Stereotactic Radiosurgery

Stereotactic RadiosurgeryBy Angela Powers, RN1ObjectivesDescribe the trend of Stereotactic Radiosurgery.Describe/evaluate hardware/software utilized.Describe/evaluate information systems used.Assess role of the nurse informaticist.Examine legal and ethical issues involved.Discuss advantages/disadvantages from nursing perspective.

Dont forget to add an objective that addresses the informatics competencies that a nurse would need when using this trend.SRS allows fast, safer treatment for a variety of conditions, including malignant and benign lesions, brain metastases, arteriovenous malformations, and functional lesionsThere are 3 different kinds of SRS: Particle beam (proton), Cobalt-60 based (photon), and Linear accelerator based (linac). Used in most is a powerful linear accelerator, which rotates around the patient to deliver treatment beams from any angle with a set of advanced image guidance and motion management tools that guide patient set-up and positioning, and monitor motion during treatment. A high-definition multi-leaf collimator shapes the treatment beam so it matches the shape of the tumor from every angle. (Medical News Today, 2008).Involved in the procedure is a multidisciplinary team involving specialists inradiation oncology, neurosurgery, neurology, neuro-ophthalmology and neuroradiology (UCLA, 2010). SRS combines available technology for high resolution imaging (MRI, CT) with software that allows for intervention and excision of the tumor.The role of the Nurse informaticist involved with the development and implementation of the technology is to facilitate the integration of data, information and knowledge of SRS and make it accessible to be used to support patients, nurses and other providers involved in their decision making (McGonigle & Mastrian, 2009, pg. 108).As with all medical procedures, legal issues may come up in cases of malpractice when a clinician fails to properly conduct the procedure, leading to poor patient outcomes. Ethical issues may involve the high cost of the procedure. If a person who is uninsured or underinsured would benefit from the procedure, who will decide if they get it or not and who will pay. Disadvantages include risk for improperly aimed radiation and subsequent adverse outcomes, high cost and potential for necessity of repeat visits for certain conditions. There is generally only one nurse involved in the procedure and he/she is the one to prepare and educate the patient before the procedure and provide care directly afterwards. This allows for continuity of care and establishment of rapport with the patient. There is also the reward of knowing that the nurse is involved with a technology that is associated with fast and excellent outcomes.

2Stereotactic Radiosurgery:Treats brain disorders with a single, high dose of radiation.Works the same as other radiation therapies.Doesn't remove tumor, but distorts it's DNA.Causes tumors to lose ability to reproduce. (International Radiosurgery Association, 2010)

Mostly head and neck disorders are treated with radiosurgery as these are the areas that are able to be fully immobilized for the purpose of the surgery. As with other radiation therapies, Stereotactic Radiosurgery (SRS) does not remove the tumor, but distorts its DNA, causing the tumor to lose its ability to reproduce and regulate basic functions. After a few months to 2 years, the tumor will shrink and hopefully disappear.

3Procedure:

(Mongia, 2009)Here, we have described by a leading Gamma Knife surgeons website, the way in which the Gamma Knife treatment works. Stated is how it is possible for the beams to destroy tumor mass, yet leave areas of the skull and healthy brain tissue undamaged. 4HardwareMRILinear AcceleratorCollimatorPatient Docking DeviceTarget Verification Device

-MRI scans are used to get a visualization of the tumors location, as well as to determine its size and volume. -The linear accelerator or "LINAC" treats very small and very large tumor volumes by treating over time during cell division. A LINAC produces radiation that is referred to as high energy X-ray, and has been used in cancer treatment for years. It is a general purpose, precise and accurate radiation delivery machine that is often used in radiosurgery. To be used in radiosurgery, a LINAC's hardware must be upgraded with precision bearings and various sized precision collimators (devices that modify the size of the radiation beam) (Johns Hopkins Radiosurgery, n.d.)-Collimators are housed within the helmet the patient must wear during the procedure. Their purpose is to focus the individual beams of radiation necessary for the function of this system.-Patient Docking Device couples that frame to the treatment machine and must be as mechanically rigid as possible. The docking device is able to be aligned within 1mm of the linac coordinate system. (Schnell et al. 1995) -The target verification devices ensure that the patient is treated at the correct target coordinate, that the target coordinate is aligned with the isocenter, and that the patient is aligned with the isocenter. (Schnell et al. 1995)

5LINACShort for Linear Accelerator.Produces radiation needed in SRT procedures.Operated by a Radiation Therapist.Dosage calculated by a Radiation Oncologist.Beam exits through the rotating Gantry.Beams are shaped by the Collimator.

