Dear viewers, thank you for tuning in to Münchner Medizintalk. Today we cover another fascinating topic with Dr. Martin Marianowizc and Professor Dr. Alexander Muacevic. Did I pronounce that correctly, Professor?

Absolutely.

Great. Today, we will talk about state-of-the-art tumor therapies. Dr. Marianowizc, you are an advocate of new technologies and high-tech medicine. What exactly do we mean by that? And what about CyberKnife, for example?

We try to use the latest approaches available to us. But we simply cannot provide all these technologies to our patients, which is why we work together with several centers that are known for their progressive approach. Today, we are at one of those centers to talk about a fairly new type of treatment for tumors, i.e. high-precision radiosurgery. There are currently eleven specialized centers in Germany carrying out these treatments – which do not require incisions or hospitalization –, but it is still less known to the public or even deliberately kept secret. After all, people who perform surgeries tend to recommend surgery. But the CyberKnife allows patients to avoid that.

This is a very modern radiology institute. Sometimes, you discover tumors in patients with back pain, or a tumor in the back area.

Primary tumors are quite rare in and around the spinal cord, but there are many diseases associated with metastases in the spine. We discover these and, if the indication is right, we refer the patient to Professor Muacevic.

Professor, you mentioned radiosurgery as an innovative method for treating both benign and malignant tumors. Can you tell us a bit more about it?

CyberKnife is a very modern method for treating tumors with the great advantage that a single treatment session can replace an entire surgery.

So, the patient comes to you first – you are also a radiologist.

Neurosurgeon and radiologist.

Right. It starts with the scan; you make the diagnosis and then you can get very close to the tumor with this method. Is there any pain? Does it hurt?

No, and that is the crucial thing: It does not hurt. Our job is to effectively select the right cases. What are the right cases? Small tumors, tumors with clear demarcations. Their locations does not really matter. However, it must be possible for us to properly identify them on the scans. That is what we can treat with our single-session treatment on an outpatient basis.

What do you mean by small tumors? How big are they?

Great question. It depends, of course: "small tumors" in the brain are not the same as "small tumors" in the liver. But they should never be bigger than three to four centimeters.

Can you give us a better idea of how it works? This is, after all, a treatment that involves robotic technology. The beam must be very precise, and the patient probably cannot move. They probably have to lie in a particular position, or how does it work?

Thank you for pointing that out. In fact, it's the other way around. The beauty of this technology is that it adapts to the patient who simply lies down on the treatment table as they normally would – they can move, they can breathe – it's just like they lie down on their couch.

And if they were to sneeze, then what?

If they sneeze, they sneeze. No big deal. Since this treatment involves up to 150 different directions from which the radiation is emitted, sneezing once won't cause a problem. If they sneeze twice, the system temporarily shuts down.

Why? Because the robot is connected to an image-guided system, a digital imaging device that tells the robot where to go. Thus, it always hits the tumor with pinpoint accuracy – with a variance of less than half a millimeter.

If I may add, the robot we use was originally developed for the automotive industry. In other words, if you drive a German car, it was most likely assembled with the help of this robot.

The robot is exceptionally precise. Its so-called technical precision is 0.06 millimeters. Hard to imagine, isn't it? Although technical precision is not the same as clinical precision, which ranges from 0.4 to 0.5 millimeters, this is still incredibly precise and ensures that we target only the tumor. In short, we can spare the surrounding tissue as much as possible which is crucial.

Let me see if I understand this correctly: To give an example, if you have a tumor in the cranial region, and you undergo radiosurgery with this robot, with CyberKnife, the tumor could practically be gone in an hour?

Many patients assume that this is a very drastic procedure, that the tumor is virtually burned away by a laser. It is not like that at all. We induce a process causing the tumor to gradually disintegrate over the following weeks or months. This happens at the cellular and genetic level: As the genetic information is destroyed by the high-energy beams, the cells form scars, causing the tumor to disintegrate over time.

I have heard that the treatment takes a different amount of time depending on the type of tumor. Does that mean the follow-up intervals vary?

Correct. The follow-ups take place between three and six months after treatment, depending on the type of tumor. Malignant tumors degrade faster because they consist almost entirely of tumor cells. Benign tumors degrade at a slower rate because they consist of a lot of connective tissue and supporting tissue cells. The body takes longer to break these down.

