Providing noninvasive neurosurgery for metastatic diseases of the brain and spine, JD Lipani Radiosurgery Institute helps patients preserve mental and physical function.
Many cancers, including breast, lung, gastrointestinal and prostate, can metastasize to the spine and brain. In fact, the spine is the third most likely place for metastatic tumors to occur. Brain metastases also happen more frequently than primary brain tumors. Metastases to either location can cause physical and mental disability, including paralysis, incontinence and impaired cognitive function. At earlier stages, spine metastases can result in extreme pain, while brain metastases can cause headaches, light sensitivity, nausea, vomiting and seizures.
After a patient has become cognitively impaired, incontinent or paralyzed due to brain or spine metastases, he or she will probably never recover the lost capabilities. For this reason, John D. Lipani, MD, PhD, FAANS, FACS, Founding Director of both the JD Lipani Radiosurgery Institute and Princeton Neurological Surgery, and Clinical Assistant Professor of Neurological Surgery at Thomas Jefferson University Hospital and Jefferson Medical College, seeks to educate physicians and patients about the importance of early identification and treatment of these lesions.
“When patients have metastatic cancer, their medical or radiation oncologists often wait to refer them to a neurosurgeon until they need emergency care,” Dr. Lipani says. “I want patients with brain and spine disease to see me before it becomes too late. The treatments we offer at JD Lipani Radiosurgery Institute are 98 percent effective in preventing irreversible damage to the brain and spine.”
With the goal of protecting the central nervous system from the effects of metastatic disease, Dr. Lipani offers focused, high-dose radiation as an alternative to traditional radiation therapy. Gamma Knife and CyberKnife technologies target tumors with intense, directed radiation, often eliminating them for good, Dr. Lipani says.
“Broad radiation therapy is excellent for its indications but limited in its scope of application because both healthy and diseased tissue are affected,” Dr. Lipani says. “For instance, radiation therapy to the spine can harm the spinal cord, so its uses are limited. Similarly, chemotherapy does not always get into the central nervous system because many chemotherapy agents cannot cross the blood-brain barrier.”
Dr. Lipani is eager to spread awareness of radiosurgery’s potential.
“Patients need to understand that it is not necessary to irradiate the whole brain to treat a few metastases,” he says. “It is possible to defer whole-brain radiation therapy until it is necessary. However, it is important for patients to be referred for radiosurgery early in the disease progression so they can still benefit.”
Instituting a New Subspecialty
Dr. Lipani describes the overuse of radiation therapy and open surgery for brain and spine metastases as a function of economics, among other factors. Radiosurgery, he says, is underrepresented in residency programs. Additionally, radiosurgery requires the expertise of a neurosurgeon, radiation oncologist and medical physicist, as well as special technology and facilities. Due to these high opportunity costs for medical students and healthcare organizations, the field remained narrow until the late 1990s, when the CyberKnife was introduced.
“The Gamma Knife, which had been in use for many years, was able to treat only intracranial lesions, but the CyberKnife treats cancers throughout the body, making it more widely applicable,” Dr. Lipani says. “Now that we have more than a decade of research demonstrating the effectiveness of the CyberKnife, institutions are beginning to acknowledge it and invest in it.”
From the inception of Dr. Lipani’s career, he strategically trained in many modalities and disciplines — including obtaining a PhD in neuroscience — to create a subspecialty in the new field of radiosurgery. He studied with John Adler, MD, who pioneered the use of the CyberKnife, and trained at the University of Pittsburgh under L. Dade Lunsford, MD, who introduced the first Gamma Knife to the United States. Drs. Adler and Lunsford both trained with Lars Leksell, MD, the inventor of stereotactic radiosurgery and creator of the Gamma Knife, so Dr. Lipani’s connections to radiosurgery go back to its source.
David D’Ambrosio, MD, Medical Director of New Jersey CyberKnife and radiation oncologist, Karen Koza, medical dosimetrist, and Dr. Lipani review a patient’s chart prior to CyberKnife treatment delivery.
With this background, he first directed a neurosurgical oncology program in a hospital setting, then moved into private practice, establishing Princeton Neurological Surgery and the JD Lipani Radiosurgery Institute.
“I wanted to spend quality time with my patients and be available to them 24 hours a day, seven days a week,” he says. “Between the two practices, I am able to offer patients a wide range of options, from noninvasive radiosurgery to minimally invasive spine procedures to open brain and spine surgery. This allows me to provide all relevant neurosurgical options to my patients in an unbiased fashion.”
Who Can Benefit from Radiosurgery?
Any patient with metastatic tumors of the brain or spine is a potential candidate for radiosurgery, Dr. Lipani says. This includes patients who may not yet have been deemed sufficiently advanced for a referral by their oncologists, or those who may have been told they have little chance of benefiting from treatment. In particular, if patients have back pain, radiculopathy, neuralgia or other symptoms associated with systemic cancer that may have spread to the central nervous system, radiosurgery has the potential to improve their condition.
Dr. Lipani reassures a patient on the CyberKnife treatment couch at New Jersey CyberKnife office at Community Medical Center.
“Often, there is no alternative to treatment,” Dr. Lipani says. “I am able to stop the growth of metastatic lesions in almost all cases. In fact, I rarely see a tumor that continues to spread after treatment. If I do find a recurrence, most often I can re-treat that patient. When patients come into my office, they can rest assured that I will not let their brain and spine lesions become an irreversible problem.”
Patients with certain primary brain tumors, including acoustic neuromas, pituitary adenomas and schwannomas, may benefit from radiosurgery, too.
“Many people with these tumors receive open surgery and require ICU stays,” Dr. Lipani says. “I can treat those conditions noninvasively using radiosurgery.”
