Radiotherapy can be used against various forms of cancer, but some of the most cutting-edge and precise uses involve brain tumours.

There are very good reasons for this. Brain tumours vary in their impact, as some are benign and simply need to be shrunk to prevent secondary problems such as pressure on the brain or nerves. Others are cancerous and radiotherapy, alongside chemotherapy and surgery, can extend the life of patients by varying amounts.

With any form of radiotherapy treatment, calibrating the right dose and hitting the right targets is vital. This is especially true when targeting a brain tumour, given the dire consequences of damaging healthy brain tissue nearby, but there is also the general consideration that the less radiation there is, the less severe the side effects.

For this reason, anything that helps increase the precision of the radiotherapy, either in its delivery or in the preparation and assessment of treatment will help ensure it is given in the right places, in the correct doses and that this is linked to the correct supplementary treatment.

The Importance Of Tackling Glioblastomas

In the cases of benign tumours, this can help with the process of enabling the patient to live a normal life. For those with cancerous tumours, the challenge is greater, especially in cases such as glioblastomas, aggressive tumours arising from glial cells that show up in the brain and spinal cord and can, if unchecked, kill sufferers within months.

With the best treatment, however, some glioblastoma patients can live for up to five years, so there are clear benefits to be gained from good treatment. Moreover, as they are the most common form of brain tumour, accounting for 32 per cent of all cases, there is plenty of incentive to develop treatments to improve outcomes for patients.

For that reason, new research in the United States has indicated that patients may benefit from a novel new use of MRI scans to help guide radiotherapy on glioblastomas, with the two being delivered simultaneously to help provide a new method of analysis.

MRI, Radiotherapy and Real-Time Data

The study on this approach was carried out by researchers at the Sylvester Comprehensive Cancer Centre in the University of Miami’s Miller School of Medicine. The research was published in the International Journal of Radiation Oncology – Biology – Physics, as well as being presented at a meeting of the American Society for Radiation Oncology.

What this showed was that having daily MRI scans delivered alongside the radiation therapy could help guide radiotherapy treatment more precisely, as well as keep track of developments, which meant oncologists could make adjustments daily to treatment when necessary to deal with the very latest developments and tackle them accordingly.

Known as MRI-linac, the method produced scan results that matched the normal standard MRI scans carried before and after courses of treatment in 74 per cent of cases.

In the other 26 per cent of instances, the MRI-linac system projected tumour growth when in fact it shrank. However, this does mean that, crucially, there were no instances where a tumour increased in size without the MRI-linac predicting this would happen. 

Why The System Could Enhance Radiotherapy For Glioblastomas

Consequently, an effective way to utilise the system is to use contrast imaging as a follow-up means of confirming if a tumour is indeed growing, which, the study suggests, will be the case in three-quarters of indicated cases.

Lead author Dr Kaylie Cullison, said: “Our study shows that these daily scans can serve as an early warning sign for potential tumour growth.”

The key finding was that using MRI scans is more effective in spotting developments than standard imaging techniques, helping offer better treatment guidance and therefore paving the way for better treatment. The research team has concluded that this could eventually become the standard approach for using radiotherapy on glioblastomas.

At present, this is not the standard way for treating glioblastomas, with Sylvester Comprehensive Cancer Centre being unique in providing this approach, but that may change over time. However, it adds to an array of new techniques, technological developments and ongoing research that could enhance the care of patients.

Radiotherapy Technology Keeps Progressing

Many of these developments have occurred in specific areas, such as the development of ever more precise gamma knife technology. Invented by Swedish scientist Lars Leksell in 1967, the invention has been further refined, first with the second version in 1975 and several times subsequently as the technology has advanced.

If you need radiotherapy, our staff will guide you through not just what you can expect in a course of treatment, but explain how various developments have enabled patients to enjoy better outcomes as a result of increasingly better technology, diagnostics and understanding of tumour treatments.

One of the most important developments ever made in a radiotherapy centre was the invention of stereotactic radiosurgery.

Also known as the Gamma Knife method, Lars Leksell’s pioneering innovation allowed for an unparalleled level of precision in treating and removing brain conditions, including lesions, growths and trapped nerves.

However, one of the most interesting aspects of Gamma Knife is that the two core components of it were developed largely in parallel with each other.

Radiotherapy went through a wide range of developments as the understanding of how it should and should not be used increased, whilst the stereotactic aspect of Gamma Knife was not initially intended to be used for radiotherapy doses.

In fact, it was originally a surgical method looking for a reason to exist, although it did manage to contribute a great deal to neurosurgery even at an early stage.