But how can you tell whether a tumor is benign or malignant? Do you take a tissue sample?

Good question. We can do a lot with modern imaging. Based on personal experience, we can often tell whether a tumor is benign or not – using MRI scans, PET-CT and other modern imaging techniques. If we are uncertain, we will have to take a small sample beforehand, for example at the University Hospital.

Most likely in Großhadern?

Yes, in Großhadern because we are a satellite center of the LMU University Hospital in Munich. This way, we know exactly what we are actually treating before the treatment can begin.

Of course, this is also what happens if you opt for conventional surgery. If you use the older method, you also have to take a tissue sample. You can do without, but it is always better to know what you are dealing with beforehand.

Very true.

So, when it comes to the preparations, the approaches do not differ much.

In this regard, I see some parallels between you. As an advocate of exploring all possible forms of therapy before turning to surgery, I think you are in the same camp. Which is great, of course.

What I wanted to ask you: What is the difference between proton technology and what you do? Both are similar procedures, but with proton technology the patient must be fixated.

Yes, of course. I could give a whole lecture on this – there is so much to say. In a nutshell, proton therapy is basically a refined form of conventional radiotherapy. And it always takes place in multiple sessions – 20 to 25, in many cases. We always carry out our treatment in a single session.

Plus, proton therapy cannot achieve the same results for tumors in moving organs. Unlike our robot, it does not adapt to the patient's movement. The massive gantry revolving around the patient cannot track their position. Hence, if I want to treat a lung tumor with protons, I must induce anesthesia to immobilize the patient and accurately target the tumor.

I was just about to say: It is indeed very, very impressive that this robot can treat moveable organs. Now, I'm sure we're all thinking that moving organs are perhaps the lungs and heart – heart tumors are not the issue here. But what impressed me so much is treatment of the prostate. I'm now at an age where many of my friends have unfortunately already had to undergo surgery. Many didn't even know that there was an alternative option. Of course, this makes me question things even though I am not immediately affected.

If you compare the two options, conventional surgery comes with plenty of risks and side-effects – it can take a big hit on your quality of life. CyberKnife is a great alternative allowing you to avoid risks, especially if the tumor is still in its early stages. And from what I've heard, the results are excellent.

So far, you have treated more than 3,000 patients with this method.

6,000.

6,000 already! When I googled it, there were still 3,000.

Worldwide there have been over 100,000 patients, I have heard. That was still numbers from 2015.

Well, when we started in 2005, we were the first center in Germany. In the US, CyberKnife is a much more widespread method with over 200 treatment centers.

In Germany, these things take a little longer. In many cases, it is also a question of funding since the robot is very expensive. How do I pay for it? How do I integrate it into an existing structure? How do I get health insurance companies to pay for this modern yet technically elaborate treatment?

But it is also very gentle!

Indeed. And, at some point, it becomes more and more relevant to the entire medical system. In Munich and Bavaria, we have excellent conditions. We are very pleased that we were able to secure AOK Bayern as a partner from day one. They were highly motivated and immediately recognized the appeal for their customers – and that it would even save them money in the long run.

In a sense, we are competing against conventional surgery; not so much against conventional radiotherapy, because it is less suitable for the cases we can treat. To give you an example, let's say you have a brain tumor of two centimeters on the auditory nerve. We see quite a few of these so-called acoustic neuromata, but, in most cases, these patients would receive conventional surgery. This requires a four to five-hour procedure, a few days in intensive care, a week in hospital and probably six to eight weeks of rehabilitation.

And there are high risks.

After all this time, you can slowly return to your normal environment. We can treat this type of tumor just as effectively in a one-off, 30-minute session – as has now been scientifically proven. Of course, this makes a big difference for the patient, but also for the healthcare provider as it is simply cheaper. However, I want to stress that I do not consider us to be competitors of surgeons, but rather a complementary service.

We closely cooperate with the University Clinic and its various Departments. And after all, we are not able to treat all types of tumors. Larger ones often still require conventional surgery – for that there is no alternative. But, as part of our network, we can provide patients with many different options for the various indications.

This brings us back to the topic of prevention. You must detect the tumor while it is still quite small and not when it is so big that there is no other option left.

I was recently on a program with Professor Mayer, who is an excellent surgeon, and he said that preventive measures are of little use when it comes to brain tumors, because they can grow back very quickly.

