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Brain Tumors David A. Sun, M.D., Ph.D. Neurosurgery Disclosures • I have no relevant personal financial relationships • I do not intend to discuss offlabel/investigational use of commercial products/devices Types of Tumors Primary brain tumors • Brain tissue origin Secondary brain tumor • Non-brain origin Secondary brain tumors • Non-brain origin = Cancer metastasis – Most common – 25-45% of cancer patients • Lung: >50% of all; most common in men • Breast: Most common in women • Melanoma: Highest propensity for brain – 50% of melanoma patients develop brain mets; Multiple • Renal Cell • Colorectal • Any primary can metastasize to the brain Primary brain tumors • Meningioma (35%) • Glioma (30%) – Astrocytoma Skin Skull Meninges Brain • Glioblastoma – Oligodendroglioma – Oligoastrocytoma – Ependymoma • Pituitary Adenoma (13%) – Within skull – Beneath brain Neuron Astrocyte Oligodendrocyte Ependyma Is this cancer? Is this cancer? Benign • • • • Slow growing Non-invasive Does not spread Less likely to recur Malignant • • • • Fast growing Aggressively invasive May spread distantly More likely to recur Is this cancer? Benign Meningioma Malignant Glioma Is this cancer? Benign Malignant Meningioma Grade 1 92% 2 6% 3 2% Is this cancer? Benign Malignant Meningioma Grade 1 92% 2 6% 3 2% Glioma Grade 1 2 3 4 Is this cancer? Benign Malignant Meningioma Grade 1 92% 2 6% 3 2% Glioma Grade 1 Pilocytic astroctyoma (surgically curable) 2 3 4 Glioblastoma (15 month median survival) How do brain tumors cause problems? • Mass effect – Tumor pushes on normal brain • Local invasion – Tumors invade normal brain • Microscopic • Edema – Swelling of normal brain Presentation • Generalized symptoms and signs → Elevated intracranial pressure • Headaches (50%) – New or different – Worsening over time – Worse on awakening, them improve – Other symptoms • Seizures (30%) • Cognitive change (30%) • Personality change (25%) • Nausea/vomiting (15%) • Blurred vision/papilledema • Lethargy Presentation • Focal symptoms and signs → site specific to location Presentation • Focal symptoms and signs → site specific to location; Weakness Incoordination Personality Cognitition Expressive language Receptive language Vision Incoordination Balance What are our options? • Surveillance – Serial MRI scans What are our options? • Surveillance – Serial MRI scans – Watch it What are our options? • Surveillance – Serial MRI scans • Surgery – Biopsy • Diagnose the tumor – Resection • Diagnose the tumor • Remove as much of tumor as possible What are our options? • Surveillance – Serial MRI scans • Surgery – Biopsy – Pick a few weeds out • Diagnose the tumor – Resection – Pull as many weeds as possible • Diagnose the tumor • Remove as much of tumor as possible Surgery Surgery Surgery • Where is the tumor? • What bone is in the way? • What brain is involved? – What does that brain do? • What arteries/veins are involved? Surgery • Where is the tumor? • What bone is in the way? • What brain is involved? – What does that brain do? • What arteries/veins are involved? X X Transnasal Transsphenoidal Primary motor cortex X Primary motor cortex Awake Crani Biopsy Surgical tools - Microscope • Improves visualization – Increased light – Increased magnification • Improves surgeon comfort – Adjust scope angle, instead of bending/twisting Surgical tools - Navigation • GPS system for the OR – Pre-plan surgical approach – Confirm anatomic position • Brings radiology data into the OR • Functional MRI • White mater tracks Surgical tools - Robotics • Navigation systems with built in surgical assistant – Pre-plan surgical approach – Utilize the robot to align the instruments • Minimally invasive – Single stitch incision – Maximizing precision Surgical tools – Laser Ablation • Minimally invasive – Single stitch incision • Pass a probe into the tumor – Reduced risk to normal brain • Utilize heat to destroy tumor cells Pre-op 1 year post-op Radiation Therapy • No clean margins • Can never pull every single weed • Whole brain radiation – Multiple small doses to entire brain SRS • Stereotactic radiosurgery (SRS) – High dose to a small area – Limits exposure to normal brain Team Approach • • • • • • • • • • • Neuro-oncology Radiation oncology Behavioral oncology Neurosurgery Neuro-radiology Neuro-psychology Neuro-pathology Nurse Navigator Research Nurse PT/OT/SLP Support services • Make the diagnosis • Deliver individualized treatment • Provide clinical trials • Provide support for our patients and families • Maximize quality of life Questions?
