tai, Chief of Oncology and Dr. Alvaro Martinez from William Beaumont Hospital. Mona Lee, Regional Sales Manager, Elekta Asia Pacific Singapore Elekta recently opened an office in Singapore, a further commitment to support this emerging market. Its first order was secured for two Elekta Synergy systems, an Elekta Compact and full MOSAIQ oncology information system and treatment planning solutions. Kai Yan Wong, Business Marketing Manager, Software Systems, Elekta Asia Pacific Australia The first Leksell Gamma Knife Perfexion in Australia has been installed at the Macquarie University Private Hospital in Sydney. This leading edge School of Advanced Medicine will also take delivery of Elekta Synergy, MOSAIQ, and treatment planning and delivery software, providing the most advanced radiation therapy and stereotactic radiosurgery solutions to patients throughout Australia. Brendan J. Vahey, Vice President, Business Marketing, Elekta Asia Pacific Elekta healthcare news from your worldwide Elekta team 22 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 23

13 In the midst of treatment at Seattle Cancer Care Alliance, Caitlin Holloway found ways to help other cancer patients. It s one thing for a child with cancer to hear what it s like from an adult, but it s a different thing for a child with cancer to hear it from another child with cancer. Caitlin Holloway was just 14 years old when she came home complaining of a sore throat and neck after playing her saxophone in the school marching band. Shortly after helping her to bed, her mother peeked into Caitlin s room to check up on her. She was having difficulty breathing, so I woke her up and took her to the emergency room. After being sent to Seattle Children s Hospital, she was diagnosed with Hodgkin s Lymphoma, says Karen Holloway. The tumor was over 11 cm, and was pushing against Caitlin s trachea. Karen was all too familiar with the diagnosis. She lost a brother to Hodgkin s Lymphoma in 1965, when the cure rate was less than three percent, in stark contrast to today s 96 percent cure rate. Furthermore, Karen deals with the diagnosis and treatment of cancer every day as Chief Therapist and Department Manager in Radiation Oncology at Seattle Cancer Care Alliance (SCCA, Seattle, Washington, USA). I so wanted Caitlin treated at the Center, because I knew that the combination of our physicians, our care team and our equipment would give Caitlin the very best outcome. Dr. Russell and I have worked together on and off for the past 20 years; he has known Caitlin since birth. We had also just installed our new Elekta Synergy a few months before. The first hurdle was getting the Seattle Children s Hospital protocol accepted at SCCA so that Caitlin could be treated there. Fear quickly changed to determination The next hurdle was helping Caitlin deal with her diagnosis. Not surprisingly, Caitlin was a little scared at first. But I talked to my mom about it, and it quickly became more of a what do we need to do now? kind of thing. Because she and her family live on an island off the Seattle coast that is accessible only by ferry, she needed to stay in Seattle in case her blood counts dropped too low and she needed immediate care. Sometimes she and Karen stayed at the home of one the Center s staff members. Caitlin was exhausted throughout most of her treatment. I was out of school for seven months total. I was very weak, and I didn t like being dependent upon other people all the time. Though she struggled with breathing capacity, muscle weakness and occasional nausea, she knew very early on that she could be of use to others like her. When she visited Web sites for more information on her cancer, she also found other patients her age who had cancer. Caitlin and SCCA s Elekta Synergy system Caitlin and Tyler 17-year-old cancer survivor becomes advocate for teens Left to Right: Connor, Caitlin, Scout, Karen and Tyler at the Make-A-Wish Foundation party I ran across a couple of sites specifically for teens with cancer and met some people online who really wanted to talk and compare experiences. So I got involved in a lot of one-on-one counseling with people my age who were going through the same things I was going through. Some of the children and teens Caitlin met online have not had the best of results with their illness. Some have relapsed. Others have died. But she continues to cultivate and maintain relationships with people her age who want to share their experiences, compare notes or just talk to someone who will listen. Through her counseling work and her research, Caitlin also found out about the Blue Star Connection. This organization gives the gift of music to children and teens with life-threatening illnesses. When the organizers found out Caitlin played alto saxophone, they asked if she d be interested in playing another instrument. As a result, Caitlin