CINCINNATI—In 2008, approximately 215,000 Americans will be diagnosed with one of more than 100 types of brain tumors. Patients who receive such a diagnosis should remain hopeful, however, as treatment options at the nation’s leading brain tumor centers have never been better, according to Philip Theodosopoulos, MD, assistant professor of neurosurgery and director of the division of skull base surgery at the University of Cincinnati (UC).
“There’s no question that these tumors remain a difficult problem to deal with. But there are options—good options—and there is plenty of reason for optimism,” says Theodosopoulos. “We have gotten much better at the treatment of these tumors, and we have minimized the risk to the point that a patient’s risk of developing a new, permanent neurologic symptom as a result of neurosurgery at a major center is close to zero. That was not the case even 10 years ago.”
Brain tumors fall into two categories: primary and metastatic. Primary brain tumors, which strike 45,000 Americans each year, originate on their own. Metastatic brain tumors, diagnosed in 170,000 patients annually, arise from a cancer elsewhere in the body.
Two developments in particular have revolutionized the treatment of brain tumors in the last few years. One is functional MRI, which enables brain tumor specialists to locate functional (e.g., language and motor) areas of the brain before surgery and to chart a safe passage around these areas to the tumor.
The other revolutionary development is minimally invasive cranial surgery, in which surgeons operate through tiny openings in the nose, eyebrow or skull, with minimal disruption to the brain. Patients who would have been hospitalized a week after traditional surgery are often able to go home the next day, says Theodosopoulos.
Even large tumors can be removed through openings of 1.5 to 3 centimeters, says Theodosopoulos. “We have a whole set of tools that are much smaller than they used to be. We have unishafted scissors and other tools that are essentially miniature instruments at the tips of very long holders that can reach through small corridors.”
At large brain tumor centers, treatment of a single tumor often involves multiple therapies. As a result, patients routinely come under the care of a team of specialists, including neurosurgeons, neuro-oncologists, neuro-radiologists, otolaryngologists, neuro-ophthalmologists and radiation oncologists, says Theodosopoulos, who is a member of the multidisciplinary brain tumor team at the Neuroscience Institute at UC and University Hospital.
“Aggressive, or malignant, tumors require surgical treatment, along with chemotherapy, radiation therapy or radiosurgery,” says Theodosopoulos. “Often the treatment must be repeated.”
Brain tumor specialists are even chipping away at their greatest nemesis, the highly malignant glioblastoma, extending life spans incrementally through multimodal therapies. Because the tumor is diffuse and ill defined, it cannot be easily removed or contained.
“We have made significant advances in treatment safety and in the diagnosis of glioblastoma,” says Theodosopoulos. “And we have made advances in the actual survival. But we’re nowhere close to where we want to be. We want to make it a curable disease. There is no question that this is the biggest challenge that we have in the field of brain tumors, and it’s unlikely that it will ever become an easy one.”
Theodosopoulos says neurosurgeons today have high expectations for patients diagnosed with benign primary tumors.
“Patients with meningiomas, acoustic neuromas, pituitary tumors, low-grade gliomas and cysts of the brain are expected to live with their disease for decades. And usually they do.”
Safety takes on special significance with these patients, says Theodosopoulos, because any deficits they incur from surgical treatment will be permanent.
“When the brain tumor team treats these patients, we try to minimize the morbidity—the life-degrading side effects—of surgery. We may do this, for example, by leaving some tumor that is near an important functional area behind and then radiating it. Endocrine treatments and medical treatments are also very important in the treatment of pituitary tumors, which are the most common of the benign tumors.”
The division of skull base surgery is part of a joint cancer program involving the University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center and University Hospital. The collaborative initiative brings together interdisciplinary research teams of caring scientists and health professionals to research and develop new cures, while providing a continuum of care for children, adults and families with cancer.