Date:		December 19, 1999

To:		Dr. Ramsinghani, MD (UCI Medical Center)
		Dr. Radany, MD (UCI Medical Center)

Subject:	Your record of patient outcomes regarding IMRT

Dr. Radany and I did discuss patient outcomes in a general way on 11/16/99; however, I’d sure like to have some real data to review.    Do you have statistics similar to Dr. Lederman’s which I can use to help me decide what to do?  I realize the examples I cite below are not IMRT, and I’d much rather opt for the treatment that affords me the best chance of no hearing/balance problems or facial palsy or facial neuropathy—that’s IMRT as far as I can see.   

Dr. Gil Lederman, MD, of  Staten Island Hospital posted these statistics on his website at http://www.siuh.edu/  radoncology/acoustic.html#article11, based on 2000 Centigray
(cGy) divided into 4 or 5 fractions.  Clinical follow-up was 14-64 mos (median 32.2).  No patient had surgery for treatment failure.

Graph 1:  Post-treatment tumor size – 75 patients
•	39% decrease
•	61% stable
•	0% increase

Graph 2:  Post-treatment hearing – 56 patients
•	12.5% improved
•	75% stable
•	12.5 worse

Graph 3:  Post-treatment balance – 68 patients
•	57% improved
•	41% stable
•	2% worse

Dr. Jefferey Williams, MD,  of Johns Hopkins published the following statistics regarding patient outcomes.  Source:  “Fractionated Stereotactic Radiosurgery for Treatment of Acoustic Neuromas,” presented at the quadrennial meeting of the American Society for Stereotactic and Functional Neurosurgery, July 9, 1999, Snowbird, Utah (can be viewed at http://www.med.jhu.edu/radiosurgery/publish/msweban.html): 

•	31 patients, 25 Gy over 5 daily fractions
•	Follow-up 6 to 44 months
•	Mean tumor volume was 1.1 cm
•	All tumors controlled, 9 smaller, 22 unchanged
•	2 patients had new trigeminal neuropathy
•	2 patients with pre-existing trigeminal nerve symptoms had improvement
•	Balance improved in 3 patients, unchanged in 20, worsened in 7
•	Of 12 patients with useful hearing, 9 retained useful hearing
•	Of 25 with any hearing, 2 had improvement, 10 unchanged, 13 worsened
Here are some recently published statistics I found through PubMed from  the Department of Neurological Surgery, University of Pittsburgh, PA,   “Long-term outcomes after radiosurgery for acoustic neuromas,”  Kondziolka D, Lunsford LD, McLaughlin MR, Flickinger JC,   N Engl J Med 1998 Nov 12;339(20):1426-33:
•	162 acoustic neuromas patients from 1987 through 1992
•	5-10 years after procedure
•	Avg dose to tumor margin was 16 Gy
•	Mean transverse diameter was 22 mm
•	Resection had been performed previously in 42 patients (26 percent)
•	In 13 patients, the tumor represented a recurrence of disease after a previous total resection. 
•	Facial function was normal in 76 percent of the patients before radiosurgery, and 20 percent had useful hearing.
•	The rate of tumor control (with no resection required) was 98 percent. 
•	One hundred tumors (62 percent) became smaller;  53 (33 percent) remained unchanged in size, and 9 (6 percent) became slightly larger. 
•	Resection was performed in four patients (2 percent) within four years after radiosurgery.
•	Normal facial function was preserved in 79 percent of the patients after five years (House-Brackmann grade 1), and normal trigeminal function was preserved in 73 percent. 
•	51 percent of the patients had no change in hearing ability. 
•	No new neurologic deficits appeared more than 28 months after radiosurgery. 
•	An outcomes questionnaire was returned by 115 patients (77 percent of the 149 patients still living). 
•	54 of these patients (47 percent) were employed at the time of radiosurgery,and 37 (69 percent) remained so. 
•	Radiosurgery was believed to have been successful by all 30 patients who had undergone surgery previously and by 81 (95 percent) of the 85 who had not. 
•	36 of the 115 patients (31 percent) described at least one complication, which resolved in 56 percent of those cases.

I’m still in the process of coordinating with Regence/Blue Shield regarding the medical acceptability of  IMRT.  I’ve provided a diagnosis code of 225.1 and procedure codes of 93.59 for the headframe and 92.2 for the stereotactic radiosurgery.  I was hoping they could look up in their own records and see that they have covered this in the past.  If these codes are incorrect, please let me know.   

I appreciate your help.  I seem to be talking louder and hearing less lately.

Sincerely,

Inez P. Petersen
3306 Lake Wash Blvd North #2
Renton, WA  98056		
Telno 425-255-5543		 
Email   webgirl@seanet.com