received an electric guitar and concert tickets, along with the opportunity to play at a music festival in Colorado (USA). Soon she began to work with the Blue Star Connection to help find donors for the organization, as well as kids who might benefit from the group s generosity. The Blue Star Connection is an amazing group of people. I go into hospitals and social service agencies and tell them about the program and see if they can connect me with other kids who have cancer. We re helping to spread the word. Support, humor make treatment a positive experience While Caitlin was away from home for treatment, her older brother Connor, a senior in high school, maintained the family home, went to school and cared for the family dogs. Her other brother Tyler was away at college. When Caitlin began to lose her hair from the effects of chemotherapy, he and several of his college friends shaved their heads too. This kind of support was the norm, both at home and at the Center. One of the Elekta software guys was in the Center around the time Caitlin started to lose her hair, says Karen, and he made a joke to Caitlin about using a marker or a shaver to make the Elekta logo on her head. Without missing a beat, Caitlin turned to him and said, OK, but it ll cost you. That kind of humor helped us all get through the long months of treatment. Caitlin is now 17 years old and in full remission from her cancer. In June 2009, she finished her junior year in high school with exceptional grades, despite missing seven months of the school year. She recently received a Golden Retriever puppy named Scout from the Make-A-Wish Foundation, and she s training him to be a therapy dog. In a few months, Caitlin will be 18 years old, and will begin taking Scout to Children s Hospital to visit the patients. I m much more involved and focused now than when I began. I ve learned so much, Caitlin says. I just try to help as many people as possible. 24 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 25

14 Dr. Russell planning Caitlin s treatment with SCCA staff Seattle Cancer Care Alliance Beyond cancer care there s human care Caitlin s Healthcare Partner Caitlin s physician is Ken Russell, MD, Professor and Vice Chairman, Radiation Oncology at Seattle Cancer Care Alliance, and University of Washington Medical Center. Dr. Russell says Caitlin was a wonderful patient. Very early on in her chemotherapy treatment, she began to focus on helping others. In turn, everyone on our staff was committed to giving Caitlin the best possible care and helping her and Karen through her treatment. Caitlin was treated on a Children s Oncology Group prospective clinical trial, with combined modality therapy of chemotherapy followed by radiation therapy with Elekta Synergy. The SCCA is a pretty tightly integrated Elekta shop, says Dr. Russell. Our fluoroscopic simulator, EMR software and linear accelerator are all from Elekta. The imaging quality on Elekta Synergy is very good. We were able to visualize the necessary anatomic detail and make even slight adjustments to Caitlin s treatment accurately and as needed. Even though the SCCA was not an accredited radiation oncology site for treating children on the Children s Oncology Group studies, the entire department and all of its various disciplines rallied to meet the accreditation requirements. Everyone worked hard to acquire and submit the required dosimetry, physics, and quality assurance data, and become an accredited site so we could treat her here, close to her mom. It took a lot of effort willingly given on everyone s part, and it was very gratifying to see Caitlin giving her own efforts back to others. The staff at SCCA nurtured and cared for both Caitlin and Karen throughout the treatment process. There was a lot of upbeat kidding and clowning around, remembers Dr. Russell. We wanted to make Caitlin s treatment as positive as possible for everyone involved. Caitlin s advocacy work has been an inspiration, not only to those she helps, but those who see what she s doing. It s one thing for a child with cancer to hear what it s like from an adult, but it s a different thing for a child with cancer to hear it from another child with cancer, says Dr. Russell. The way Caitlin communicates with other teenagers with cancer is more intuitive and resonates more. She s at their stage of life, their trajectory for the future. She s been through the same issues in her personal life. Caitlin s story, says Dr. Russell, is less about technology and equipment than it is about the unique person she is, and the focus and motivation that she found during her treatment. She inspired us all, he says. Because of her mom s work here, she was a frequent visitor to our department even before her diagnosis, and we got to know her on a personal basis. When her cancer was diagnosed, we all wanted to pull together