Plus, they are quite rare. Whereas men should get tested for prostate cancer every year from the age of 50, this is not the case for brain tumors. They are simply too uncommon for such a comprehensive measure.

In all your time in practice, you have also detected some metastases in the back – an area where your treatment method can also help.

We have an ageing society, and back pain is a common problem. Many patients come to us with such issues. In some cases, we discover that it is caused by metastases from a tumor that has already been treated – typically in the prostate. But for some patients, the primary tumor was never discovered, and their symptoms are – unfortunately – caused by a metastasis.

And then, of course… there are many cases in which you cannot do much with conventional, invasive surgery.

If I may add: There are often very good combinatory approaches for such cases. The issue is that these spinal metastases are often located in front of and behind the spinal cord which is problematic for the surgeon.

It's relatively easy to access them from behind because you can reach them via an incision in the back. But for the frontal part, the surgeon has to maneuver around the spinal cord, which makes it difficult. This usually entails major side effects.

And that's where we can combine our approaches. In cooperation with our colleagues from the University Hospital, we would first relieve some pressure from the back – with a relatively small effort. And our job is then to eliminate the critical part, in front of the spinal cord. Thus, we provide the patient with a combination of non-invasive radiosurgery and minimally invasive conventional surgery.

How involved are you in the technological aspects, Professor? You must have a lot of technological expertise.

Yes and no. Of course, I must be familiar with the technology to some extent. But we have a team of three medical physicists at our center who are responsible for quality assurance, setting up the systems, refining the accuracy and so on. In the past, people used to go into the operating room and carry out surgery. Now you just sit at your computer, plot the structures, calculate the procedure and then the robot carries out the treatment 'independently', so to speak. That’s very different from what it used to be.

Since we are already talking about this, there is one more important feature I want to mention: The robot can readjust itself during treatment. Most patients believe that there is someone controlling it with a joystick. But, in fact, the robot is too precise for that. That is, we could hardly control it with this level of accuracy. So, the system guides itself and that's actually the most fascinating thing about it.

Even if the patient moves a little, the robot immediately responds accordingly. This works for deviations of up to one and a half centimeters. If the patient were to move more substantially, the robot would automatically pause so that the treatment table can be adjusted and then it would continue.

Is there any noise involved? Does the patient hear anything?

There is a bit of humming. But patients can listen to their favorite music, and they can take a break at any time.

They can also talk to you.

Yes, we have a microphone to communicate with the patient. They can talk, they can go to the toilet, they can call their girlfriend. In other words, it is very pleasant. But most people want to get it over with, so it's not really a problem.

It looks a bit like NASA. It's impressive how far the technology has come and how precise it is.

You always seem to find great colleagues here at the Marianowizc Center. How do you find each other? After all, you must get along with one another. But you also have to be sure that he has what it takes – that he is capable. So that's very important.

I think we think similarly. We also get along very well.

Do you share the joy of healing?

Yes, and I think our philosophy is similar. Prof. Muacevic is at the forefront of this – despite all the difficulties that the German healthcare system presents. And we talked about it before: In the US there are over 200 centers. Here in Germany, there are only eleven – everything just takes a little longer around here. And we also get a lot of comments like: "We've always done it this way. Why should we leave it to any Tom, Dick or Harry?"

So, Germany is certainly tricky in that respect. But I do believe that if there is a good treatment and if it benefits the patient, it will catch on. Plus, it is also more cost-effective: On the one hand, you have an inpatient stay with multiple weeks of rehabilitation. Whereas, on the other hand, you have a one-off treatment.

I've done some research on how this technology came about. It was first developed in Sweden in the 1960s. It was called Gammaknife back then, as it made use of gamma rays, and was later adapted for serial production at Stanford University. The development costs involved were staggering, of course.

At the same time, when you realize that you can benefit from such a wonderful innovation, you might have to dig into your own pockets. After all, people also spend lots of money on cars. You should take good care of your health and put some money aside for it. At last, not every health insurance company will pay for all types of treatment.

To put that aside, it is wonderful that so many different types of tumors – and I've googled it: lungs, liver, kidneys, prostate – can be treated with CyberKnife.

What is the ideal situation?

Ideal indications, you mean?

Yes, which areas are most suitable?