(Montagno & Sabbatini, 1997)The Linear Accelerator is used to focus high energy Xray onto the tumor site, disrupting its DNA. (IRSA, 2010). It uses microwave technology (similar to that used for radar) to accelerate electrons in a part of the accelerator called the "wave guide", then allows these electrons to collide with a heavy metal target. As a result of the collisions, high-energy x-rays are produced from the target. These high energy x-rays will be directed to the patients tumor and shaped as they exit the machine to conform to the shape of the patients tumor. (Radiologyinfo.org, 2010, How Does the Equipment Work, 1). 6SoftwareThree dimensional software for treatment planning.

Dose delivery software.

-Three dimensional software is necessary for treatment planning. This software takes images from MRIs and forms them into 3 dimensional images that allow the surgeon to visualize the location, size and volume of the area to be operated on. The NovalisTX is such a software.-Dose delivery software, such as the TrueBeam STx is designed to treat a moving target with unprecedented speed and accuracy. Real-time imaging tools allow clinicians to "see" the tumor they are about to treat and respiratory gating enables clinicians to synchronize beam delivery with patient respiration (Varian Medical Systems, 2010).7NovalisTX:

(Jefferson Radiation Oncology, 2010)The Novalis Tx platform incorporates two complementary imaging systems that work together to enhance treatment precision by enabling doctors to target areas being treated. The ETX(ExacTrac) room-based X-ray imaging system provides real-time imaging and fine-tuning of a robotic couch that moves in six dimensions to ensure that the targeted lesion is aligned with the treatment beam during treatment. The OBI (On-Board Imager) cone-beam CT imaging system quickly generates a high-quality 3-D image of the targeted lesion and surrounding tissues, so clinicians can see the precise location and shape of the tumor, fine-tune the patient's position, and make sure that the internal anatomy has not shifted or changed prior to treatment. (Medical News Today, 2008, About the Technology, 1)8UsabilityEase of UseEase of LearningSatisfaction with UsingEfficiency of UseError ToleranceFit of System to the Task

-Ease of Use: Compared with other types of brain surgery, SRS is a much simpler process that is aided largely by the computer system. -Ease of Learning: This is a user friendly system which aids the surgeon and his team every step of the way. The surgeon is guided by the treatment plan by the 3D imaging software. During the procedure, the software is able to deliver accurate doses of radiation to within a millimeter, even adjusting for the patients breathing. (Medical News Today, 2008, About the Technology, 2)-Satisfaction with Using: The leading software systems are build with patient safety and ease of use in mind. The human-technology interface is claimed to be seamless. -Efficiency of Use: The SRS procedure lasts about 1 hour, whereas traditional brain surgery can take up to 12 hours. (Radiologyinfo.org , 2010, How is the Procedure Performed, 5) Use of this technology to assist in planning and implementation cuts down on surgeon fatigue and error. For the patient there are many added advantages as well, such as the much lower incidence of associated symptoms such as chronic headaches, numbness and dizziness. Error Tolerance: As stated previously, the software used in SRS is able to accommodate for a patients normal respiratory movements and still deliver doses that are accurate up to a millimeter. The collimator aims the two beams of radiation into a concentrated area and only where the two beams intersect is the radiation powerful enough to destroy tissue, leaving the surrounding brain, skull and skin unharmed.Fit of System to the Task: as SRS has evolved, the technology and genius put into it has made it a virtual medical masterpiece. Based on the excellent outcomes, ease of use and shortened procedure and recovery times, this is a system which is perfectly fitted to its task. 9Varian OncoView Picture Archiving and Communication System (PACS)

Collects, stores and distributes diagnostic images.Digitalizes CT, MRI and X-ray results.Enables ease of image sharing.Enables collaborative approach to treatment.Reduces data filing and retrieval times.Saves time and money. Reduces liability caused by errors and loss.(Varian Medical Systems, 2010)MRI and CT scans are used in Stereotactic Radiosurgery before treatment begins. The three dimensional software used (such as the before described Novalis TX) takes images of the area in need of treatment and then a Picture Archiving and Communication System (PACS) is used to digitalize these images for easy electronic storage and distribution (About.com, n.d.). With the images in an easy to distribute digital format, one care provider can easily share the images with other providers, allowing for greater collaboration for the treatment of any one patient. Digital files are also much easier to store and retrieve than other methods, such as paper images, allowing organizations to spend less time and money on such activities. With less chance of loss or misfiling of patient images, there is less worry about liability if such an event were to occur. 10Varian OncoView PACS System ReviewRadiology Information SystemUsed by all members of team. Enables digitalization of image results.Generally part of Local Area Network.HL7 and ANSI Data Standards.Necessary for use of SRS.

