steretactic radiosurgery at Duke

[carolk]

Has anyone had any experience with Dr. John Kirkpatrick in radiation oncology at Duke?  Thanks!

[becknell]

 Carol — We have not had experience with him, but my husband had surgery at Duke in August for a rather large AN. They left some residue that was too stuck to the brain stem and other structures to remove, and now he needs radiosurgery for the residue. Our surgeon at Duke (Friedman, top dog in neurosurgery) said we could either have the radiosurgery done at Duke or we could go to the Universitty of Virginia for Gamma Knife. He said he' be fine with us having it done at Duke, but he spoke quite highly of the U Va. program, and said he has sent lots of patients there and they have a very renown program, so we decided to look into that. That's one of the most experienced radiosurgery centers in the world — as opposed to Duke, where they haven't been doing it as long. Also upon questioning Friedman said the LINAC at Duke is not "dedicated" for radiosurgery, which I understand means they may have to do some alterations to use it for radiosurgery, which COULD potentially reduce the accuracy, according to what I've read. All that is up for debate, though. I do know another patient who had radiosurgery at Duke, and she seemed to be pleased with it and said the guy who did it was great. I don't know if any of this is helping you or not. Send me an e-mail if you want to talk more.

[Mark]

Sorry I misposted this earlier

I'm not sure what the term "dedicated" means in this context either. I think the first question is what kind of machine is Duke using. A GK is "dedicated" to radiosurgery because it really isn't capable of anything but one dose treatments. If Duke is using a radiotherapy LINAC machine such as Novalis or one of the others, then it would not be dedicated to radiosurgery but in conjunction with a head frame could approach the accuracy of GK or CK. That would be my guess as to what is being referred to based on the information provided.

It is true that UVA is one of the oldest utilizers of the GK and thus one of the most experienced with it. Based on the recent posts relative to misinformation both they and Wake forest have used on their web sites in comparing GK to other systems, I have lost a measure of respect for them from an ethics standpoint. That certainly is no reflection on their medical skills with GK, but rather a reflection of their financial ties to the maker of GK.

I think the more relevant question if radiosurgery is being pursued is which machine and approach is the best. Radiotherapy with treatments of 20-30 days is usually done with proton beam and LINAC machines such as Novalis, Radiosurgery is done by GK and CK with the latter being the more advanced technology. All can be effective, in the end you have to decide which is best for you

Mark

[becknell]

Hey, Mark, I understand why you feel the way you do. We're supposed to talk to Dr. Steiner at UVA on Wednesday morning and I plan to ask him about the info they have posted on the Web site. I'll let you know what he says if you'd like. But it's probably not significant enough for us to change our decision -- I think other factors are more important, honestly. As far as "dedicated," it just refers to a unit specifically reserved for radiosurgery. If it's not dedicated to radiosurgery, but also used for radio therapy, they may have to make some adjustments in the unit to use it for radiosurgery. I've read about this in several places, so I asked about it, right now I honestly cannot remember where I read this but it was in more than one place, so it stuck with me as something significant enough to question, and when I asked our surgeon, he knew exactly what I was talking about and told me the Duke LINAC is not dedicated.
One other thing, Mark -- why all this brou-ha-ha about the "more advanced technology"? I have seen you make references to this in other posts. And my thought here is, what does it matter if it's more advanced if it doesn't offer a significant advantage in your specific case? And I'm speaking in our case, for example, I can't see what advantage CK would offer, and Dr. Medburry seemed to concur with that when I asked that question on the CK board, so what difference does it make that it's "more advanced."?? What matter is what's right FOR YOU.

[Mark]

Becknell,

I believe your explanation of "dedicated" matches up precisely with my comments based on the information provided in the original post about what was available at Duke. No more , no less.

Yes, I would be interested in Dr. Steiners explanation of the comments made on the UVA web site in terms of the CK / Gk comparison. They are so blatantly wrong that I find it embarassing that any professional clinician would put their name behind them. Either GK or CK can be equally effective in treating an AN which is not in debate, however, the claimed "advantages" of GK on the web site are absurd. It would be my belief that UVA's long ( and probably financially based ) relationship with Elektra certainly is a factor, but I would be stunned if Dr. Steiner would acknowledge that if asked.

As far as the technology advantages between GK and CK it really comes down to a couple of issues.

1) until CK was developed, GK was the gold standard in terms of radiosurgical accuracy. Clinical studies indicate that CK is equal or better than GK in accuarcy, without the invasive headframe. Is the difference in accuracy significant in terms of outcome on a one dose to one dose basis, probably not. However, if there is no clinical advantage to one over the other, then why on earth would someone choose to have four screws put in their skull when they didn't have to in order to achieve a  better outcome?

2) If someone chooses a FSR protocol over one dose on the assumption it provides better nerve preservation with equal tumor control, then Gk is not an option and CK is. The other LINAC systems that can do FSR tend to fall more into the radiotherapy category which means the patient sacrifices accuracy in an exchange for staged treatment. CK allows for the same level of accuracy in a FSR protocol as GK does for a one dose scenario, without the headframe being required.

I think the "brouhaha"  is about those areas of differentiation. When Dr. Medberry addressed those issues he clearly stated that GK and CK were probably equally effective in successfully treating an AN. He also said that no one who has access to both ( as he does) would say GK is superior to CK for the reasons listed above. If you're comfortable with a one dose protocol and are fine with the headframe, then GK is a very effective option. If you want the same or better accuracy, the option of staging and avoidance of a headframe then CK would be the clear choice. Based on that , you're right it is what is best for the individual   That would be my perspective on your question


Mark