Welcome everyone to CyberKnife TV. We are delighted to have you with us again. This time, we are back from the European CyberKnife Center here in Munich. Today, we are talking all about the spine. Discover the latest treatments available here. We will discuss the state-of-the-art CyberKnife technology with our experts Professor Alexander Muacevic and Dr. Markus Kufeld.

Professor Muacevic, before we dive into this special type of treatment, please say a few words about this Center so that those who are not yet familiar with it can get to know it. How did it all start? What are your specialties?

15 years ago, we established the center here in collaboration with Klinikum Großhadern. Since then, we have treated almost 10,000 patients – which is incredible – covering all types of tumor diseases. We started with brain tumor treatments. Then we expanded our work to include spinal tumors, lung tumors, liver tumors and kidney tumors. More recently, we have also turned to prostate treatments. But the spine has certainly been a specialty of ours from the very beginning.

In fact, and as the spinal surgeon who is with us today will be talking a little more about later, spinal tumors are very common.

Of course, our approach is not suitable for all cases, but is often a are very good option for tumors that would otherwise be treated with conventional surgery.

Dr. Kufeld, what makes it so special for you to be part of the team here?

As neurosurgeons, Professor Muacevic and I have a special interest in treating the head and spine – just as we did in our basic training. With CyberKnife, we can treat tumors in the entire spinal region and, in some cases, use it as an alternative to conventional surgery. We have certainly been one of the driving forces behind this. We have been able to create good conditions and gain a lot of experience in radiosurgery of the spine. And it's been particularly enjoyable to offer this as a good alternative to patients.

I would like to talk about this in a little more detail. After all, the two of you are highly specialised wen it comes to this form of treatment of the spine. How would you describe yourselves in this reagrd?

We are both neurosurgeons by training, i.e. we are trained in conventional surgery, yet we have also obtained special qualifications to provide radiosurgical treatment. And it really makes a difference whether you treat these tumors using surgical expertise or whether you have only seen a few images. This is particularly important when you must decide which cases are more suited to conventional surgery and which for CyberKnife radiosurgical therapy.

There is a lot to consider and we are happy to have some highly qualified colleagues here – not only among our team, but of course also with regard to our collaborations. Togehter with Professor Tonn's Department of Neurosurgery for example, we decide on what is the best possible treatment for each patient.

Speaking of treatment: What is so special and unique about the CyberKnife technology that you use here?

We have been able to establish a single-session radiosurgical treatment for spinal tumors, just as we have done for treatments of the head – which still make up the majority of our cases. That is, we can carry out the actual treatment in a single sitting. We still need to make some preparations beforehand, of course. The actual irradiation though is carried out in a single treatment session.

Obviously, this is much more convenient than having to come in repeatedly for many lengthy sessions, which cany impede the patient's quality of life. Patients are very happy with our single-session treatment.

Patients – that's my cue, Dr. Kufeld. If I come to you as a patient, what am I in for? What is the treatment like? I have heard that it is quite different from what it used to be back in the day – when patients were terrified of tumor treatment and anxious about what they might experience.

What is it like around here?

Well, there's no need to worry at all about the treatment. However, I am well aware that if you're not familiar with the procedure, you're facing the unknown. That's why we have two separate appointments: The first one is the consultation, where we make sure that we can offer a good therapy for your indication. If so, we carry out what is called a Planning CT, i.e, a computer tomogram that provides the basis for our computer-aided planning of the further treatment.

And then there is usually only one more appointment, i.e. the actual treatment. You come by in your street clothes, are picked up by one of our staff who takes you to the treatment room and simply lie down on the couch. We have the latest generation of radiosurgical equipment around here so most treatments take no more than 30 minutes.

Once you lie on the couch, the robot circles around you to direct the rays directly at where we have told it to via the planning software. After 30 minutes you get up and, after a short final consultation, go home. If you need a break during the treatment that's fine. So if you feel unwell, for example, or if you have an itch somewhere, or if you need to go to the toilet, you can do all that. It's perfectly fine to interrupt the treatment and then resume it.

Our focus for today is on the spine. What kind of diseases can occur that you can then treat with this technology?

When it comes to the spine, CyberKnife is used almost exclusively for tumor treatment. We are talking about two types of tumors. First, there are metastases of malignant diseases – cancer metastases, essentially – which often occur in the spine, but can also affect the spinal cord.

These treatments account for the majority of our spinal treatments.

Second, there are so-called primary tumors – both benign and malignant ones occur in the spine. If the MRI scan gives us a clear indication and as long as the strict criteria are met, we can treat them well with CyberKnife radiosurgery.

It is also important to note that we often advise patients to undergo conventional surgery as the first option. However, if a patient has already had surgery or even has several tumors on the spine, CyberKnife is particularly suitable as an alternative to another operation – especially in the case of relapses.

