Remarkable progress has been made in the treatment of once-fatal brain tumors. Thanks to precise imaging techniques, new non-surgical approaches, such as stereotactic radiosurgery, and improved medication delivery systems, skilled neurosurgeons are offering new hope to many.

To a merchant seaman like Bob Joyce, a noisy ship is part of the job. But when he developed hearing loss and ringing in his right ear about eight years ago, he went to a doctor. An exam and an MRI showed nothing out of the ordinary. Mr. Joyce was feeling well, so he considered his hearing problem merely an annoyance.

But Mr. Joyce's hearing deteriorated even further, and about three years ago he went to another physician. This time, the MRI showed a suspicious mass, which was diagnosed as an acoustic neuroma. Also called a vestibular schwannoma, this is a benign, slow-growing tumor located on the eighth cranial nerve, which leads from the brain to the inner ear. "I was told that I had three options: open brain surgery, stereotactic radiosurgery, or do nothing," says Mr. Joyce, now 67. "I was then referred to a neurosurgeon at University Hospital, Dr. Michael Schulder. When I went to see him, he explained that I only had two choices, and doing nothing wasn't one of them." Although not a malignancy, an acoustic neuroma can be quite serious. As the tumor grows, it can press on a nerve that controls facial sensation and eventually, the brainstem and cerebellum.

Dr. Michael Schulder

Mr. Joyce opted for stereotactic radiosurgery (SRS), in which beams of radiation are precisely delivered to the tumor site, avoiding adjacent healthy tissue. "I'm a very active person, and I was concerned about how the treatment would affect me," he says. "Dr. Schulder said I'd be able to do the same things after the SRS that I did before, and to my surprise, he was right." It has been three years since Mr. Joyce's acoustic neuroma was successfully treated, and although he still has a hearing loss, he has passed three rigorous physicals and from time to time, works at sea.

Without technological advances such as stereotactic radiosurgery, Mr. Joyce and many other brain tumor patients might not have as positive an outcome. Brain tumors are still very rare; their treatment can be lengthy and difficult, and some are deadly, but there has been progress made in neurosurgery, neurooncology, neuroradiology, and imaging, with more to come.

"Unquestionably, the treatment of brain tumors requires a multidisciplinary approach," says Dr. Schulder, associate professor of neurological surgery at New Jersey Medical School , who is director of the Center for Image-Guided Surgery and of the Stereotactic Radiosurgery Center at University Hospital's Brain Tumor Program. "Innovations within each specialty bring new promise for the patient and take brain tumor treatment to a new level."

Take imaging, for example. New Jersey Medical School's University Heights Advanced Imaging Center is one of seven facilities in the country using a powerful MRI scanner with a field strength of 3 Tesla, which enables an earlier and more precise diagnosis of brain tumors. Magnetic resonance spectroscopy (MRS), a non-invasive analytical technique, can be used to study metabolic changes in the brain and differentiate between types of tumors. And computed tomographic (CT) angiography, which takes X-rays of the brain's blood vessels, can produce information that is very important when planning surgery - but in a noninvasive manner, a big change from "conventional" techniques using catheters inserted via the groin.

	The image on top illustrates Mr. Pinkham's brain tumor prior to surgery. The image below shows the scan after surgery.

While imaging is key in the pre-treatment stages, recent inroads in technology have given it a whole new role in the operating room. "The neurosurgeon no longer has to rely on external measurement as a guide during surgery," says Dr. Schulder. "Our operating room-based intraoperative MRI system, the PoleStar N-10, provides real-time imaging of the brain. This enables the neurosurgeon to make any necessary adjustments to the surgical approach while the patient is on the operating table." Even advances in neuroanesthesiology contribute to the patient's well being. Safer pulseoximetry, the non-invasive monitoring of oxygen/carbon dioxide levels, can be critical to patient outcomes, he notes.

The brain is a complex structure, making navigational tools indispensable to the neurosurgeon. A metal frame affixed to the patient's head serves as a reference point during stereotactic surgery, which combines imaging techniques with sophisticated computer technology to create a three-dimensional map of the brain. Frameless stereotactic surgery also maps the brain, but using special wands instead of the frame. "Both provide exquisite details and crucial anatomical information about the brain," says Dr. Schulder. "Functional image-guided surgery, which incorporates frameless stereotactic surgery with functional MRI scanning, goes a step further and locates and references the 'eloquent' areas of the brain that control speech, movement, and other important functions."

Then there's radiation and chemotherapy. Radiation can be used alone to treat a brain tumor, together with chemotherapy, or following surgery to curtail a tumor's growth or reduce its size. One concern with traditional radiation is that the beams can reach healthy tissue as well as the cancer cells. That's where stereotactic radiosurgery, with the precise delivery of radiation to a specific site, becomes beneficial. Not only can healthy tissue be avoided, but the beams can be directed to otherwise inaccessible tumors. Additionally, University Hospital has been a test site for GliaSite®, which delivers radiation through a balloon catheter to the space left after removal of a brain tumor.

Newer chemotherapeutic agents, like PCV and temazoliade, can slow the growth of brain tumors. University Hospital is leading a multicenter study of Gliadel®, a chemotherapeutic wafer, along with radiation therapy and radiosurgery for patients with newly diagnosed malignant gliomas.

Brain Tumor Basics

Brain tumors can be slow growing and benign (non-cancerous), yet problematic because of their size or location in the brain. Or, they can be malignant. From a strictly numerical standpoint, the incidence of brain tumors has increased slightly in recent years; that growth is largely attributed to improved diagnostic capabilities and better reporting.

