Innovations in Brain Tumor Surgery Provide More Options, More Hope

Brain tumors are understandably perceived as quite a grim diagnosis. Medical, surgical and technical advances like those available at The University of Kansas Health System, along with discoveries in research such as those in progress at our academic partner, the University of Kansas Medical Center, provide more options and more hope than ever before.

Why is it so difficult to treat these aggressive brain tumors? It's important to understand distinctions between tumor types. First, there are metastatic tumors, which invade the brain from elsewhere in the body. The tissue from which they originate isn't brain tissue or supportive cell tissue. They grow in rough spheres and have a reasonable capsule surrounding them. They can almost always be completely or nearly completely removed.

In contrast, tumors that originate in the brain behave differently. Intrinsic to the brain, they infiltrate the brain tissue, traveling from one part of the brain to another and intertwining among functioning neurons and supporting brain cells. They lack a sharp margin, meaning that, while we can surgically remove almost all the tumor cells we can see on an MRI scan, there are tumor cells that have spread well beyond the area in which the tumor originated. This leaves tumor cells behind and allows growth to recur.

We are living in encouraging times for those fighting brain tumors. For the last 50-60 years, we've had little to offer but radiation and 1-2 types of chemotherapy. Today, we have new chemotherapies. We have new delivery mechanisms for getting chemotherapy into the brain. We can treat brain tumors with immunotherapy. We can perform genetic testing that reveals details unique to each patient, allowing us to recognize different tumor types and attack them individually.

And when surgery is appropriate – often helpful to reduce the tumor size, even if we cannot remove every tumor cell – we have more tools and techniques available to make surgeries safer, more efficient and more effective.

A powerful tool in our surgical arsenal is the intraoperative MRI. We have an MRI scanner within our operating room, adjacent to the surgical table. Neurosurgeons begin the resection and remove as much of the tumor as we safely can. We then slide the patient on the surgical table directly into the MRI scanner to capture real-time images that may show us more tumor cells that can be removed during the same surgery. In years past, we acted conservatively, closed the surgical site, awaited new scans days later, and possibly subjected the patient to a second surgery. Multicenter studies and trials have shown that the extent of the resection is directly correlated to the patient's survival and time to the tumor's recurrence. As such, removing as much of the tumor as possible in the first surgical procedure is greatly beneficial to the patient.

There are numerous issues associated with transporting an anesthetized patient to different floors or rooms of the hospital for imaging. Many are quite a distance away. With our MRI immediately adjacent to the surgical suite, and the patient not even having to be moved from the operating room bed, we can preserve sterility, maintain the anesthesia circuit and obtain real-time imaging read promptly by specialized neuroradiologists to inform next steps of the surgery. It is a much safer experience for the patient.

Another innovation that helps us achieve the best possible outcomes for patients with brain tumors involves procedures done while the patient is awake. If a tumor occurs in a relatively silent area of the brain, we can often get a wider margin around it and remove more. This is more complex when the tumor occurs in a critical portion of the brain, for instance, near the speech area or primary movement area. When patients are awake during surgical procedures a– meticulously overseen by specialized neuroanesthesiologists to ensure the patient is safe and feels no pain – they can interact with us and guide our path. For example, we ask patients simple questions to keep them talking or instruct them to perform simple movements as we stimulate the brain during surgery. When they stop talking or stop moving, we know we’re in an area of the brain that we must preserve.

We also use fiber-tracking to take advantage of the truly phenomenal imaging capabilities we have today with MRI and functional MRI. With a technique called diffusion tensor imaging, we can see all the nerve fibers around a brain tumor. The surgical team can precisely see how much of the tumor we can remove without damaging the critical motor fibers. This view is beamed into our microscope field so, as we're operating, we can see and carefully avoid the fibers. Without this high-tech view, the fibers appear as normal brain tissue.

Advanced brain tumor care requires a comprehensive approach by a large number of people who specialize in all aspects of cancer care and supportive care. From the neurosurgeon to the neuro-oncologist and radiation oncologist to the neuroradiologist to the neuropathologist, neuropsychologist and neurorehabilitation specialist and so many more critical contributors, a highly experienced, highly focused team is essential. Together, we strive not only to remove tumors and eliminate cancer, but also to preserve and optimize quality of life after brain surgery.

This is a very special high-tech, high-touch program.

Advances in brain tumor surgery invite more opportunity to hope than ever before. Surgery is an important first step in many cancer care journeys, but is just a first step. Advances in surgery, chemotherapy, radiation therapy, research and clinical trials all suggest a much more hopeful future. Our team stands with our patients and their families every step of the way.

Dr. Camarata's clinical practice is focused on brain aneurysms and other vascular disorders of the brain, skull base surgery, brain tumor surgery and epilepsy surgery. His specialties include cerebrovascular surgery, cervical spine surgery, epilepsy surgery, frameless stereotactic surgery and lumbar spine surgery.