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Gamma Knife in South Africa

South Africa’s first and only Gamma Knife was made possible through a partnership between Netcare’s Milpark Hospital and leading oncology company, Eurolab, in 2017.

For the first time, patients in South Africa had access to less surgically invasive treatment at a rate they can afford. Previously, patients had to travel internationally for this specialist radiosurgery.

Gamma Knife South Africa has successfully performed over 1,000 radiosurgery treatments.

Installation of the Leksell Gamma Knife® Icon™ at Milpark Hospital in Johannesburg has placed Gamma Knife South Africa on the international radiosurgery map.

Gamma Knife: quick history roundup

The first Gamma Knife was developed in 1967 by Lars Leksell, a Swedish physician and professor of neurosurgery, with the assistance of biophysicist Börje Larsson.

Today’s Gamma Knife, manufactured by Elekta AB, is based on this early prototype which has since benefited from some 40 years of advancements in engineering, radiation physics, and computer imaging technology.

The Leksell Gamma Knife is currently one of the world’s most technologically advanced instruments in use today.

1951

The beginnings

In 1951, Swedish neurosurgeon Dr Lars Leksell wrote a seminal paper on radiosurgery. The first radiosurgery procedures were then performed using an industrial x-ray machine attached to the designed Leksell arc and frame. These were reasonably successful.

Leksell and the physicist Börje Larsson then refined this technology to perform radiobiology experiments to determine and quantify the effects of focused fine beam radiation on the brain. The experiment aimed to destroy brain tissue, with a view to ultimately treating functional disease in the brain using focused radiation.

1951

Proton radiosurgery replaced by the Gamma Unit

There was wide dissatisfaction with proton radiosurgery at the time. It became accepted in Sweden that proton beam radiosurgery was too complex and impractical.

A new machine was needed. This prompted Leksell to design complex collimators, which used sources of 60 Cobalt and could produce beams with acceptable characteristics. The machine’s geometry was determined using the distance of the sources from the patient and the optimal distance between the sources.

The first Gamma Unit was built on these designs, with private money and without contribution from the Swedish state. This nonetheless required detailed design information to ensure radiation safety. This original machine was built with rectangular collimators to produce lesions for thalamotomy for functional work.

However, with the introduction of dopamine analogues, this indication for the use of the machine virtually disappeared overnight, and the inventors were free to focus on other conditions.

The first patient

The first patient to use the Gamma Unit was driven from Stockholm for the first treatment in Studsvik. The treatment was a technical success.

From here, the new machine was installed at a Stockholm hospital. A further eight patients were treated. Treatments formally began. For 14 years, Stockholm was the only location where a Gamma Unit was in use. During this period, a variety of indications were treated using the technology. The Gamma Unit design was also updated with round collimators, which were more suited to the task at hand.

Over the 14 years, 762 patients with vascular conditions, tumours and functional disorders were treated. This was before the introduction of computerised imaging, but the results were still remarkably successful

Demand grows

It took time, but eventually, the demand for Gamma Units began to grow.

When two of Leksell’s students wanted machines in Buenos Aires and Sheffield, there was no possibility for manufacture in Sweden, as Leksell had not anticipated the demand. Arrangements were therefore made for a Swiss company to make two machines, which were installed in the two centres.

The demand continued to grow. Arrangements were made to continue manufacture in Sweden by Elekta, the company which still makes them today.

Gamma Knife arrives in the USA

Once manufacture had been sorted, the first USA model was installed in Pittsburgh. This was a crucial development, partly because the machine was now established in the United States, but also because of the quality of the academic publishing from Pittsburgh, which helped to spread the word about the treatment. It was the Pittsburgh group who coined the term Gamma Knife.

Expansion of indications

Following growing acceptance of Gamma Knife radiosurgery there were debates about the treatment for various indications. The indications had quickly grown to include arterio-venous malformations, meningiomas, pituitary adenomas and vestibular schwannomas. Metastases, which had not been treated in Stockholm because of Leksell’s opposition to the treatment of malignant disease, also became a popular indication.

Introduction of computerised dosing

In the earliest days, there was no computerised dose planning system. However, it was not long before the first dose planning system, KULA, was developed in the mid-1980s. While this was geometrically accurate, it became apparent that it was not as visually attractive as programmes used by other technologies. It had been designed in the era prior to computerised imaging and had only limited capacity for dosimetry.

KULA was, therefore, swiftly followed by GammaPlan, which has evolved over the years into a sophisticated multiparameter system with advanced graphic features.

Onwards and upwards

From here, the Gamma Knife continued to evolve.

The first machines used helmets containing collimators of different diameters to increase the flexibility of the treatment. However, changing these helmets was time-consuming and tedious. The original model introduced into the USA was the U model, where the patient was inserted with the helmet into the machine inwards and upwards, using hydraulics.

A new simpler machine was then devised called the B model, where the patient simply moved in and out. However, there was still the problem of changing helmets.

Then the C model was introduced, with a robot called the automatic positioning system (APS), which permitted the patient’s position to be moved automatically.

However, the helmets still had to be changed when collimators of different sizes were required.

Finally, an entirely redesigned model called Perfexion was introduced where there were no helmets. The patient, once placed in the machine, would be completely treated following a single press of a button.

The History of the Gamma Knife by Jeremy C. Ganz

“In the search for less invasive techniques, neurosurgery has gone through a phenomenal journey over the last century. It evolved during the era of maximum trauma (both world wars) and gained its momentum with the development of micro-neurosurgery. Still, unsatisfied with its results and in the realm of success with alternative treatment options, Prof. Lars Leksell marched on an uncharted territory of stereotactic radiosurgery with photon beams. Martin Luther King, in his famous speech, mentioned that “Blood alone moves the wheels of history.” Probably, this is the first stance, when history moved but in the absence of blood. Though in practice for five decades, there was no dependable account of the history of Gamma Knife radiosurgery (GKRS). Jeremy C. Ganz should be congratulated for filling this void. “The History of The Gamma Knife” is a fascinating and breviloquent tale of the development and practice of GKRS in 15 chapters.”
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Gamma Knife South Africa is a specialised brain radiosurgery unit and a centre of excellence that offers world class care.

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