-Radiology Information System systems that schedule, result, and store information as it relates to diagnostic radiology procedures. (McGonigle & Mastrian, 2009, p. 210)-Team members using this system may include any and all that participate in the procedure: these may include a radiation oncologist, neurosurgeon, neuroradiologist, medical radiation physicist, dosimetrist, radiation therapist, radiation therapy nurse, and neurologist or neuro-oncologist. (Radiologyinfo.org, 2010)-As described in previous slide, this technology enables providers ease of use and collaboration, as well as cutting costs and liabilities.-May be configured as part of a Local Area Network for sharing in many workstations within an organization, but may also be sent outside the network through email.-According to HL7.org (2010), imaging integration systems such as PACS are subject to data standards of both HL7 and of the American National Standards Institute (ANSI) -I would definitely recommend this system to others implementing this trend. Its use is necessary for treatment planning in SRS.11Advantages of SRSSimpler ProcessShorter surgery timesShorter patient recovery timesLess invasive Fewer side effects vs. brain surgery.Ability to reach deeper brain tissue.

-No need for shaving the head, opening the skin or cutting the skull. It is sometimes even an outpatient procedure. -Much shorter than an open brain surgery, cutting down on fatigue and possibly error by surgeons and technicians.-Reduces trauma to surrounding tissues, allowing a quicker recovery.-As previously stated, no need for opening the skin or cutting the skull.-Less brain swelling after procedure which can lead to multiple other problems (Medical News Today, 2008).-Dont have to cut and damage brain tissue to reach deeper tumors, so surgeons are better able to reach deeper within the brain.12Disadvantages of SRSHigh cost of purchase and useRisk of neurological injuryRisk of mechanical inaccuracyPotential necessity of multiple visits

-The technology itself is a huge initial investment with a high cost of maintenance as the cobalt sources must be replaced periodically.-If radiation is mis-aimed and damages healthy brain tissue or causes a bleed, there is risk of harm to the patient. Though these risks are present, they are less common in SRS than in open brain surgery. -Some tumors and Arteriovenous malformations will take repeated efforts to obliterate, making traditional brain surgery a better option if the condition is causing severe side effects.13Ethical/Legal IssuesNot available to everyoneMalpractice suits

-Due to high costs, this procedure will not be available to all who may need it or will benefit from it. -As with many medical procedures, in instances where there are poor outcomes, there are risks to providers that a medical malpractice or wrongful death suits may be brought.14Required Informatics Competencies and Role of Nurse InformaticistTechnical competencies - Modifier levelUtility competencies - Modifier levelLeadership competencies - User level

The registered nurses role in SRS is to prepare the patient for the procedure, and to care for the patient before and directly after it has occurred. Besides the necessity that he/she be able to implement basic nursing care and operate the institutions own information systems, only a beginning nurse level of competency is required.

Modifier level for technical competency is required because the nurse is required to use the technology in place in order to provide evidence based practice, he/she must apply data obtained from multiple sources in practice, access documents electronically and access literature and new information pertinent to her practice. (Kaminski, 2009, Technical Competencies). Modifier level for utility competency is required because the nurse must understand all processes of the computer and systems involved and how they relate to the procedure, he or she must be able to recognize ethical issues and follow ethical standards. The nurse mush assess the patients information needs and use available technological resources to meet those needs. (Kaminski, 2009, Utility Competencies)User level is required of the SRS nurse because this level encompasses basics of knowledge in areas of implementing the Code of Ethics in regards to patient privacy, competent use and basic knowledge of systems already in use, and an understanding of the patients rights (Kaminski, 2009, Leadership Competencies).

15Functions and Responsibilities of Informatics Nurses in SRSTechnical capacitiesUtility capacitiesLeadership capacities(Kaminski, 2009)Technical roles- Requirements include the use of the SRS operating systems; Operation of SRS technology; use of available patient education and information management systems to provide patient educate; organization of applications of files shared within the system; participation in making improvements and new functions within the already present systems of SRS; collaboration with other members of the team as to what changes may need to be made to improve the human-computer interface; participation in feedback towards development of evidence based practice as related to the SRS procedures. Utility roles- Requirements include seeking out continuing education opportunities to keep up with changing technologies and trends; knowledge and competence in the operation of functions of the SRS system involved in the nurses role in patient care; following rules and regulations concerned with upholding patient safety and confidentiality; Gathering, storing and processing of related information for use to generate improved practices within the SRS procedure. Leadership roles- Requirements include the recording of patient, procedural and administrative data into computer systems; Knowledge of nursing informatics and the role it fills in the nurses area of practice; Playing a part in the development of new policies and means of completing tasks, and in technology updates within the SRS systems; Analysis of ergonomic integrity of the work station and SRS portable technology (Kaminsky, 2009, Leadership Capacities) such as the LINAC, patient bed and mobile hood in practice; Knowledge of and participation in development and implementation of quality management measures as related to nursing practice and patient care; Encouragement and mentoring of other nurses in the development of competency in the technology used in practice; Awareness of the development of trends and issues within scope of practice.

