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Treatment

Program: The ABC's for Primary Brain Tumors
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Andrew Schorr:

Thank you for joining us tonight. Now, if you're listening to our program on brain tumors, there's somebody in your family or yourself where this scary diagnosis has come down and you're worried, and so as we stressed in our last segment it's very important to get a specialized team on your side. Also we've done many, many programs on a whole variety of health issues sponsored by Northwestern. It's all in the ihealth area of nmh.org. So be sure to take a look at that. Also in two weeks we'll have a program with a cancer brain surgeon on the team at the brain tumor institute, and that's Dr. James Chandler, and he's going to help us understand specifically about surgery. But I wanted to ask Dr. Raizer about it too.

If I've got it right, typically when there is an operable brain tumor surgery happens first. Is that right? And you try to be as aggressive as you can in the surgery because that makes a big difference in recovery in trying to beat or knock back the cancer?

Dr. Raizer:

Correct. On occasion there is one type of tumor of the brain called lymphoma that you make a diagnosis based on the spinal fluid, but barring that we always have to have tissue because even if it looks like something on a scan and we think we know what it is there's many cases I can think of where the pathologist gives me a report and it's different than what I was thinking of. I have a patient in the hospital now that we'd actually thought had a tumor that spread from somewhere else, and we did a biopsy and it looks like brain lymphoma, so without that somebody might have just said, well, it looks like tumor from somewhere else. We'll radiate his head. He's an older guy. The radiation would have actually hurt him a lot given his age, and we have the potential chance of maybe curing him with chemotherapy because of the type of tumor he has. So it's extremely important to get tissue. We always have to make the right diagnosis so that we can treat the patient appropriately.

Andrew Schorr:

And then the surgeons try to cut out without harming function, try to cut out as much as they can, right?

Dr. Raizer:

Right. And they have some tools where they can do that. We have something called diffusion tensor imaging which allows us to look at the motor fibers and the optic nerve fibers, and it tracks so that they know where to stay away from. We can do functional imaging which also tells us where the motor center activates or the sensory center activates or the language center is so when they go into the operating room ahead of time they kind of know where they want to stay away from. And particularly in some areas like speech they may do the surgery with the patient awake so they can converse with them. It's not wide awake, but it's sort of a sleepy type of state. So they have tools that can optimize the amount of tumor that they can take out surgically.

Andrew Schorr:

Right. And Dr. Chandler in our next program will explain that in detail. Just a question about sort of intraoperative therapy, I know one of the approaches that's used sometime is actually putting in sort of a wafer that is sort of delivering drug, if I've got it right, right to the site. Is that correct?

Dr. Raizer:

Correct. One of the older drugs we used to use and we still actually use for some of our primary brain tumors from gliomas is a drug called BCNU. And the thought was if you could put it into something and put it directly into the tumor you would actually avoid all the systemic side effects, particularly on the bone marrow. It's something that's been FDA approved because it's had some overall survival advantage, but if you look specifically at the glioblastoma population it didn't really seem to have as much impact as it was thought. So I haven't polled anybody, but most of my colleagues at the major academic centers actually don't use Gliadel wafers. I don't use them very often but certainly they're FDA approved. They can be used, they do have some activity, but again I also do a lot of clinical trials and so using them would sort of eliminate people from going on to studies, and I know those studies are probably more important in the future.

Andrew Schorr:

Right. This brings up a good point I want to stress for people too, and that is the art of medicine. So, Dr. Raizer, with your experience in neuro oncology, things are FDA approved or not, things are tried elsewhere or not, but I think when someone goes to a specialist such as you they're really looking for your experience and your opinion as you kind of survey what's right for them.

I want to bring something up and maybe you can comment on it. You know, you can drive down the road and you hear a lot of ads for technology, and sometimes it relates to brain cancer. So for instance these sometimes multi million dollar devices to fire various kinds of radiation at your head to try to do surgery that way, do you have any comment on that? Because it seems like the treatment of an individual's brain cancer is more complicated than any one device.

Dr. Raizer:

I would agree, and again most of these things, they all do same thing, a lot of them, called radiosurgery. They have different names like Gamma Knife, CyberKnife, tomotherapy, but they all essentially do the same thing. The one issue with that again is if it's used before you see somebody who may have clinical trial options is, you know, bumped out of a study.

The other thing is in the absence of any other therapy they really don't probably add very much in most cases because we're talking about a focal treatment for a nonfocal disease. And so the analogy I give to patients a lot is if you have an iceberg sticking out above the water and you take the top off and you're in your boat and you kind of go, oh, it's gone, but if you keep going you're eventually going to crash into the part that's underwater. So trying to treat, using something that infiltrates brain much more diffusely and using a focal therapy at the end of the day probably doesn't do all that much. And at least when it was looked at in one study in newly diagnosed patients it actually didn't add anything beyond standard radiation and chemotherapy.

So that's not to say I never use these technologies, I certainly use them, but I think as you pointed out it's the art of knowing when to use it and sort of the timing of it. My role is always maximize patients’ options. Somebody could always get radiosurgery, somebody could always get commercially available drugs, and so you want to be able to give them the most you can but not limiting their therapies. So yes, I think they're there. I think some people buy them for marketing issues and try to attract patients, but again I think when you have a team approach with people who see and do this all the time we actually think about the problems and not just do things on a broad level.

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