to give her whatever she needed as a patient, to get through treatment and get healthy again. The feeling is obviously mutual. Dr. Russell is a very nice guy, says Caitlin. He s very supportive and always available if I have questions or concerns. The therapists are awesome; they were fun and easy to be around. The whole staff has helped me see my cancer from a different perspective; I m only 17, and look what I ve already been through. I m just really happy to be here, and to have the opportunity to help other people. Every day, more than 100,000 patients worldwide are diagnosed, treated or receive follow-up with the help of an oncology or neurosurgery solution from Elekta. We believe that helping patients is more than just cancer care, it s human care. Through innovation and collaboration, we are advancing new human care standards. Visit elekta.com. Human care makes the future possible 26 wavelength vol. 13 no. 1

15 Associates in Radiation Oncology is a study in efficiency with Elekta technology Comprehensive cancer center provides personalized care Therapists Michael Garcia and Charles Kelleher treat a patient on Elekta Synergy at ARO Associates in Radiation Oncology (ARO, Fairfax City, Virginia, USA) is a freestanding, comprehensive cancer care facility that delivers state-of-the-art external beam treatment with Elekta Synergy to patients with all types of cancer. With 20 to 25 new patient consults per month and an average of 30 patients per day, ARO is one of only a few independently owned and operated freestanding radiation therapy facilities nationwide, and one of only three in Virginia. Anu Gupta, MD, Medical Director for ARO, says the goal of the facility is to provide easy access to radiation care for patients who might prefer an alternative to a large hospital setting. Parking is right at the front door, says Dr. Gupta. I am the primary physician at this facility, so there is excellent continuity of care. And because it is a smaller setting, the care is far more personalized; our office administrator, dosimetrist, and therapists know patients by name. It is one-on-one treatment with all the best technology available. ARO uses a complete Elekta solution: Elekta Synergy, MOSAIQ oncology-specific EMR, and XiO treatment planning. Along with a CT simulator, patients are able to receive state-of-the-art care that rivals any hospital setting. Using one vendor definitely makes a difference, says Dr. Gupta. All the components are very well integrated. Once the CT images are acquired, treatment planning is done by XiO and transferred directly to the Elekta equipment. Elekta Synergy is equipped with a cone beam CT, which allows us to do imaging at the time of treatment. Because of Elekta s superior imaging capability, I am able to do 3D imaging with soft tissue matching within seconds. Treatment modifications can be made immediately, if necessary. There is a seamless integration between the key components. Service is simplified with one vendor as well, says Dr. Gupta. There is essentially one point of contact, and a service person who helps to make sure that all our Elekta components are working well together. Elekta Synergy first choice for linear accelerator Dr. Gupta trained on equipment from another manufacturer, but soon found herself looking for a new system. When it came time to replace our linear accelerator, I looked to see what else was available and was actually quite pleased with everything from Elekta, from the sales rep to the installation process. Changing vendors was a huge step for Dr. Gupta and her staff, but all agree that it was the right move. Elekta is a pioneer in cone beam technology, and the images we acquire are much better than those from other systems. If I had to buy another system, I would buy Elekta without hesitation, because the equipment is fabulous and the customer service is superb. ARO collaborating with Johns Hopkins on partial breast study Dr. Gupta will soon be collaborating as a Co-Principal Investigator on a study with Johns Hopkins University regarding partial breast radiation. Because Hopkins will now be converting to an Elekta Synergy as well, her site was a perfect fit for the study. It is a partial breast radiation study with concurrent chemotherapy, Dr. Gupta explains. The radiation is done in 15 treatments, and, unlike previous studies, patients actually receive chemo right along with radiation. Investigators are hoping to show that partial breast radiation with concurrent chemotherapy is a safe and viable treatment Anu Gupta, MD Because of Elekta s superior imaging capability, I am able to do 3D imaging with soft tissue matching within seconds. Treatment modifications can be made immediately, if necessary. There is a seamless integration between the key components. option. Concurrent therapy allows both treatments to begin closer to the time of