We specialize in brain tumors. For example, benign tumors such as meningiomas or acoustic neuromas. But of course – and we have talked about this before – we can also treat tumors in the rest of the body, i.e. lungs, liver, kidneys and so on. However, there are some restrictions. CyberKnife is no magic bullet and I do not want to present it as such. We must be careful about buildiung up false hopes.

Why do I say that? If you have a lung tumor, it is rarley only a single tumor. Instead, you usually also have metastases in other places, such as the lymph nodes or perhaps the bones. Of course, we cannot tackle them all with our method.

We are always carrying out a local treatment. I might be able to destroy the lung tumor. But that doesn't really help the patient because of all the metastases. However, in the rare case that the rest of the body is free of tumors and there is a lung tumor, or kidney tumor, or liver tumor of two centimeters, then we can use CyberKnife as an alternative to conventional surgery.

When it comes to these sizes, it is really about prevention. Because I don't think the patient will experience any symptoms if the tumor is still so small.

No, they won’t.

I am still interested in the topic of the prostate, although, thank God, I am not yet affected. In most cases, when a man is diagnosed with prostate cancer, there are no metastases yet.

The system is ideally suited for treating prostate cancer. However, I have some disappointing news: We currently have no approval to carry out treatments for prostate cancer – it's a major political issue.

Does that mean that even if a patient would like to have the treatment, you are not allowed to carry it out?

It is different in the US, for example. It is common practice there.

In the US, it is very different. There are studies with thousands of patients and we are currently in talks with the authorities about this.

To convince them?

Yes, to convince them. It's not easy though. Prostate cancer is a mass disease, but it is also – and many of my colleagues feel the same way – a big political issue, because there are many medical disciplines involved.

And treatment methods.

That's why it's so difficult to establish a new type of treatment in this area. Hence, we have to team up with our colleagues to convince the authorities that this method is a good option for German patients as well. Especially since it is not only used in the US, but is also explicitly recommended by the professional associations over there. And yet, we are still struggling with it in Germany.

But you are on it.

Every single day!

Very good. Keep at it, Professor. How do people contact you?

That's easy, actually.

Via your website?

Through the website, through doctors who work with us and know us, through word of mouth, and through the University Hospital. Since we are associated with the University Hospital, we are also reluctant to market ourselves more vigorously. Some people keep saying, "Why don't you do more? People don't know you. They've never heard of you." But if we do more, the dear colleagues will come up to us and say, “Hang on a second, this is all just a huge marketing ploy. And all of it because of some robot?”

So we must find the right balance. We want to be credible and we have published all our data for people to review. We have to build up reputation slowly and that takes time. It takes time.

Have I read correctly – you offer online consultations?

Yes, we do.

You do. Right.

You can also find it by searching for CyberKnife.

How importnat are the people you treat to the both of you? In other words: If I go see a doctor, am I a person first and then a patient? Or is it the other way around? How important are they to you? Especially with these modern technologies: People may have different backgrounds and fears. So you have to address these.

You put that very well, if I may say so right away. Our philosophy is: The more you deal with high-tech medicine, the more you have to take care of people.

Because if I come here and see robots and radiation equipment and computers, it's all very technical and impersonal. I might think to myself, "Oh God, my fate is in the hands of all this equipment now."

That's why I take a lot of time: to build trust, to explain everything, to explain it in detail, to reconsider, to return after some time, so that I – as a patient who has never had anything to do with all this technology before – can slowly get to grips with it.

I always tell my patients: "I won't begin your treatment until you have really come to terms with this." Once they are committed and say, "Yes, now I am convinced and this is the right thing for me to do.", then everything will be fine.

It's the same for you. You take time for your patients, whether it's Saturday or Sunday. If you have a medical problem, Dr. Marianowizc calls you back.

I think that a good doctor, an understanding doctor, does not distinguish between the patient and the person. The person sitting across from you is always first and foremost a human being. And when you have been diagnosed with a tumor and are already afraid – because you don't know what the future holds – then the conversation with your doctor is especially important. And so is the relationship, the empathy and warmth that your doctor offers you, and the reassurance that you are in this together and will get through it as a team.

Gentlemen, thank you very much! What an exciting topic. Dear viewers, thank you for tuning in to todays's Medizintalk on Modern Tumor Therapies. We have had the chance to talk to two very empathetic doctors today. See you next time. Until then, have a nice day.