Transcript Brain Tumors

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
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Slow growing
Non-invasive
Does not spread
Less likely to recur
Malignant
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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
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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?