CyberKnife allows surgeons to boldy go where no scalpel can cut

John Sinclair has spent four years pitching the promise of a $4-million knife that doesn’t even have a blade.

The neurosurgeon has told anyone who will listen, including colleagues at The Ottawa Hospital, government officials and potential funders, that a technology called CyberKnife will revolutionize brain surgery and the treatment of many cancers.

Sinclair describes the CyberKnife as a cross between a robot’s arm and the sensor wand that Dr. Leonard McCoy used to pass over his mates on the Starship Enterprise to cure all sorts of ailments. But mostly, Sinclair talks about how the CyberKnife will improve the lives of many patients.

“Some cancer patients who had inoperable tumours can now be treated,” he says.

The CyberKnife uses targeted radiation to destroy tumours anywhere in the body, reaching into places a surgeon’s scalpel cannot. “Some patients will be spared invasive surgeries. No cutting up of the insides. No stays in the Intensive Care Units. Or long recovery times,” he says.

The CyberKnife has shown in recent clinical trials that it is as good as conventional radiation — without the side effects — in treating many different types of cancer, says Sinclair. Instead of daily treatment over six or seven weeks, it can be done over two or three days.

“That’s three radiation treatments instead of 35,” he says. “Imagine.”

After four years of asking others to “imagine” the possibility of the CyberKnife, the 42-year-old Sinclair learned recently that Cancer Care Ontario has chosen Ottawa and Hamilton to be the first centres in Ontario to test this technology. (A CyberKnife just began operations in Montreal.)

“I always knew we would do it,” says Sinclair. “It wasn’t if, but when.”

First, The Ottawa Hospital must raise about $3.5 million. For that it will be turning to the Hospital Foundation, as well as help from patients, medical staff and other private donors.

“When we get CyberKnife here our Cancer Centre will be the state of the art. It will be one of the best in country,” says Paula Doering, the hospital’s vice-president of clinical programs.

It was after Doering heard Sinclair give a talk in 2006 on the merits of the CyberKnife that she joined him in his mission.

“I thought, ‘Come hell or high water, this is coming to Ottawa’,” Doering recalls. She could imagine the immediate benefits. Operating rooms would be freed up because cancer patients would elect to have radiosurgery instead of an operation. Others would have their radiation times drop dramatically.

She said Sinclair’s passion for the new form of radiosurgery excited her.

Sinclair, who graduated from the University of Ottawa medical school, is the only Canadian trained in the CyberKnife’s use after completing a fellowship at Stanford University that included a year of training with its American inventor.

He turned down jobs at Stanford and Harvard University to return to Ottawa in late 2005 with his Ottawa-born wife and their three children. He made it his mission to bring the CyberKnife with him.

“What I see here is a change in the future of surgery. Not elimination of surgery but another treatment modality that a surgeon will be part of that will take us one step closer to the Star Trek situation where you pass the little wand over the tumour and get rid of it,” he says.

Sinclair didn’t set out to be a brain surgeon. He imagined a career in teaching. After getting a degree in kinesiology at the University of Ottawa, he applied to teacher’s college — and medical school.

He didn’t get into teacher’s college.

At the University of Ottawa medical school he decided to focus on orthopedic surgery. But he realized, after two years of residency, that he wanted to do more than bone and joint work.

“I did a rotation in neurosurgery and thought ‘Oh my goodness I’m in the wrong line of work’.” He enjoyed dealing with the life and death issues involved in brain surgery on critically ill patients.

He decided he wanted to be a cerebrovascular neurosurgeon, specializing in problems with the blood vessels of the brain. He was accepted to do a fellowship at Stanford University. There he learned to treat arterial venous malformations — “AVMs,” abnormal tangles of blood vessels in the brain that have a propensity to leak.

At Stanford, these AVMs were being treated with — among other radiosurgery tools — the CyberKnife. It was developed at the university by neurosurgeon Dr. John Adler. Sinclair asked to stay a third year to train with Adler.

“The world of radiosurgery exploded for me,” recalls Sinclair. He imagined his future. “It was neurovascular radiosurgery with oncology and radio surgery — one day, when I had a job, it would mesh them all.”

In 2005, when his fellowship was over, Sinclair had five job offers to remain in the U.S. Among them was the offer from Stanford and another from a hospital affiliated with Harvard University that had a CyberKnife waiting for him to use.

But his heart and his hopes were in Canada.

“My wife is from Ottawa. We had three kids by this time. And all our tax dollars went to train me. Our plan all along was to come back to Canada — at some point.”

A neurosurgeon job opened up at The Ottawa Hospital.

Sinclair recalls the reaction when he turned down the job at Harvard. “‘Tell me again why you want to go back to Ottawa?’ These were amazing job offers that you don’t get again. You can’t go back in five years and say ‘Hey, remember me?’”

But Sinclair packed up his family and came back.

He was the only surgeon in Canada trained to use the CyberKnife. The only problem: How was he going to get one?

Surgery using radiation — radiosurgery — is fairly common in Ontario. There is a Gamma Knife in Toronto and The Ottawa Hospital uses radio surgery techniques. It is used to treat cranial lesions and requires that a head frame be bolted onto the skull of the patient. The patient cannot move during radiation treatment, allowing for more accurate brain surgery, although this point is debated.

The Gamma Knife makes radiosurgery possible only in the upper part of the head, but the CyberKnife is being used against cancers throughout the body.

The technology destroys cancerous tissue by using multiple small radiation beams that are generated from a linear accelerator mounted on a three-metre-long robotic arm. A computer guidance system aims each beam with sub-millimetric precision, allowing extremely high doses of radiation to be delivered very close to normal tissue and organs, says Sinclair. Delicate adjacent tissue is spared.

The genius of the CyberKnife is that it can perform surgery on moving tissue.

As a patient breathes in and out, or makes other small movements, the machine uses X-ray cameras and its on-board computer to track the location of tumours in real time. The CyberKnife’s software adjusts to target the radiation beams to keep them aimed at the cancerous tissue.

The CyberKnife requires a team of medical professionals, including a medical physicist to help plan the radiation, a radiation oncologist to help design the treatment plan, and a surgeon who determines what needs to be removed or dosed with radiation. Everyone comes together to generate a treatment plan.

Dr. Shawn Malone, a radiation oncologist at the Ottawa Hospital Cancer Centre, says he is excited by the potential of the CyberKnife to treat tumours outside the brain.

“There is no bolting,” Malone says. “We can treat tumours in the lung and liver and abdomen.”

Sinclair always hoped he could help bring CyberKnife to Ottawa. “It’s a huge part of the reason why I came back. If someone told me, you’re going to go back but you’re not going to do radiosurgery, I would have thought long and hard about returning.”

The next weeks are crucial as The Ottawa Hospital looks for donors. The Ottawa Hospital Foundation is raising money. An order for the machine must be placed. Sinclair is confident it will all come together.

He hopes to be able to have a CyberKnife operating at The Ottawa Hospital by May.

http://www.canada.com/health/CyberKnife+revolutionizes+brain+surgery/2365293/story.html