Posted on: Thursday, March 15, 2001

New surgical tool saving lives

By Beverly Creamer
Advertiser Staff Writer

Neurosurgeon Leon Liem with the radiation Gamma Knife. Deborah Booker • The Honolulu Advertiser

For Ella Tong, it seemed like science fiction.

The strange metal cap that screwed into her head in four places, making just four tiny punctures.

The silence except for Keali'i Reichel playing on the sound system.

And the miraculous radiation aimed at killing four inoperable brain tumors, all in different spots inside her skull.

"Without this, I would probably have had no chance," said the 46-year-old educational assistant in special education, who underwent Gamma Knife surgery in January for metastasized breast cancer that had found its way to her brain.

"The tumors were spaced out, so surgery was impossible," said the soft-spoken Tong. "It wasn't even discussed because the Gamma Knife was available."

In the past three years, the $3 million Gamma Knife based at St. Francis Medical Center has been used for 190 surgical procedures that would have been impossible without it.

Malignant brain tumors. Clumps of abnormal blood vessels with a 20 percent risk of bleeding and causing a stroke or death. Recurrent tumors. Trigeminal neuralgia, which causes stabbing facial nerve pain so severe it has driven people to suicide. Those and many more once inoperable lesions are being treated with equipment that is not a knife at all, but converges 201 beams of cobalt-60 radiation on trouble spots inside the brain.

It's still so rare and expensive that there's not a single machine in Canada, Australia or New Zealand.

And that's why St. Francis is mounting a marketing effort to attract patients from the rest of the Pacific and beyond.

"We're going to say, 'You can have your Gamma Knife brain surgery today and recuperate on the beach tomorrow,'" said neurosurgeon Dr. Maurice Nicholson, who helped bring the equipment to Hawai'i and headed the first local surgical team trained in its use.

"It won't bring them in in droves, but I'm confident we can attract people from these other areas where there are no Gamma Knives. There are a lot of people who don't want their head opened up. When they know this technology is available and it's so easy to come on an eight-hour flight and we all speak the same language, it makes it very easy."

One of the amazing selling points is the recovery time: essentially none.

"I got there at 5:30 in the morning and left about 1:30 or 2 in the afternoon," said Tong. "They want you to kind of sit quiet for awhile because the holes might bleed, and it lets them heal up. But they're less than a centimeter, and they put Band-Aids on."

Another patient wrote Nicholson that she had brain surgery in the morning and went shopping the next afternoon.

Presently, only two procedures are being performed a week, mostly on Hawai'i patients, but there's potential to do two a day. Generally, the procedures can be performed more cheaply than surgery - the $20,000 average fee for Gamma Knife treatment is half the cost of a craniotomy - and without expensive in-hospital recovery time.

"That's one of the reasons we're trying to expand our market. It's under-utilized, and we know there are a lot of people who could benefit from it but just don't know about it," said Nicholson.

Web sites have recently been mounted aimed at the three English-speaking countries bordering the Pacific from which Nicholson hopes to attract patients. As well, interest has come from Web chats on various medical problems the Gamma Knife can be used to treat.

Nicholson said Hawai'i patients will continue to have access to Gamma Knife service. "We would never ever reach a situation where we could not treat people in the right time period," said Nicholson.

Gamma Knife technology was invented in Sweden in the 1980s, and the first one in the United States came to the University of Pittsburgh in 1987. "But it didn't catch on for awhile because everyone wanted to see what the five-year follow-ups were," said Nicholson.

The follow-ups were good, and now there are approximately 148 machines worldwide, with 40 or so in the United States. As dramatic as it is, the technology doesn't eliminate the need for conventional brain surgery, or conventional radiation for chemotherapy. It's used in select situations where it's the best choice, in the case of deep-seated or spread-out tumors, for example - and in many cases where there is no other choice.

"In the old days (two or three years ago), everybody had whole brain radiation," said Nicholson. "It was a six-week course, they'd lose their hair, have nausea and vomiting, and if they lived long enough, they'd sometimes have dementia." But the Gamma Knife eliminates all those side effects and allows people to live longer, staving off, at least temporarily, the need for more radical treatment.

Dr. Leon Liem, a second St. Francis neurosurgeon trained on the machine, said the treatments stop tumors from growing, or slow them down. "The goal is not to vaporize it, but control its growth," said Liem. "If it doesn't grow any further, it shouldn't cause any more symptoms. If we control the tumors in the head, we hope we can extend the patient's life."

Liem specializes in Gamma Knife treatment for abnormal tangles of blood vessels that occasionally form in the brain. If they should start to bleed, they can cause a stroke. "If (the blood vessels are) . . . small or in a safe area on the surface of the brain, surgery is the best way to take care of it," he said. But if the trouble area is deep in the brain, Gamma Knife treatment is preferable.

The Gamma Knife doesn't immediately destroy the blood vessels, but causes them to shrink and close off over the course of two to three years. The Gamma Knife is also starting to be used to treat Parkinson's disease, offering new hope that the abnormal cells which cause tremors can be successfully destroyed.

Meanwhile, the Gamma Knife Center of the Pacific at St. Francis, which has sponsored training for local neurosurgeons, will be marketing its services to patients in hopes they will decide that Hawai'i is the place. For surgery. And sun.