'Brain tumor' may be the two most frightening words a patient will ever hear a surgeon speak. After the shock, there will be questions--most will ask what can be done.
In finding the answer likely to lead to the best outcome, there are no simple templates for treatments that fit everyone.
"The important thing is to look at the patient sitting in front of you," neurosurgeon Joshua Menendez MD of Neurosurgical Associates said. "Each case has its own unique considerations.
"The location and size of the tumor, the patient's age and other morbidities, and the type of tumor and how aggressive it is are all factors in developing a treatment plan. Depending on the circumstances, the recommendation most likely to benefit the patient may be open surgery, radiosurgery, a combination of both and perhaps follow-up with other therapies."
The location of the tumor can influence the choice of treatments. A tumor near the brain stem is likely to be higher risk for both traditional surgery and radiosurgery than one near the right frontal lobe, which would be more accessible for either.
However, location isn't always the only factor. "The nonmalignant tumors we often see rising out of nerve tissue near the brain stem are an example of how we might approach the same type of tumor differently in different patients," Menendez said. "These tumors don't spread cancer cells to other areas of the body, but as long as the tissue is there it continues to grow, compressing surrounding structures of the brain and causing damage.
"We can do radiosurgery in half an hour and then send the patient home with very little time needed for recovery. Treating the tumor with open surgery could take all day, plus a hospital stay and time for recovery. For older patients with other health issues, radiosurgery is likely to be a better choice. However, for younger patients in good health, there could be advantages in traditional surgery. When the tumor is removed, it's gone. Younger people with more years of life expectancy can live those years without as much worry about whether a trace of tissue could have survived and might start growing again."
The size of a brain tumor can affect whether or not radiosurgery is an option.
"As of now, we typically don't use radiosurgery for tumors over three centimeters. As tumors get larger, targeting them without damaging surrounding tissue becomes more difficult. However, neurosurgeons in some research centers are pushing the envelope in using radiosurgery for larger tumors. As their techniques are refined and developed, we hope to be able to offer this choice to more patients," Menendez said.
The nature of the tumor itself is one of the most important factors in deciding how to treat it. Some tumors respond to radiation better than others. More aggressive tumors, particularly glioblastomas, need to be targeted with every weapon in the treatment arsenal to make a difference in the patient's survival.
"Glioblastomas are so tenacious, and they don't have the more defined borders you see in other types of tumors. Even with surgery, it's difficult to know if there is more. We tend to combine surgery with radiosurgery and possibly chemotherapy. Research is making progress toward gene therapies using viral vectors to target and destroy malignancies. We're hoping this will give us a more effective way to treat aggressive brain tumors in the not-so-distant future," Menendez said.
Radiosurgery itself has come a long way since the early days of the gamma knife.
"Instead of being immobilized with all that heavy, uncomfortable head gear we had to use in the past, patients now wear a lighter mask to assure precision placement. The equipment uses 3D computer tracking with an automatic shutoff if there is any variation in alignment. This protects healthy surrounding cells while making sure the therapeutic dosage is going where it is needed."
Radiosurgery may be completed in one session or delivered in fractionated doses in multiple sessions depending on the treatment plan.
"We work closely with radiation oncologists to plan treatment, and with an entire team in the St. Vincent's lab as we perform the procedure," Menendez said. "With advances in radiotherapy, open surgery and new therapies, we have come a long way in what we can do to fight brain tumors."