All in all, tumors seldomly occur in the spine. Compared to tumors in general, such as prostate or breast carcinomas, they are very rare in the spine. We can essentially distinguish between two types: On the one hand, there are tumors that originate from the nerve tissue and the nerve membranes. On the other hand, there are tumors that affect the bone.

Bone tumors are highly likely to be metastases, i.e. metastases of a malignant tumor which itself is located somewhere else in the body. Nerve tumors are often benign tumors that originate in the nerve sheaths, the meninges, meningiomas and neurinomas. In rare cases, tumors can also develop in the spinal cord itself. These are usually less benign.

What are your experiences with spinal treatments in particular?

Of course, the experience is always very good if the indication is right. These treatments are often critical, because we are working close to the spine and the spinal cord, which must always be protected. Compared to its surrounding structures, the spinal cord is tiny: only eight to nine millimetres in diameter, in some cases. And its surroundings, where most of these tumors are located, are much bigger and more coarse.

In fact, we can even treat tumors in the so-called spinal canal, i.e. where the spinal cord runs through. But we must look at every case indivisually and it always depends on: How large is the tumor? What kind of tumor is it? Where exactly is it located? What was the previous treatment like? It's difficult to make a general statement, as we have to examine each individual case.

Here, you can see the scan of a patient with a spinal tumor who has already undergone surgery. You can tell by the vertebral replacement right here at the front. These white areas are all tumor tissue. And now we are faced with the question of how to resolve the situation from a surgical and radiosurgical perspective.

In cooperation with our colleague Dr. Medele from the Spine Center in Munich, we are planning a therapy that combines conventional surgery with radiosurgery. We provide relief from the back with conventional surgery to remove pressure and carry out radiosurgical treatment to the anterior structures – which would be difficult to operate on, surgically. The anterior structures are always more difficult to operate on, which is why CyberKnife can be a good option.

Looking at the scan, I also think that we cannot solve this with surgery alone. Reducing the dorsal parts of the tumor by surgery and providing supplementary radiosurgery in the area where there is an increasing surgical risk makes perfect sense to me. This way, we can minimize the risk for our patient.

I don't expect there to be any major problems here. However, a significant amount of the tumor will remain after surgery which is why the best approach is to combine it with CyberKnife therapy, so that we can tackle the remaining tumor.

It would probably take one and a half or two hours to perform the surgery. After that, it will probably take the patient a week to recover before we can take the next step. The spinal cord, right here in the middle, is fairly small compared to the tumor and bony structures surrounding it. Of course, the spinal cord must be protected by all means and that is why we are considering this approach.

I believe, we have come up with an approiach that poses minimal risk while retaining the greatest possible benefit for the patient.

What about aftercare with this type of procedure? What do patients need to consider?

As with all our patients, we try to provide them with high-quality, comprehensive aftercare – and in most cases that is exactly what we achieve. With malignant diseases, we typically need new imaging every quarter for the first year. Patients return to us with their MRI scans, sometimes CT scans, and we assess them based on the existing findings and in comparison to their previous scans.

In fact, it is quite difficult to assess and evaluate these scans after radiosurgery. Did we manage to eliminate the entire tumor? Some changes to the spine prevail for a long time which makes it more difficult to interpret the scan. Hence, we must ensure that patients continue to see us. And, of course, we are available at any time if patients face any issues.

We must look at each case individually. With benign tumors, we often act because they are simply growing too big. Conventional surgery is often a good option to remove the entire tumor. In some cases, especially if the patient's anatomy would pose a high risk for surgery or we can already tell that we cannot remove the tumor in its entirety, complementary treatment - such as CyberKnife radiosurgery - can be very beneficial for the patient.

We are in the midst of the coronavirus pandemic. How have you adapted to this special situation here at the CyberKnife Center? And are there any advantages to this type of treatment in these times?

In general, we did not have to adapt much at all. CyberKnife treatment is ideally suited to these difficult times. Why? Because there is no need for the patient to be hospitalized. Hence, I can't catch anything at the hospital. As physicians, we can always keep a sufficient distance from the patient – which is no different from our 'normal' procedure. During treatment, which takes place in an air-conditioned room where there is a constant flow of because the technology requires it, there is practically no chance of contracting a virus.

Thus, we find ourselves in a favorable situation. One thing we have changed is that we ask patients not to bring too many family members in order for us to maintain social distancing in the waiting rooms. But in general, we haven't had any major changes here and some patients have even chosen this type of treatment specifically to avoid a stay at the hospital.

Dr. Kufeld, how do you see the current situation? People are talking about a new normality.

