Treatment

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Brain and spinal cord tumors are extremely diverse -- both biologically and in their response to treatment. Treatment for these tumors includes surgery, radiation therapy, and chemotherapy, delivered alone or in combination. Doctors at Memorial Sloan-Kettering use all of these types of treatment and are also conducting clinical trials to assess new chemotherapy agents, multimodal treatments, and biological therapies.

Surgery is the treatment of choice for any brain tumor that can be reached without causing severe damage to normal tissue. Although it is not possible to completely remove some of the more aggressive brain tumors (such as glioblastoma), surgeons operate to help refine the diagnosis, remove as much tumor as possible, and release pressure within the skull caused by the tumor. Additional goals are to relieve symptoms, improve neurologic function, and extend the duration and quality of patients' lives. Improvements in surgical techniques -- particularly image-guided stereotaxy -- have revolutionized brain surgery in recent years.

Our Intra-Operative Imaging Suite View a slide show of our intra-operative imaging suite equipped with a MRI scanner go

Intraoperative Imaging Suite

To improve the outcome of brain surgery, Memorial Sloan-Kettering's neurosurgeons perform brain surgery in an intraoperative imaging suite that has a magnetic resonance imaging (MRI) scanner in the operating room. At any point during surgery, the neurosurgeon can rotate the patient into the MRI machine to determine whether the tumor has been removed completely. If any residual tumor is found, surgery can be resumed and the remaining tumor removed. Being able to reevaluate the patient's tumor with MRI during surgery allows neurosurgeons to operate with increased precision and will reduce the need for and risk of a second operation.

Operations performed using intraoperative MRI are also likely to reduce tumor recurrence rates and minimize complications.

Image-Guided Stereotactic Surgery

Frameless stereotaxy, a very precise method of operating on deep-seated brain structures, is based on the idea that all points on the brain can be described using a three-dimensional system of coordinates. Stereotaxy allows surgeons to better plan operations in advance and provides enhanced orientation and guidance during surgery.

Before the procedure, technicians attach six plastic self-adhesive dots around the patient's scalp, and an MRI is performed. At the start of surgery, the exact location of these dots is registered and used to relay the position of the patient's head to the surgical navigation system.

The team directs a wand-like viewing device at the patient's brain that simultaneously projects an image onto a monitor in the operating room. The image is synchronized with the patient's MRI scan taken immediately before surgery. This image gives the neurosurgeon up-to-the-moment orientation as he or she plans an approach through healthy tissue to remove the tumor. Also, the neurosurgeon can use the viewing wand to help see through the tumor to its margins (outermost edges of the tissue that is being removed) during the operation, giving assurance that the entire tumor has been removed.

Frameless stereotaxy is used in conjunction with Memorial Sloan-Kettering's intraoperative MRI.

Functional Imaging & Intraoperative Brain Mapping

Functional imaging and intraoperative brain mapping have greatly improved the safety of brain tumor surgery. Functional magnetic resonance imaging (fMRI) uses high-speed MRI to map areas of the brain associated with vision, speech, touch, movement, and other functions, the locations of which can vary from one person to the next. The map then allows a surgeon to plan surgery precisely to avoid disrupting these important areas so as to optimize the patient's quality of life.

Many of our brain tumor operations are performed while the patient is awake but sedated. During intraoperative brain mapping, the neurosurgeon electrically stimulates the brain the area around the tumor using small electrodes, while asking the patient to talk, count, look at pictures, and perform other basic tasks. This process helps our surgeons locate the "eloquent" regions in the brain, which govern speech, the senses, and movement, and a "map" is created of the areas where preserving brain tissue is an absolute necessity. Surgeons can then avoid these sensitive tissues while removing as much of the tumor as possible.

This kind of sophisticated brain mapping allows the neurosurgeon to remove tumors that are otherwise deemed inoperable, while maximizing preservation of the patient's normal function.

Neuroendoscopy

Some procedures are now performed using neuroendoscopy, in which the neurosurgeon works through a small opening in the skull using a thin tube with a powerful lens and high-resolution video camera to see into the skull and brain. Advantages of this minimally invasive neurosurgical procedure include a small incision site, an enhanced ability to perform microsurgical procedures, and potentially less trauma to healthy tissue.

Following surgery, an MRI is performed to determine the extent of tumor removal and to help plan further treatment.

New methods of radiation therapy allow doctors to raise the dose of radiation delivered to a tumor, while enhancing precision and minimizing the amount of radiation that reaches healthy tissue.

These technological advances rely on Memorial Sloan-Kettering's team approach to cancer care, involving specialists in radiation oncology, neurosurgery, medical physics, and neurology, whose combined expertise is critical to ensure that the treatment is delivered as effectively as possible and with a minimum of damage to normal brain tissue.