The Horsley-Clarke Apparatus

The first stereotactic device was developed by two English doctors as their last collaboration together as peers.

The latter part of the name, Robert H Clarke, is far less well known than the former, Sir Victor Horsley, but was just as critical to the device’s creation.

Dr Clarke believed in the importance of applying mathematical concepts to the field of neurophysiology and wanted to create a workable method for producing brain atlases using Cartesian coordinates.

His counterpart, Sir Victor, was a pioneering neurosurgeon, who innovated a range of surgical techniques to make brain surgery more effective and less risky during a time when surgery as a field was changing rapidly.

He was one of the first surgeons to develop a consistent working method for treating trigeminal neuralgia and also developed bone wax and the skin flap method, as well as making several notable breakthroughs in surgical innovations that could treat epilepsy, something that would later be attempted through radiotherapy by the start of the 20th century.

Mathematics

By 1905, he had started working with Dr Clarke, and the pair developed a mathematical method for undertaking neurosurgery, where different parts of the brain could be identified through coordinates that could be mapped consistently onto a frame.

However, its biggest achievement as described in a 1908 article by the pair was the development of their neurosurgical frame, known as the Horsley-Clark Apparatus, as a system to create an atlas of the brain and a three-dimensional map of where critical brain structures are located.

The system worked in that regard, but it was ultimately designed for cat brains rather than human ones. Despite this, it was still an incredibly important first step and would shape neurosurgery for decades to come.

Influence

The system would prove highly influential, and a decade after its invention, Aubrey T. Mussen commissioned an adaptation of the frame designed for human brains, inspired by the three working at the National Hospital in London.

However, the brass frame does not appear to have ever been used on human brains and did not receive a lot of attention at the time.

In fact, it would take another 15 years after Aubrey’s adaptation for Martin Kirschner to use a similar system to treat an actual patient.

In 1933, the German doctor used a minimally invasive surgical method to insert an electrode into the trigeminal nerve and burn it, treating a condition Sir Victor pioneered the surgical method for with a system extremely similar to stereotactic radiosurgery aside from the use of a physical electrode.

However, by the 1940s, the Horsley-Clark method would reach both its peak of importance and obsolescence within the span of three years.

Human brain atlas

In 1947, after the end of the Second World War, Henry Wycis and Ernest Spiegel used a Horsley-Clarke frame with a cartesian coordinates system to develop the first human brain atlas in history, as well as use the system as part of the now-controversial field of psychosurgery.

The later Talairach coordinates system would evolve from this, which used the brain atlas information to create a grid system more relevant to the actual structure of the human brain.

In 1949, Lars Leksell would effectively make the Horsley-Clarke method obsolete by developing his Gamma Knife system to use a system of polar coordinates as part of his stereotactic radiotherapy system.

This system, alongside a new generation of more advanced three-dimensional imaging systems that allowed brain surgeons to be more precise, led to the obsolescence of the Horsley-Clarke method.

However, without these two doctors and their pioneering system, the Gamma Knife would not have existed.

For over a century, people who have cancers, lesions and growths have been advised to go to a radiotherapy centre, where one of the most advanced medical treatments ever invented is used with utter precision to reduce, remove and destroy potentially cancerous cells.

It is the ultimate example of the iterative nature of medical advances, as this cutting-edge technology allows for treatments such as the Gamma Knife to be used effectively to treat brain tumours without causing harm to a particularly delicate part of the body.

As its inventor Lars Leksell once noted, there is no level of precision too precise for the brain.

However, radiotherapy is at least half a century older than the Gamma Knife, and the idea of using radiation to treat disease is almost as old as the discovery of radiation itself.

One Year Later

On 8th November 1895, Wilhelm Roentgen discovered X-rays largely by accident, and within a year of a discovery so groundbreaking it invented the field of radiology, it would also be the inspiration for another new field of medical treatment.

He published his original paper a month later on 28th December 1895. A week later, a newspaper in Austria reported the discovery of a new type of radiation, and within weeks of this, doctors were already experimenting with the potential for X-rays not just for diagnosis but for treatment.

Emil Grubbe claimed to be the first person to attempt to treat cancer with X-rays, although the evidence on this is somewhat disputed. Meanwhile, Leopold Freund and Eduard Schiff suggested within a month of the announcement that X-rays could be used to treat diseases such as lupus.

However, the first major treatment using radiation and one of the most influential medical cases in the field of radiotherapy was by French doctor Victor Despeignes, who showed just how effective radiation could be in the treatment of disease if used correctly.

This remains the case even if Dr Despeignes was very wrong about why he thought it would work.