surgery, theoretically maximizing the benefits of each. It shortens the overall length of treatment, and it might improve local control of residual cancer cells as well. Dr. Gupta points out that ARO is a particularly good match for these types of studies. Because of our freestanding structure and independent ownership, we are able to align ourselves with a variety of different organizations and groups, and I am able to participate in studies that are an appropriate fit for this kind of setting. Convenience and quality care meet ARO continues to provide excellent care for patients in Virginia, with easy access to high-quality cancer treatment, advanced technology and one-on-one care. Just because we have this convenience factor does not mean that patients are sacrificing quality in any way, emphasizes Dr. Gupta. We are a smaller operation than most hospital-based facilities, so we can often provide the personalized care that hospitals cannot, without compromise on technology. In fact, the facility is one of a few radiation therapy facilities to voluntarily seek and receive accreditation from the American College of Radiology. Dr. Gupta shows her commitment to quality care and has been recognized as one of Washington, DC s top doctors by Washingtonian magazine. 28 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 29

16 Posters and Presentations: AAPM, ASTRO and ESTRO 2009 CLINICAL USE OF ELEKTA VMAT ARO Patients benefit from Elekta Elekta VMAT (Volumetric Modulated Arc Therapy) is Elekta s next generation arc therapy technique that establishes new standards for radiation therapy treatment speed and dose reduction to the patient. With Elekta VMAT, single or multiple radiation beams sweep in uninterrupted arc(s) around the patient, dramatically speeding treatment delivery. Three-dimensional volume imaging technology integrated into Elekta treatment systems increases the precision of Elekta VMAT. This enables physicians to visualize the tumor target at the time of treatment and to guide therapy that both maximizes the radiation dose to the target and minimizes exposure to surrounding healthy tissues. ARO s commitment to state-of-the-art technology and high quality care is evidenced by its patient outcomes. Patient #1: head and neck This 70-year-old white male was diagnosed with a squamous cell carcinoma (stage T2N2C) at the base of the tongue. He initially presented with progressive dysphasia and bilateral neck masses, including a rapidly enlarging right neck mass. A CT scan of the neck showed bilaterally enlarged lymph nodes at level II. The right mass measured 4x3 cm, and the left measured 2x3 cm. He underwent biopsy at the base of the tongue and the lymph node, which both showed squamous cell carcinoma. He went on to receive concurrent chemotherapy and IMRT treatments with daily cone beam CTs. After about fraction #20 at 4,000 centigray (cgy), he had had a significant reduction in the right neck mass, which was evident on the cone beam CT. Because daily imaging showed a continued regression of the neck mass, he underwent new simulation and treatment planning, and then resumed treatment. He received a dose of 7,000 cgy to the base of tongue and 6,000 cgy to the bilateral neck nodes. Without cone beam imaging capability, he may have gone through more treatments before it was evident that the mass had reduced dramatically in size, and his treatment needed replanning. He is now one year out of therapy, and is without evidence of disease. He has minimal to no xerostomia and is eating and swallowing without any difficulty. That is the beauty of IMRT treatments with daily cone beam CT imaging, comments Dr. Gupta. With a different treatment, he may have had the same outcome long term, but he would have had significant persistent side effects. Most important, compared to other commercial arc therapy techniques, Elekta VMAT provides the oncologist with the greatest freedom of choice regarding how the optimal dose will be delivered. This is achieved through the unique flexibility of Elekta treatment systems to simultaneously apply digital control to all treatment parameters, allowing doctors to manipulate the radiation dose and the imaging dose. Both advantages mean patients receive the lowest possible dose outside of the targeted area with their Elekta VMAT treatment. Posters and presentations on VMAT were in abundance at the 2009 meetings of the American Society for Radiation Oncology (ASTRO) and the European Society for Therapeutic Radiation and Oncology (ESTRO). Here are a few examples. Please visit elekta.com/proof for the complete studies. ASTRO Case Study Patient #2: prostate This 66-year-old white male was diagnosed with a T2BN0 adenocarcinoma of the prostate and a PSA of 15 ng/ml. A biopsy showed a Gleason 6 (3+3) adenocarcinoma involving the right lobe and a Gleason 7 (4+3) involving the left lobe