IMRT & IGRT

Our physicians are working to develop new techniques to further improve the targeting accuracy of radiation therapy and to minimize its side effects. Our radiation oncologists use intensity-modulated radiation therapy (IMRT), which allows more precise treatment planning and the ability to deliver higher radiation doses with greater safety. With IMRT, radiation therapists can shape pencil-thin radiation beams of varying intensity to conform to specific tumor shapes and sizes, reducing the dosage of radiation to healthy tissues and possibly the side effects of treatment. In addition, an enhanced form of radiation therapy known as image-guided radiation therapy (IGRT) is used to treat brain tumors. By incorporating real-time image guidance within IMRT, radiation oncologists can make adjustments in the radiation beam so that radiation is delivered with even more precision.

MRI/CT Image Fusion for Treatment Planning

Physicians use specially designed software to align MRI and CT scans, superimposing the images from the two imaging techniques to plan radiation treatment.

Stereotactic Radiation Therapy

Memorial Sloan-Kettering radiation oncologists use a micro-multileaf collimator system for radiosurgery and also for more conventional radiation treatments. The radiation beam is covered by many layers -- called multileaves -- that shape the beam to the outline of the tumor, as interpreted by an MRI scan. Radiation is then delivered with great precision only to that tissue. The radiation beam is conformal (meaning that the instrument looks at the tumor in three dimensions and shapes the radiation beam to its outlines) and intensity modulated (the beam moves so that it spreads the radiation dose, and no area gets too large a dose).

The conformal radiotherapy method used for stereotactic radiosurgery treats brain tumors that are four centimeters (about an inch and a half) or less in diameter, including malignant gliomas, acoustic neurinomas, meningiomas, and brain metastases. The instrument is very precise and fashions the radiation dose much closer to tumor boundaries than other instruments used for this purpose, such as the Gamma Knife. This spares the surrounding brain tissue from any significant dose of radiation.

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Very few conventional chemotherapeutic drugs can penetrate the blood-brain barrier, a "wall" that protects the brain by pumping toxins out of brain tissues and back into the blood stream. This barrier greatly limits the choice of chemotherapeutic agents that can be used to treat brain cancers. But some drugs are effective, and some tumors do respond to therapy. In recent years, researchers have refined and expanded the use of chemotherapy as a next-line approach after surgery and radiotherapy for the treatment of brain tumors.

Our neuro-oncologists are involved in the development of a number of new chemotherapy drugs for brain cancer, including targeted therapies. For example, the relatively new drug temozolomide (Temodar®) is used as a targeted therapy. It interferes with cell division, thus slowing tumor growth. Because the basic building blocks of temozolomide are small molecules, the drug is able to cross the blood-brain barrier and reach tissues other chemotherapeutic agents cannot. Temozolomide has been shown to prolong survival and improve patients' quality of life. It was initially approved by the Food and Drug Administration (FDA) in 1999 for patients with anaplastic astrocytoma who had relapsed after chemotherapy. In 2005, the FDA approved its use in patients with newly diagnosed glioblastoma multiforme. Memorial Sloan-Kettering researchers continue to study the best ways to use temozolomide and are also investigating many other small-molecule, targeted therapies for brain cancer.

Other drugs used in the treatment of central nervous system tumors are nitrosoureas agents such as carmustine (also called BCNU) and lomustine (CCNU), both of which can penetrate the blood-brain barrier.

Some oligodendrogliomas, in particular those with a certain molecular makeup, can be highly responsive to chemotherapy such as temozolomide, or with the combination treatment known as PCV (procarbazine, CCNU, and vincristine).

Scientists are currently studying the genetics of other central nervous system cancers for clues as to why some of these diseases can be treated while others are resistant to therapy.

Researchers at Memorial Sloan-Kettering develop and evaluate promising new treatments for central nervous system cancers, new technologies for diagnosis, and the integration of different modes of treatment. These investigational therapies are sometimes offered to eligible patients through the clinical trial process. Some of these research efforts are highlighted below.

Novel Chemotherapy Agents

Researchers are evaluating new types of drugs that block or interfere with cancer cell growth, particularly for malignant brain tumors that often recur or continue to grow despite therapy. Among these agents are angiogenesis inhibitors, which prevent the growth of new blood vessels that supply tumors with nutrients and allow them to grow and spread; growth-factor inhibitors, which block tumor growth factors (such as epidermal growth factor) from reaching their receptors and interfere with cancer cell growth; and drugs designed to reduce the ability of cells with genetic mutations associated with malignancy to multiply and divide.

Combined Modality Therapy

By combining radiation therapy with one or more chemotherapy drugs, our investigators hope to kill more tumor cells and overcome tumor resistance to single therapies. Drugs evaluated for combination therapy include angiogenesis inhibitors such as bevacizumab combined with irinotecan, temozolomide, or other chemotherapeutic agents.

We are also combining new biologic agents, such as angiogenesis inhibitors and signal transduction inhibitors, which have the potential to enhance the therapeutic effect of radiation by increasing the sensitivity of the tumor to radiation while sparing healthy tissue.

Immunotherapy

Memorial Sloan-Kettering investigators are evaluating monoclonal antibodies designed to spur the patient's immune system to respond to his or her brain cancer. These antibodies are created in the laboratory and are designed to latch on to a specific tumor antigen or protein present on the surface of the tumor cell. In one approach, a monoclonal antibody is tagged with a radioactive isotope to identify and kill tumor cells.