Various radiological platforms at JD Lipani Radiosurgery Institute give patients a choice of approaches to curing their spine and back tumors and treating their back pain, radiculopathy and other conditions. For the most part, these are noninvasive procedures. Patients remain fully clothed throughout and can leave the office the same day. Treatments are typically completed in one to five sessions, depending on the clinical condition.
Example scenario of an intracranial renal cell metastatic tumor (left), after treatment with CyberKnife radiosurgery (middle), and similar tumor treated with alternative therapy (right)
Example scenario of a spinal metastatic tumor (left), after treatment with CyberKnife radiosurgery (middle), and similar tumor treated with alternative therapy (right)
A noninvasive radiosurgery platform, CyberKnife can deliver a high dose of targeted radiation to any location in the body. Before the procedure, patients receive a CT scan, which the surgeon uses to create a treatment map. The CT image is then uploaded to CyberKnife’s software. The system uses intraoperative X-rays to locate nearby anatomy and guide radiation delivery, matching it against the treatment plan.
“If a patient moves even a little bit, the X-rays will inform the robotic arm, which compensates for those small motions,” Dr. Lipani says. “It is amazing to see the large arm as it adjusts ever so slightly in response to the patient’s involuntary motions.”
CyberKnife enables hypofractionated delivery, in which radiosurgery is performed over a few sessions to spare vital tissue and ensure patient safety. Patients typically need no more than five CyberKnife treatments. Sessions are painless, and patients can return to their regular activities immediately.
A platform that can combine radiosurgery with stereotactic radiation therapy, Elekta Synergy S is useful for treating tumors where it is necessary to preserve a very tight margin. Combining 2-D and 3-D imaging, Elekta Synergy S makes stereotactic radiation therapy available to patients who otherwise could not have benefited from it.
Gamma Knife, also by Elekta, has been available in the United States since 1987. Similar to CyberKnife, the technology uses sharply honed radiation to target and destroy tumors. Thousands of extremely fine beams — no more than 0.5 millimeters in diameter — intersect to destroy tumors while sparing other tissue. Patients typically need only one treatment. Gamma Knife is limited to intracranial procedures.
During Gamma Knife procedures, patients wear a stereotactic head frame so they keep absolutely still during the procedure. Although local anesthesia is used when the head frame is affixed, patients can typically return to full activity immediately after their procedure unless they have had an angiogram to guide imaging.
“Many people will say that Gamma Knife is more accurate than other radiosurgery apparatus because patients are secure in the apparatus during the procedure,” Dr. Lipani says. “However, the delivery of radiation is very different between technologies. Gamma Knife delivers multiple beams to the center of the radiation field, while CyberKnife delivers single beams in succession.”
Varian TrueBeam is a platform that offers combined capabilities for radiosurgery and radiation therapy. At the JD Lipani Radiosurgery Institute, TrueBeam therapy is used to treat tumors of the brain and spine. Like CyberKnife, TrueBeam adjusts for even tiny patient movements, following a 3-D treatment plan with accuracy to less than 1 millimeter. Treatments last only a few minutes.
Christina Dombroski, RN, OCN, and Dr. Lipani remotely review films of a potential CyberKnife patient.
One overarching distinction between radiosurgery and conventional radiation therapy is that the surgeon creates a treatment plan customized to each patient, with risk factors carefully balanced to suit the patient’s objectives.
“The beauty of radiosurgery is that we can identify exactly how much radiation will go where,” Dr. Lipani says. “Because the process is automated and digital, we can decide doses very narrowly, specifying how much and in what fractions we deliver to the tumor and the tumor margin.”
Other Patient Considerations
Patients with metastatic brain and spine tumors are often undergoing other treatments, such as chemotherapy. Typically, radiosurgery does not negatively impact patients’ oncology treatment plans. Instead, it specifically targets lesions to preserve patients’ neurological status and functionality.
“In oncology, many physicians have taken a ‘watch-and-wait’ attitude toward patients with metastatic cancer. We have to get away from this philosophy and act aggressively when patients are not responding to therapy. At JD Lipani Radiosurgery Institute, we will not allow metastatic brain and spine lesions to become an irreversible problem. With a 98 percent success rate for tumor eradication, we enable patients to retain their cognitive and physical abilities.”
— John D. Lipani, MD, PhD, FAANS, FACS, Founding Director of both JD Lipani Radiosurgery Institute and Princeton Neurological Surgery; Clinical Assistant Professor of Neurological Surgery, Thomas Jefferson University Hospital and Jefferson Medical College
In addition to working closely with referring physicians, Dr. Lipani keeps close contact with his patients, performing follow-up studies every three months after the initial procedure. Patients report satisfaction and even amazement with their results. Many had been wheelchair-bound or expected to soon become paralyzed; now, they are free of pain and can go about their daily activities with a much higher level of function.
Dr. Lipani does not market his practices based on a single platform or procedure. Instead, he takes a synergistic approach to neurological surgery, which has shaped his career from its inception. He is also skilled at open brain and spine surgery. His advanced degree in neuroscience gives him a sound understanding of the nuances involved in radiosurgery.
CyberKnife Radiosurgery team at New Jersey CyberKnife, J. Phillip Citta Regional Cancer Center, Community Medical Center, Barnabas Health: David D’Ambrosio, MD, Rajesh Iyer, MD, John D. Lipani, MD, PhD, FAANS, FACS, Joe Garcia, RTT, Richard Tenpenny, Karen Koza, Hongkui Ma
“It’s not the technology but the person behind the technology that’s important,” he says. “It’s extremely unusual to have a physician who has studied both Gamma Knife and CyberKnife technology in depth. I can discuss the relative advantages of many different technologies and surgical approaches without attempting to steer patients toward one or another based on my particular expertise.”
To learn more, please visit www.radiosurgeryinstitute.com.