with focal perineural invasion. He was also found to have a left-sided nodule on examination. He underwent a total of 40 external beam IMRT treatments to the prostate, receiving a minimum dose of 7800 cgy with IMRT treatment and daily cone beam imaging. Because of the daily imaging, the necessary shifts could be made immediately, in order to minimize exposure to bladder and rectum. He completed treatment without any interruption, and without any side effects from bladder or rectal issues. He is now two years out of treatment with a well controlled PSA. Dr. Gupta comments, This is one of our earliest patients. He is now without any evidence of disease, with a stable PSA. In the past, without daily imaging, he most likely would have had urinary issues. In addition, without the cone beam imaging and the IMRT capabilities we have with Elekta Synergy, we would never have reached these kinds of doses. TOP: Dose distributions for an SBRT lung patient. IMRT is shown in A and C, and VMAT is shown in B and D. RIGHT: DVH comparisons for the corresponding patient (solid line is IMRT, dashed line is VMAT). VMAT for stereotactic body radiation therapy: initial clinical experience William Beaumont Hospital, Royal Oak, Michigan, USA William Beaumont Hospital was one of the first institutions to implement VMAT treatments. This paper presents the Hospital s initial experiences using VMAT for SBRT of the lung and spine. Six lung or spine SBRT patients were treated with VMAT, which had equivalent or better plan quality than alternative IMRT or conformal plans. In two of the lung cases, VMAT reduced the dose enough that SBRT treatment was possible, where it might not have been possible with another treatment method. In three spine patients, planning target volumes were improved and MUs were reduced over IMRT. Treatment times were shortened by up to 13 minutes or 59 percent. This reduction in treatment times reduces the potential for patient motion and may enable better patient comfort and tolerance. 30 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 31

17 ASTRO Case StudIES EStrO Case StudIES VMAT plans for treatment of prostate cancer: dosimetric verifications and comparison with IMRT IMRT (top) and VMAT (bottom) dose distribution plans of one of the 15 patients included in this study VMAT for stereotactic body radiotherapy of spinal/paraspinal tumors Casa di Cura S. Chiara, Firenze, Universita A di Firenze, Italy Researchers in this study compared prostate cancer treatments using IMRT and Elekta VMAT. Plan verifications by different dosimetric systems were studied using the VMAT technique. In eight prostate cases, plans were optimized for Elekta Synergy for a total of eight IMRT plans and 16 VMAT plans (eight single arc and eight double arc). With a dose of 76Gy in 38 fractions, the same organ-at-risk constraints were used for both IMRT and VMAT. Plans were evaluated for number of MUs, treatment delivery times, dose coverage, conformity and homogeneity. Measurements were performed in phantoms to verify the TPS dose calculation and the accuracy of Elekta Synergy delivery. The study showed that VMAT has the potential to safely replace IMRT step-and-shoot techniques in clinical practice, due to VMAT s reduction in MUs and treatment times. Comparison of Elekta VMAT with helical tomotherapy: plan quality, delivery efficiency and accuracy Swedish Cancer Institute, Seattle, Washington, USA This study compares the plan quality, delivery efficiency and accuracy of VMAT to tomotherapy. Twelve cases were studied: four prostate, four head and neck, and four lung. In each case, both VMAT and tomotherapy plans were generated, with a single arc for all prostate and lung cases, and two to three arcs for head and neck cases. Both VMAT and helical tomotherapy plans used the same CT images and structure contours. The study concluded that VMAT provides comparable plan quality to helical tomotherapy in both target coverage and critical structure sparing, as well as an accurate delivery of the calculated dose distribution. However, treatment time with VMAT is significantly reduced when compared to tomotherapy. University of Toronto, Princess Margaret Hospital, Odette Cancer Center, Sunnybrook Hospital; Toronto, Canada Because SBRT requires longer treatment times, VMAT, with its continuous dose delivery while the gantry rotates, is an excellent treatment option. This study compares delivered IMRT treatment plans to retrospectively-generated VMAT plans for spinal SBRT. Single-arc VMAT plans were generated for 15 patients with spinal metastases who were previously treated with IMRT. Researchers concluded that VMAT provides a significant reduction in delivery time and improves spinal cord sparing, while providing target coverage that is equivalent to IMRT. Comparison of VMAT to tomotherapy with regard to plan, quality, delivery efficiency