According to the American Brain Tumor Association (ABTA), more than 186,000 brain tumors will be diagnosed in 2002. Most of them are secondary tumors that begin elsewhere in the body and spread, or metastasize, to the brain. That was the case with former Beatle George Harrison, who had been treated for lung cancer before succumbing to the effects of a brain tumor in 2001. Primary tumors, which originate in the brain, are far less common. Dr. Marnie Rose, a pediatric resident who appeared on the reality television show "Houston Medical," had a glioblastoma multiforme, a type of primary tumor. She passed away in August.

Nonetheless, there are some encouraging statistics regarding brain tumor survival. The NCI collects and tracks data about cancers through its Surveillance, Epidemiology, and End Results (SEER) program. According to SEER data, 22 percent of Americans diagnosed with a malignant brain tumor during 1974 to 1976 reached the five-year survival mark; between 1992 and 1997, 32 percent survived at least five years. Although those percentages may seem low, they reflect a broad range of the most deadly brain tumors. Another study found that the five-year survival rate for patients with the less deadly oligodendrogliomas increased from 45 percent to 65 percent.

And consider the dramatic improvement in treating medulloblastomas, malignant tumors that account for more than one-fourth of childhood brain tumors. "Thirty years ago, medulloblastomas were almost uniformally fatal," says Dr. Peter Carmel, an internationally renowned pediatric neurosurgeon, director of the Center for Pediatric Neurosurgery at University Hospital, and professor and chair of neurological surgery at New Jersey Medical School. "Today, we can remove practically all of the tumor and with new treatments using chemotherapy and radiology, achieve a cure rate approaching 70 percent. That's quite a remarkable change."

Brain Tumors and Children

Brain tumors affect people of all ages, even children. About 2,200 American children are diagnosed with brain tumors every year, according to the ABTA. And yet, the outlook for these young patients has never been more promising.

"Through computer-guided neurosurgery and intraoperative MRI, we can visualize the entire tumor, navigate to where it is, and remove it," says Dr. Carmel. "We have medically sound reasons to tell parents that the outlook for practically all pediatric brain tumors is hopeful."

Several years ago, a professor of endocrinology from Argentina brought his 11-year-old son, who had been diagnosed with a craniopharyngioma, a brain tumor near the pituitary gland, to see Dr. Carmel, an expert in treating these types of tumors. The boy would probably lose his vision and have stunted growth, they were told by other doctors. Through surgical resection of the tumor, neither of these predictions came true, and today the patient is a professor of pediatric endocrinology at the University of Chicago.

Still, not every brain tumor treatment that's suitable for an adult can be used with children. "We very rarely use radiation therapy on children under age 4," says Dr. Carmel. "Now that children with brain tumors are living longer, we're finding consequences attributed to radiation therapy that we didn't know about before. In some cases, we've successfully treated a malignant tumor, only to have a radiology-induced benign tumor occur years later. For those reasons, surgery and chemotherapy are the primary treatments in very young children."

A Race Against Time

Although there are more treatment options for brain tumor patients than ever before, that doesn't mean that they are always quick or easy. For some patients, like Jeff Pinkham, a 46-year-old accountant and former marathon runner, it's been a long road.

The image on the left illustrates Mr. Pinkham's brain tumor prior to surgery. The image on the right shows the scan after surgery.
On December 31, 1993, Mr. Pinkham came home from work and soon had a grand mal seizure. In the course of examining him, doctors found a meningioma, a brain tumor that is slow-growing and usually benign. "The neurosurgeons at a local hospital removed the tumor, but told me they saw something else they couldn't get to. Because I had already been on the operating table longer than anticipated, they closed me up."

Mr. Pinkham then began being treated for seizures by Dr. Stephen Kamin, a neurologist at University Hospital and an associate professor of neurosciences at New Jersey Medical School. In June 1996, when while working in his garden, Mr. Pinkham felt a weakness in his left arm. "Dr. Kamin said, 'You know what this means?' and I knew that surgery would be the only way to know the truth," says Mr. Pinkham. He was referred to Dr. Schulder, who, with the assistance of frameless stereotactic techniques, removed an oligodendroglioma, which was located on the right frontal lobe of his brain.

The accountant alternated visits between Dr. Kamin and Dr. Schulder every three months, the former for seizures, the latter for follow-up on the tumor. In 1998, weakness in Mr. Pinkham's arm returned, along with a speech difficulty; the oligodendroglioma had returned, this time as a larger mass. By June 1999, Mr. Pinkham was back in the operating room. This time, surgery was enhanced with intraoperative MRI, a year after University Hospital installed the second unit of its kind in the world. But because the tumor had returned, Dr. Schulder recommended a course of chemotherapy. Mr. Pinkham was referred to Dr. Jonathan Harrison, a medical oncologist at University Hospital and an assistant professor of medicine at New Jersey Medical School.

Mr. Pinkham is close to completing his chemotherapy regimen, and while the father of four is grateful for the treatment he's received and convinced his doctors have provided the best of care, he is a realist. "I was invited to speak to Dr. Harrison's residents, and one of them asked me if I was optimistic about my future. I told her that she and her classmates were my future. For all that is known, science hasn't caught up with what my problem is yet."

For more information on the treatment of brain tumors, call the Neurological Institute of New Jersey at (973) 972-2323 or visit our web site at: www.TheUniversityHospital.com/braintumor.