Accidentally Correct

In the middle of 1896, the Lyon-based doctor was visited by a man with an abdominal cancer tumour the size of a baby’s head, and he endeavoured to do what he could to save the man’s life using what were at the time somewhat experimental means.

At the time, conventional medical knowledge claimed that cancer was a parasitic infection rather than a mutation of cells, and so he believed that the antibacterial effects of radiation could be effective at killing the cells

He was right, but not for the right reasons.

Using a Crookes’ tube and half a dozen Radiguet batteries, Dr Despeignes agreed to use radiation to try and kill the cancer, alongside three other treatments at the same time, starting on 4th July 1896.

The man was given a diet of milk and condurango, he was injected with artificial serum and provided a combination of morphine, opium and chloroform to relieve the pain.

These, in combination with twice-daily half-hour radiation treatments, did seem to help relieve the pain for the patient and halved the size of the cancerous tumour, but unfortunately, 20 days after the start of treatment, the 52-year-old man died.

It was far from a controlled experiment, with the issues with artificial serum already known at the time, the dangers of two opioids and chloroform established in the century since, and condurango is an exceptionally controversial choice of ingredient to use.

At the time advertised as a cancer cure and a digestive medicine, condurango could have potentially caused a side effect if the man had a latex allergy.

Because of this, it was easy to look at the positives of the case. The fact that such a huge tumour was reduced by half so quickly was seen as a massive success, and the pursuit of radiotherapy would increase as a result.

It is likely to be the first-ever treatment of cancer with radiation that produced a positive effect, but even if there was an earlier case, Victor Despeignes was the first to be widely reported. Dr Freund’s case the same year was only published in 1901 even if it was first done in 1896.

It created a huge amount of interest in the medical community for radiotherapy and the first successful treatments followed before the end of the 19th century, even if the understanding of how radiation worked and why it affected cancer cells would take a few more years to truly be understood.

However, these early treatments helped to establish the principle, and the following century would turn radiotherapy into a vital, front-line treatment for cancer.

Brain tumours come in many forms and the methods of treating them can vary in all sorts of ways. For some, the tumour is non-cancerous and can be managed, but for others the most serious treatment is needed to prevent an inevitable death from brain cancer.

While some can have all or part of a tumour excised through invasive surgery, this is not always possible, because the tumour can often be located on a part of the brain where the use of surgical instruments would cause fatal damage to the surrounding tissue. At this point, only non-invasive options remain, such as radiotherapy.

Swimmer Reveals Diagnosis

An individual who now finds himself in this situation is Scottish swimmer Archie Goodburn. The 23-year-old, who represented Scotland in the 2022 Commonwealth Games and narrowly missed qualification for this summer’s Olympic Games in Paris, has gone public with his diagnosis of three large oligodendrogliomas, a form of cancer affecting both the brain and spinal cord.

He began having unusual symptoms in December last year, revealing via his Instagram account: “They would leave me with a loss of strength and a numb sensation on my left side, a deep feeling of fear, nausea and extreme deja vu. I now know that these were in fact seizures.”

Once the Olympic trials were over, he had an MRI scan and established the cause of his problems. The diagnosis itself was bad enough, but so too was the news that the nature of the tumours made them inoperable.

However, they can be effectively treated by a combination of chemotherapy and radiotherapy. This was a point that Mr Goodburn was quick to note in his post, stating: “The silver lining to this diagnosis is that oligodendrogliomas generally respond better to radiotherapy and chemotherapy than many other serious brain tumour types.”

Oligodendrogliomas Explained

Oligodendrogliomas account for around three per cent of all brain tumours. They are primary tumours that originate in the brain rather than spreading from elsewhere in the body, a factor that makes it impossible to safely excise them.

It is very rare for anyone to be cured completely of these tumours, so their prognosis depends primarily on the kind of oligodendrogliomas the patient is suffering from, while the exact symptoms will depend on which part of the brain they are growing on.

Grade II is a slow, moving tumour and the average survival time after diagnosis is 12 years. An anaplastic grade III tumour is much more aggressive and the typical post-diagnosis survival time is only 3.5 years.

In his post, Mr Goodburn said the tumours are “slow growing and are likely years old,” which appears to indicate they are grade II, giving him a better chance of longer-term survival.

Radiotherapy may be particularly effective in slowing down and even shrinking the tumours, and it may be that it does more than simply extend life in this case, as research is taking place into other therapies that may have a transformative effect in due course.

A New Hope?

Writing about these, the swimmer noted that in his case the tumours “express a mutation of my IDH1 gene that is shared with some forms of leukaemia.” with IDH inhibitor drugs seeing “phenomenal developments” in recent years, which offers the possibility of the emergence of transformative treatments that could radically improve his prognosis.