and accuracy Results of dosimetric verification of VMAT and IMRT in treating prostate cancer DVHs for one selected patient Comparison of VMAT versus established treatment techniques for re-irradiation of spinal metastases VMAT vs. established treatment techniques for re-irradiation of spinal metastases University Medical Center Mannheim, Mannheim, Germany Re-irradiation of spinal metastases with 3D conformal radiation therapy can cause myelopathy, due to the high dose exposure to the spinal cord. IMRT can reduce the dose to the spinal cord, but at the expense of longer treatment times. This study looks at the potential of VMAT to reduce both treatment times and MUs. Five patients with spinal cord metastases were studied, using 3D radiation therapy (posterior-anterior static field technique and two-field-wedge technique), IMRT (5- and 7-beam) and VMAT (two rotations). Analysis was conducted in regard to conformity, homogeneity, dose volume, treatment delivery time and MUs. The planning target volume (PTV), consisting of the macroscopic tumor and excluding the spinal cord or medullary cone, was not sufficiently covered with 3D radiation therapy. The IMRT technique resulted in excellent coverage, but had treatment times of approximately 10 minutes. VMAT, however, showed an excellent dose distribution with treatment times of less than four minutes. In terms of PTV, VMAT provides similar homogeneity and conformity to step-and-shoot IMRT, but with shorter treatment times and lower MUs. 32 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 33

18 What is the biggest change at your center since implementing Elekta Impac Software? McKay Saphner The best thing has been the tremendous calm in the office. We re not running around, looking for charts. We had college students working for us just finding records. And there are no overhead pages, because those were always searches for records. Productivity has really improved. We had a legion of people in medical records, and it cost us five bucks to pull a chart. When you think about all the times you pull those charts, it was a lot of money. We saw that an enormous amount of energy was wasted looking for charts and even handling charts. EMR is always available to us, even if we re at home. And if you have downtime at a satellite clinic, you can use the time online, approving documents. Terry McKay, President and CEO West Michigan Cancer Center Oncology EMR users find outstanding benefits and value Centers using Elekta Impac Software praise efficiency, medical oncology focus The implementation of electronic medical records (EMR) has become a hot topic as a component of proposed healthcare reforms. For those centers already using oncology-specific EMR systems, the benefits far outweigh any negatives. We gathered advice, input and results from three experts, each of whom has implemented a medical oncology EMR system from industry leader Elekta Impac Software. Our experts (listed alphabetically): Terry McKay, President and CEO West Michigan Cancer Center Kalamazoo, Michigan, USA West Michigan Cancer Center averages nearly 80,000 patient visits annually, with more than 120 employees in 55,000 square feet of space. Thomas Saphner, MD, FACP Green Bay Oncology Principle Investigator for the St. Vincent Regional Cancer Center CCOP Green Bay, Wisconsin, USA Thomas Saphner leads the prestigious Community Clinical Oncology Program (CCOP) as designated by the National Cancer Institute. The designation makes St. Vincent one of only 63 major research sites in 34 states. Kim Willard, Impac Systems Administrator Palmetto Hematology Oncology Clinic Spartanburg, South Carolina, USA The clinic is affiliated with the famed M. D. Anderson Clinic and provides state-of-the-art cancer care for residents of upstate South Carolina. Willard The improved workflow as a result of EMR has been the most visible part of the program. You don t have four health information personnel walking around looking for charts. Charts are available at the tips of your fingers, and they can be accessed and reviewed from home via a VPN. Do you consider yourself at the forefront of technology, since you are an early adopter of EMR? McKay Saphner EMR is how you re going to practice medicine in the future. And the sooner you get on the bandwagon, the sooner you re going to save money for your practice. I get weary of people wringing their hands about the cost of EMR. That s very short-sighted, because it makes your life so much simpler. I m here to tell you that EMR is not new, it s not visionary, it s standard. You can t provide services without EMR. You can t meet Medicare requirements. It s impossible. We re big on clinical trials and have 225 per year. Without EMR to manage all that, including the documentation to insurance and Medicare, we wouldn t be able to participate in as many trials. Statistics