Neuro-oncology encompasses treatment of tumors of the brain, spine, skull base and pituitary. Siteman Cancer Center has innovative treatments not available elsewhere in the region and leads the area in research and clinical trials for these types of cancers, bringing novel treatments to the clinical area not available to patients elsewhere for truly personalized medicine.
The Siteman Advantage
Because many of our patients come from over 100 miles away, when you meet with a surgeon, you often see the radiation and medical oncologists and get advanced imaging for treatment planning. Each new patient is presented at a multidisciplinary tumor conference to personalize his or her management, which includes surgery, radiation oncology, chemotherapy, and pathology to take into account specific tumor characteristics.
Advanced brain mapping: Mapping the brain is critical for neurosurgeons who not only want to get a detailed view of abnormal areas to target for surgery but also want to minimize the risks of surgical damage to healthy tissue regions that perform essential tasks. Never is this more critical than in the brain and spinal cord.
For many years, neurosurgeons have accomplished the job using a time-intensive approach called functional magnetic resonance imaging (fMRI). Patients perform several simple tasks—saying their name or moving an arm, for example—while their brain is repeatedly scanned. Clinician-scientists at the Brain Tumor and Neuro-Oncology Program have now discovered that resting state fMRI is as useful for precisely mapping all of an individual patient’s critical brain networks: speech, motor control and others in one 15-minute session while the patient lies in the scanner and rests.
Intraoperative MRI: With the data from the MRI navigation map and the functional MRI, which provide GPS-type localization of tumor and normal brain, the surgery can commence. However, as tumor is removed and cerebrospinal fluid drained, the navigation map becomes inaccurate for tumor margins. That’s where real-time intraoperative MRI (iMRI) comes in to give the surgeons updated information to complete the surgery accurately and safely. They have done well over 1000 iMRI cases, a significant portion of which are gliomas, pituitary tumors, and spinal tumors, including metastases from lung and breast cancers.
Surgery remains a mainstay treatment for brain tumors, but advances in technology and new clinical trials mean patients have more treatment options—some noninvasive—and quicker recoveries. For more in-depth information, visit brain and spinal tumor surgery. Many skull-based tumor surgeries can be considered for a minimally invasive approach, like laser interstitial therapy or endonasal endoscopy to reach inaccessible tumors.
MRI-Guided laser interstitial therapy: Washington University neurosurgeons are among the first in the nation to use an MRI-guided, high-intensity laser probe designed especially for the treatment of inoperable brain tumors to “cook” cancer cells deep within the brain while leaving surrounding brain tissue undamaged. Patients who are candidates for this procedure will have a small burr hole the diameter of a pencil drilled through their skull. Neurosurgeons then use real-time MR imaging to guide the probe through the brain and into the tumor. Once inside the tumor, the laser discharges highly focused heat energy to coagulate and kill cancer cells. The technology is FDA-approved for several types of brain tumors: glial tumors – including low-grade gliomas – anaplastic astrocytomas, anaplastic oligodendrogliomas, glioblastoma, metastatic cancers that have spread from other regions of the body, some radiation-resistant tumors, and radiation necrosis due to prior radiation therapy.
Gamma Knife: Although Gamma Knife is a form of radiation, it is considered a surgical intervention because it can replace surgery. Some patients could have either, so the treatment is based on lifestyle and impact of recovery to the patient’s life.
Minimally invasive endoscopy: Many tumors of the skull base can be treated with endoscopic endonasal skull-base surgery, in which, rather than make an opening through the face or skull, the surgical team advances an HD endoscope through the nasal cavity to view the anatomy and perform the surgery. In other cases, minimized versions of more traditional open surgeries can be performed by our surgeons, such as eyebrow incisions.
Immunotherapy: Biological therapy, sometimes called immunotherapy, is a treatment that uses materials made by the patient’s own body or in a laboratory to stimulate the immune system to fight disease. Siteman researchers are now participating in clinical trials to test this form of therapy. These trials are especially important for patients with metastatic and recurrent cancers.
- Vaccines: Some clinical trials at Siteman will study the effectiveness of brain tumor vaccines. Creating a personalized vaccine begins with samples of DNA from a patient’s tumor and normal tissue and making a vaccine from the most likely proteins in mutant cancer genes to stimulate the patient’s T-cells to attack the cancer.Another type of vaccine targets a genetic mutation specific to glioblastoma cells, the most common high-grade brain cancer in adults and the most aggressive. Early data from these vaccine drugs shows that patients who received the vaccine in addition to the current standard therapy live more than twice as long as patients who received standard therapy alone. The side effects were, in most cases, no worse than those of a flu vaccine.
- Checkpoint blockade: Another approach to immunotherapy is called checkpoint blockade. Cancer cells shut off the T cells by activating a safety mechanism called the checkpoint system, preventing them from attacking the tissue. Drugs called checkpoint blockades disable the checkpoint, taking the brakes off of T cells so that they unleash destruction on the tumors.
Genomics: Genomic sequencing offers another step forward. By studying a patient’s DNA, researchers are learning which changes, or mutations, dictate responses to a particular drug so treatments chosen are given that are most likely to be effective.
Proton Beam Therapy: The Proton Therapy Center at the Siteman Cancer Center is the only one located in Missouri and the surrounding region. Proton beam therapy’s main advantage is that radiation specialists can control radiation beams by depth, shape and radiation dose.
ViewRay MRI-Guided Radiation Therapy: This system is a breakthrough technology initially developed at Washington University. The integrated system combines radiation treatments with a continuous magnetic resonance imaging system. By using MRI to help guide radiation therapy treatments in real time, the radiation oncology team is able to see where the radiation dose is being delivered and determine if any subtle changes are occurring to the tumor or surrounding tissue. The ability for continuous soft-tissue imaging means that a patient’s treatment plan or radiation dose can be adjusted immediately if changes are noted.
Hyperfractionated radiation therapy: Useful in the treatment of brain stem gliomas, this radiation treatment divides the total dose of radiation into small doses in treatments given in small daily doses called fractions given over several weeks. In contrast to the one-day radiosurgery, this technique is used for tumors located close to sensitive structures, such as the optic nerves or brain stem.