This highlights a major hope for many people who are suffering from brain tumours, even ones that cannot be operated on. Radiotherapy can do more than just reduce symptoms and buy time to allow patients to live for longer. In some instances, they may allow people to survive long enough to benefit from an emerging new therapy.

Whether this will be enough to cure the tumour completely in the case of Archie Goodburn or at least enable him to live normally and continue his competitive swimming career will depend on the success of attempts to advance IDH inhibitors, but it does show that there is at least hope.

Why Patients Should Take Courage

Furthermore, it shows that if you are a patient who is facing the prospect of radiotherapy, whether by gamma knife or any other method, the side effects you may suffer, ranging from tiredness and skin irritation to emotional effects and a loss of appetite, will be worth it.

Depending on the kind of tumour, the treatment may bring a full cure, combine with other treatments (including in cases where surgery is an option) to deal with the problem, or at least give you many more years of life that might not have been possible before the development of modern radiotherapy.

In addition, it may just be that you could benefit from gaining extra years so that you can benefit from the emergence of new treatments.

An unmistakable trend in the evolution of treatments available at a radiotherapy centre is that technological advances will not only allow for more effective treatments but will allow existing and highly effective techniques to be used in previously unthinkable areas of the body.

By far the most fascinating recent example of this is the study that explored the potential for one of the most groundbreaking and revolutionary radiotherapy treatments ever developed and widely used to transcend the brain and be used to treat perhaps the only other part of the body that requires even more precision.

This allows for one of the most common eye diseases in the world to receive an effective, accurate treatment that could help reduce the need for constant, uncomfortable treatments that are not always easily accessible.

Stopping Rapid Vision Loss

Two of the most common eye conditions that can lead to a permanent loss of eyesight are known as age-related macular degeneration (AMD). True to their name, it is a pair of conditions that are common whilst ageing that progressively affect the centre of a person’s vision.

There are typically two kinds, both of which affect hundreds of millions of people in the world. The first, known as “Dry” AMD, is caused by the build-up of drusen, a fatty substance that collects in the back of your eyes and causes eyesight degeneration over several years.

By contrast “Wet” AMD often progresses very quickly, and within weeks and sometimes even days it can cause significant loss of sight in an eye, something that can easily become permanent.

This is caused by tiny blood vessels that grow to an abnormal size in the back of the eyes and affect vision that way.

With Dry AMD, there is no medical treatment as of yet, but with Wet AMD, the primary course of treatment is the use of anti-Vascular Endothelial Growth Factor medication, often known as anti-VEGF injections or simply eye injections.

They work by blocking the production of the VEGF that causes blood vessels to grow and work for nine out of ten people who try them, even causing an improvement of vision in nearly a third of people who have the treatment.

However, there are two problems that make it less than ideal as a treatment despite how effective it is.

The first is that whilst its effectiveness can vary depending on how quickly VEGF activates in the eye, it is typically done at least every three months but can be as often as every month.

This is compounded by the fact that the eye injection needs to be applied directly to the eye. Whilst numbing compounds and a lot of care is taken to make sure it does not hurt, it is still quite uncomfortable, and some people defer treatment out of fear of the long-term cycle of injections.

As well as this, it can also be quite an expensive treatment to receive privately, with some estimates claiming it can cost £800 per injection, something that adds up quickly if they are needed monthly.

For a long time, radiotherapy was suggested as a solution, but it was difficult to find systems that could be as precise or accurate enough to be used within the eye.

Lars Leksell once said that no tool is too precise when it comes to brain treatments, but for a long time, even some of the most precise brain treatments such as Dr Leksell’s own Gamma Knife were not easily adapted for use in the eye.

However, a variation of the stereotactic radiosurgery method he pioneered did produce results in the landmark study, as it lowered the number of injections required compared to more conventional treatments for Wet AMD.

It worked, much like it does for brain lesions, by using multiple smaller beams that converge at a precise point, maximising the effect whilst limiting exposure to radiation.

This not only saves money on injections but is also more comfortable and lowers the risk of people withdrawing from treatment which could be vital to save their sight. The treatment’s cost itself is significantly lower than the cost of a single injection.

In one particularly notable success story, one person underwent radiosurgery and did not need another injection for two years, and as of June 2024 has not had an injection since.

The treatment itself is still in an early stage. The trial, whilst promising, also only involved 411 participants, which is far too small a sample size given how common the disease is. A wider trial would be required to confirm that these were statistically significant and not just the effect of an outlier.