show that most oncology sites are still on paper, but I can t believe it. When we made the decision, it was move to electronic records or die. If we asked our team to go back to paper, they d revolt. About MOSAIQ MOSAIQ comprehensive electronic medical record (EMR) meets the specific challenges of both medical and radiation oncology practices. From patient intake through scheduling, billing, treatment and follow-up, MOSAIQ streamlines the entire therapy workflow. Capable of supporting multi-vendor, multi-disciplinary and multi-site organizations, MOSAIQ provides a central database to ensure information is available everywhere, every time it is required. With MOSAIQ, Elekta combines real-world clinical experience with proven software solutions that reduce or eliminate the need for paper charts. The result is the most widely used EMR software in the field of oncology today. MOSAIQ is the market leader, built on a framework of trust and reliability. Elekta is a strong partner for the future, and can help you grow your practice. When it s time to upgrade, you can trust Elekta and MOSAIQ to take you to the next level with ease. Elekta solutions are compatible with any setting: large cancer center, private practice or hospital. Other vendors claim they are a one-stop-shop for oncology software, but they don t have Elekta s longterm customer satisfaction and industry leadership to prove their claims. 34 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 35

19 Did you have any problems getting buy-in from your staff? Willard McKay The key to our success was to put together an implementation team composed of someone from all departments. This team had a lot of meetings, timelines and roadmaps. Now that we have implementation, we have quarterly staff meetings, with all 88 employees in one big room. During this time we review errors, process changes and discuss how to improve our processes. We also have an ongoing education process. We meet two times a year with each employee for 15 minutes, one-on-one. During this time we review their information needs and capabilities for using the system so we truly understand their processes and needs. We also meet quarterly with different departments. I have mature physicians, and we all use it for medical oncology and radiation oncology. They ve become enthusiastic supporters. When they look at an enhancement, they ll ask, How many clicks is it? They ve gotten pretty sophisticated. We ve had dramatic savings. We extracted one-half million dollars from our operating system annually. Were there concerns about security? Why did you choose Elekta Impac Software? Saphner Information security is better with electronic records. With a paper document, you don t know who has seen it or where it s been. With electronic, you have a record of everyone who has opened the file. McKay Elekta Impac Software had radiation oncology and we needed medical oncology too. We tried a third-party solution out of desperation, but the result was an unhappy staff. The software had a very shallow learning curve and our staff was very happy with it. Willard EMR is sometimes seen as less secure. We have a patient population of largely elderly patients, so they had a lot of questions. We reinforced that all records are password protected. We have firewall and security, and our internal HIPAA privacy and security auditors are continuously vigilant about security. At the time, people were picking best of breed. When we chose to stick with Elekta Impac Software for billing, it led us to a decision to stick with one vendor. That has served us well, since we don t have to worry about interface issues. For us, it was a good decision. The billing module is getting better, and all others are strong. Plus, customer support is excellent. When we were acquired and became hospital-based, it made the security requirements more stringent. So we built assessments for quality, and have a real sense of pride in the levels of compliance that we ve achieved. In addition, we work with M. D. Anderson, and they ve deemed our EMR excellent. Saphner When we made the decision, they were the only game in town. We wanted a system to include billing, all clinical needs and radiation oncology, if we start offering that. However, we ve been forced to look at systems again because we re looking at binding together radiation oncology. We conducted a very thorough review and we couldn t find anything better. It s at least as good as the competitors, and we believe that Elekta Impac Software has very good people backing it up. Elekta hears you Your primary concerns for a successful EMR program Willard We started looking at EMRs in We looked at mom and pop systems, Varian and several other systems. We began looking in 1995 and continued through We laid out what we wanted in an EMR system and Elekta Impac Software brought it to us. Improved patient safety Reliable machine interfaces Ease of use Accurate billing and timely reimbursements Paperless practice and electronic medical records It s been around awhile, but I don t think anyone had the complete solution until Elekta Impac Software did. They ve always been the bomb for radiation oncology, and now they have medical oncology. What was the patient reaction to EMR? McKay Patients have new admiration for their physician because they can see the CT right on the screen. Saphner Patients are not the least bit amazed by electronic records. You go to JiffyLube and they have all your records, so why wouldn t your doctor? Patients expect it at this point. 