We have indeed taken measures and implemented all the requirements of the medical and health authorities. However, it was relatively easy for us, as we do not work with invasive procedures on patients. We can keep our distance due to our spacious facilities and, anyway, the patient is alone in the treatment room. Thus, the the usual risks of close-up contact with patients are reduced to a minimum and the risk of infection is extremely low. We have been able to carry out all treatments safely and effectively throughout this difficult phase.

What are the advantages of radiosurgery and CyberKnife technology overall? There are probably many patients who associate tumor treatments with various side effects. Can you alleviate their fears?

Yes. In most cases there is no need for fear. After all, we only treat patients with suitable indications. The typical side effects of conventional surgery cannot even occur simply because there is no need for anesthesia, there are no cuts or wounds and there is no blood. Compared to conventional radiotherapy, our patients do not experience side effects such as skin problems or hair loss.

These things cannot happen with radiosurgery. Why not? Because we work with much finer rays. In conventional radiotherapy, you usually have four to six directions of irradiation, but we have up to 150. 150 individual rays – which are almost as thin as a hair – penetrate the body without causing any damage. However, when these 150 rays overlap exactly where the tumor is located, then they become harmful – but only to the tumor. We calculate the exact position of the tumor beforehand with our medical physicists during treatment planning. This precision is what allows us to protect the surrounding tissue.

In your day-to-day interactions with patients, do you get the impression that this fear, which is perhaps a bit overwhelming at the beginning, slowly subsides and is gone by the end?

Correct. Of course, it is also our job to make patients more familiar with this technology, which may seem threatening at first. In addition, there are the fears and worries of tumor diseases per se. Naturally, it goes down very well with patients when we tell them that this treatment is basically pain-free. We can say that without a doubt, even if radiosurgery is not entirely without risk.

The risks are low, but – admittedly – they do exist. Obviously, we discuss them with the patient on an individual basis, which allows us to guide them through the procedure and allay their fears in the majority of cases.

The main advantage is, of course, that there is no surgery and therefore far less recovery time. Surgery usually requires a few days in hospital and a recovery period of around four to six weeks on average. The surgery’s consequences only subside after this recovery period when the healing process has set in.

And I should stress that this is of course not the case with radiosurgery. The treatment is carried out on an outpatient basis and there is hardly any recovery phase. We have been familiar with the CyberKnife Center for a very, very long time and we have been able to achieve excellent results over the years. Spinal diseases affect many people, and, in a large cohort of patients, there are always some very special cases for which this high-tech, high-precision treatment can achieve a better result for the patient. And that is why we really appreciate our cooperation. It rounds off the range of treatments we can provide to help patients.

You mentioned Professor Tonn earlier. Could you give us some more information on your cooperation with the University Hospital. How important is it for you?

Our cooperation with the university is extremely important. I'd say that we could not do without it. On the one hand, it takes a large group of experts to identify indiviodual cases so that we can use this method. On the other hand, we have been conducting scientific evaluations of all our treatments for many years and, of course, we do this together with our colleagues from the University Hospital.

Together, we published the first ever paper on CyberKnife treatment of spinal diseases back in 2006 – a crucial step for us. Without this cooperation, we would not have been able to carry out all this.

Most of our patients have complex conditions, particularly of the spine. Often, a range of treatments has already taken place and, usually, there are several treatment options at hand. Of course, we must evaluate these together with our specialized colleagues and then make a joint decision on what is the best treatment option for the specific patient. This requires exchange with colleagues and experts, who are particularly well versed with spinal diseases.

The source of most spinal diseases in our society is, of course, sitting. I just want to point out that this is probably the single biggest cause of back pain. It leads to damage to the intervertebral disc with all the ensuing consequences. In other words, if you can reduce prolonged sitting in your everyday life, you will be doing yourself a huge favor.

An important question for all patients: Does my health insurance company cover the costs of this treatment? What is the situation like?

We have very good conditions here in Bavaria and Munich. We have been able to establish a trifold cooperation with AOK Bayern, Klinikum Großhadern and the CyberKnife Center right from the start. Since it is often difficult to win over health insurance companies for new and modern treatment methods, this is something special. We have very good coverage here, not only with the AOK, but also with many company-related health insurers, i.e. the BKKs, the Barmer Ersatzkasse and many others. Of course, we also work together with all private health insurance companies in Germany. There are a few companies with whom we are still in talks. But we are continuously working on it, and we hope to expand our network even further in the future.

We'll keep our fingers crossed! Gentlemen, thank you very much for another very exciting talk and this fascinating insight into CyberKnife technology. Thank you very much for having us here. To all our viewers: Thank you very much for watching. That's all for CyberKnife TV today. If you would like to watch all our episodes, head to our on-demand service at www.muenchen.tv or go to www.cyber-knife.net for further information. See you next time. Take care.