Neuro-oncology and skull-base surgery program

Collaboration, Clinical Trials and the Team Approach

Patients with brain, skull-base or spinal tumors offer challenging clinical problems that often require the care and knowledge of a variety of specialists. Surgeons work closely with medical neuro-oncologists, radiation oncologists, epileptologists, neurologists, neuro-radiologists, otolaryngologists, endocrinologists, neuro-pathologists and palliative care providers to manage any problem that may arise. The neurosurgeons of NJBSC have created a network of the finest professionals and interact directly and regularly with them to ensure that communication is consistent, clear and uninterrupted.

The management and control of brain tumors will often require treatments other than surgery (Case Studies #1,2,3). Patients may choose to be evaluated in a multi-disciplinary neuro-oncology clinic involving medical neuro-oncologists and radiation oncologists together with NJBSC neurosurgeons. Standard treatment protocols involving chemotherapy, radiation therapy and radiosurgery are carefully considered and reviewed with patients in this setting. Additionally, a patient may decide to participate in a variety of promising clinical trials to offer hope for improved outcomes.

Role of Non-Surgical Management of Tumors of the Central Nervous System

Multi-disciplinary treatment of brain tumors utilizing treatment modalities such as radiotherapy/radiosurgery, chemotherapy, immunotherapy and Laser Interstitial Thermal Therapy (LITT) is often necessary for a variety of reasons. Some tumor types are exquisitely sensitive to chemotherapy and do not require resection regardless of their accessibility. The role of surgery in these cases is reserved for biopsy only to confirm diagnosis (Case Study #1). In other circumstances, non-surgical management with combination chemotherapy and radiation may be offered if the location of a tumor prohibits surgical resection due to the high risk of major disability (Case Study #2). Alternatively, in circumstances where more than one tumor is present, surgery is not feasible and radiosurgery may be offered to control tumor progression (Case Study #3). These case studies highlight the importance of a multi-disciplinary approach to the treatment of brain tumors.

Case Study 1

Patient is a 72 year-old man presenting with a three-week history of short-term memory loss and imbalance who was found to have a sizable left sided deep-seated tumor of the basal ganglia (Figure 1a,b coronal and axial T1 weighted post contast MR). Due to deep-seated location of tumor, surgical resection was deemed hazardous therefore a frameless stereotactic biopsy was recommended. A diagnosis of primary central nervous system large B cell lymphoma was established and a systemic evaluation proved unremarkable. The patient was referred to medical neuro-oncology and was treated with combination chemotherapy. Resolution of tumor was achieved as demonstrated on MR obtained 12 months after diagnosis (Figure 2a,b coronal and axial T1 weighted post contrast MR).

Figure 1

Case Study 2

This 55 year old man presented with progressive left arm clumsiness and facial numbness prompting an evaluation at an outside facility. Initial MR interpretation was felt to represent an ischemic infarct and patient was treated with Plavix. Unfortunately, symptoms worsened over the following week prompting the patient and family to obtain a second opinion from medical neuro-oncology. A follow-up MR was performed revealing the development of a larger and now enhancing lesion deep within the right hemisphere of the brain (Figure 1: a: coronal and b,c: sequential axial slices). Given this progression on imaging, a frameless stereotactic biopsy was performed thereby establishing a diagnosis of Glioblastoma Multiforme.

Since biopsy, the patient has been treated with a course of chemotherapy and radiation and has noted improvement in his overall strength. His most recent MR 6 months since treatment reveals a substantial reduction in the dimension of enhancing tumor (Figure 2: a: coronal, b,c: sequential axial slices).

Figure 2

Case Study 3

Patient is a 75 year old man with history of metastatic adenocarcinoma of the lung with multiple brain metastases. He underwent resection of a large right parieto-occipital mass and radiosurgery to the remaining three tumors. Imaging demonstrates two tumors on the right and a single tumor in the left occipital lobe (Figure 1: a: axial, b: coronal). Six months after treatment, the patient remains asymptomatic and fully functional with equivalent imaging demonstrating a substantial reduction in the dimension of the tumors (Figure 2: a: axial and b: coronal).

Figue 3