36 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 37

20 What important benefits have you realized from using Elekta Impac Software? Explore an Elekta Virtual Community McKay Willard We ve had dramatic savings. We extracted one-half million dollars from our operating system annually. We went from eight people in medical records to one, and she does other things. The other benefit has been the elimination of onsite storage of records because they ve all been scanned. The medical records room is now a fitness center for patients and employees. In the past, we took terrific care of patients, but used to measure the amount of paper that came to us every day in feet, not inches. One quality initiative we undertook was to see how fast we could get information into patient records. Four days was the best we could do, and 6-7 days was average. Now, it s instantaneous. The quality of care for the patient is at the center of what we do. We use the software s to get questions to physicians for immediate attention, so there s less waiting. It s a quick communications tool, and information is available in real time. How has your EMR helped to improve patient safety? McKay Saphner Everything is now in the electronic record. You ll find legible patient orders at your fingertips in the exam room, workstation and doctor s office. If you re covering for another doctor, you can see everything and provide better treatment. In the old days, you would order chemo and have components to be entered with a ballpoint pen. The potential for mistakes was enormous. Now, you can create a care plan and standardize on that. The result is greater accuracy and safer delivery of medicines. What do you expect to achieve in the future with your EMR system? Saphner Elekta Impac Software holds our practice together. We use it at both of our main offices; at the branch clinics, one has switched, one is in process and we have two more to go. Once we achieve that, we ll all be on the system. The real ROI happens after work patterns change, and that doesn t happen until the last doctor converts. Once that happens, you see benefits in many aspects. Once all doctors are on the system you no longer need paper charts. One goal is to get all doctors to approve treatment plans on the computer so the complete process is documented electronically, and the majority have already made that conversion. Creating clinical connections The Elekta Virtual Communities are professional networking web sites available to all staff from the oncology or neurosurgery communities of health professionals. The goal is to foster collaboration, discussion and the creation of working groups which could possibly lead to the development of workflows, protocols and ultimately the publication of work in scientific journals or at scientific meetings. The virtual communities will put new users in touch with experienced users, acting not only as a forum for sharing knowledge but also for collaboration on the development of protocols. Users will be able to directly communicate with research groups to seek guidance and test potential implementation plans, helping them to more rapidly develop their own protocols and thus set up efficient clinical practices for the implementation of the relevant new technology platform in their own institution. Elekta virtual communities: Facilitate the exchange of views and participation in discussion Provide a platform for collaboration between partners who share their specific interests, in private, on special projects Provide a diary of key events/dates specific to this specialist area Which community is for you? Willard At go-live, we were a privately owned physician group strictly focused on medical oncology. In 2008, the hospital purchased the practice, so now we re hospital owned and based. Our goal is to merge databases with the separate radiation oncology department and have a unified patient record, since we see about percent of the same patients. We re working to integrate with radiation oncology and interface with the hospital s McKesson computer system. 38 wavelength vol. 13 no. 1 wavelength vol. 13 no. 1 39

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