16In Summary:Often outpatient procedure for brain surgeryHigh dose radiation distorts tumor DNAImproved outcomes for many conditionsReduced surgery and recovery time Multidisciplinary team involved in planning, implementation.

SRS allows fast, safer treatment for a variety of conditions, including malignant and benign lesions, brain metastases, arteriovenous malformations, and functional lesions. The technology delivers a precisely aimed blast of high-dose radiation to the tumor mass, distorting its DNA, making it shrink over time (International Radiosurgery Association, 2010).Stereotactic Radiosurgery is a procedure which is generally very safe with short recovery times. So short, in fact, that it is often an outpatient procedure. Because of the SRS technologys ability to reach deep tumors and lesions without the high risks of open brain surgery, it is often preferred by patients and surgeons. Some lesions require multiple doses over time. If the lesion or malformation is causing the patient adverse symptoms in their daily life, this will probably rule them out as a candidate for SRS and necessitate open brain surgery to quickly rectify the adverse symptoms.Involved in the procedure is a multidisciplinary team involving specialists inradiation oncology, neurosurgery, neurology, neuro-ophthalmology and neuroradiology (Radiologyinfo.org, 2010). 17References: About.com. (nd). PACS What is PACS? Retrieved October 25, 2010, from: http://healthcareers.about.com/od/p/f/PACS.htm.De Araujo Montagno, & E., Sabbatini, R. (1997). Radiosurgery. Retrieved October 15th, 2010 from: http://www.cerebromente.org.br/n02/tecnologia/radiocirurg_i.htm.HL7 International. (2010). ANSI Approved Standards. Health Level Seven International. Retrieved October 25, 2010, from: http://www.hl7.org/implement/standards/ansiapproved.cfmInternational Radiosurgery Association. (2010). Stereotactic Radiosurgery Overview. International Radiosurgery Association. Retrieved on September 19, 2010, from: http://www.irsa.org/radiosurgery.html.

18References, ContinuedJefferson Radiation Oncology. (2010). Novalis TX. Retrieved October 9, 2010, from: http://www.jeffradonc.com/page.php?pID=21.Johns Hopkins Radiosurgery. (nd). Stereotactic Radiosurgery. Johns Hopkins Medicine. Retrieved October 9, 2010, from: http://www.radonc.jhmi.edu/radiosurgery/treatmentoptions/stereotacticradiosurgery.html#WhatDevicesAreUsed.Kaminski, J. (2009). Nursing Informatics Competencies: Self-Assessment. Nursing-Informatics.com. Retrieved November 15, 2010, from: : http://www.nursing-informatics.com/niassess/index.html.

19References, ContinuedMcGonigle, D. & Mastrian, K. (2009). Nursing Informatics and the Foundation of Knowledge. Sudbury, MA. Jones and Bartlett Publishers.Medical News Today. (Sept, 2008). Non-Invasive Radiosurgery With Novalis TX platform Rolling Out Worldwide. Medical News Today. Retrieved on September 19, 2010, from: http://www.medicalnewstoday.com/articles/122391.phpMongia, S. (2009). Gamma Knife Surgery. Retrieved on October 1, 2010, from gammaknifeonline: http://www.gammaknifeonline.in/.

20References, ContinuedRadiologyinfo.org. (2010). Stereotactic Radiosurgery and Stereotactic Body Radiotherapy (SBRT). Retrieved on October 1, 2010, from radiologyinfo.org: http://www.radiologyinfo.org/en/info.cfm?pg=stereotactic.Schnell, M., Bova, F., Larson, D. A., Leavitt. D. D., Lutz, W. R., Podgorsak, E. B., Wu, A. (1995). Stereotactic Radiosurgery: Report of Task Group 42 Radiation Therapy Committee. College Park, MD. American Institute of Physics. Retrieved October 9, 2010, from : http://www.aapm.org/pubs/reports/rpt_54.pdf.

21References, Continued.Varian Medical Systems. (2010). TrueBeam STx: Frequently Asked Questions. Retrieved October 9, 2010, from: http://www.variantruebeam.com/truebeamstx/faq.html

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