Brain Tumor Treatments & Surgery
Cushing Neuroscience Institute’s renowned Brain Tumor Center offers progressive brain tumor treatments for a wide spectrum of brain tumors that affect both adults and children. Our unique team consists of pioneering neurosurgeons, neurologists, neuro-radiologists and other specialists working on the leading edge of medical technology and innovative procedures to bring patients safe and effective treatments.
Leksell Gamma Knife® Perfexion™
To complement its existing stereotactic radiosurgery program, the North Shore-LIJ Health System installed the Leksell Gamma Knife® Perfexion™, earlier this year at its Center for Advanced Medicine in Lake Success, NY. With the addition of this technology, our multidisciplinary team of experts is able to provide patients with the most comprehensive options for minimally invasive treatment of neurological conditions at a single location.
Neuronavigational Treatment Options for Brain Tumors
Neurosurgeons have the ability to bring images of the patient's brain into the operating room to guide surgical approaches. Any digital scan — CT, MRI or PET — can be loaded onto a workstation in the operating room. When needed, multiple image sets can be fused, using a process known as registration. Using specially-placed skin markers or the patient's own anatomy, the image information is matched to the patient. This allows the surgeon to touch any point in the surgical field and see that point displayed on the workstation screen. With this information, the exact contours of a tumor can be mapped before surgery.
Compared to older techniques based on scalp landmarks, this method of surgical navigation greatly improves the accuracy of cranial approaches, allowing for smaller incisions and putting less "eloquent brain" at risk. The "eloquent brain" refers to the parts of the brain that allow you to interact with and process the world, via your senses, motion, language, memory and the purposeful use of tools.
While the use of surgical navigation has been an important advance in brain tumor surgery, its utility is limited by the phenomenon known as brain shift. Whenever the brain is exposed, cerebral spinal fluid (CSF) is lost. Additionally, when tumor resection is begun, the position of the surgical field can shift by centimeters, compared to the pre-surgery position. Brain shift makes it potentially hazardous to rely on preoperative images to determine the location of residual tumor. The only way to deal with brain shift and maintain accurate neuronavigation is with intraoperative imaging. For brain tumor surgery, this is best done with intraoperative MRI (iMRI).
North Shore University Hospital houses the PoleStar® Surgical MRI System, a compact, mobile iMRI. The PoleStar® Surgical MRI System was designed specifically as a tool for intracranial surgery. The compact design and low field strength of the iMRI allow it to be docked under a regular OR table, so that the full range of regular surgical instruments can be used. Images are acquired by raising the magnet to scanning position. When brain shift occurs during surgery, a new image can be acquired, and surgical navigation is then done with the updated information.
Stereotactic radiosurgery (SRS) is a form of minimally invasive surgery using radiation. During SRS, a high dose of radiation is delivered to the tumor in a highly focused manner, minimizing damage to the surrounding brain tissue. SRS has been helpful in treating small tumors located deep within the brain. It is becoming the treatment of choice in patients with many, small benign or metastatic brain tumors.
While SRS is normally applied between one and five sessions, some patients will benefit from stereotactic radiotherapy (SRT), which is administered in more sessions over a longer period of time. Stereotactic radiotherapy is a form of radiation therapy that focuses high-powered x-rays on a small area of the brain without affecting adjacent healthy tissue,
The Center for Stereotactic Radiosurgery at North Shore-LIJ features the Novalis® system, a state-of-the-art treatment device for patients undergoing SRS or SRT. During treatment, Novalis steadily moves around the patient’s body so that the radiation penetrates the tumor or lesion from different angles. The tumor receives the prescribed radiation dose, while surrounding structures receive very little.
With Novalis, the radiation beams are shaped to match the exact contour of the tumor or lesion so that even irregularly shaped tumors can be safely treated with SRS. Sophisticated software calculates the ideal access points to the tumor or lesion and defines the treatment plan. All treatments are done on an outpatient basis by a multidisciplinary team that includes a neurosurgeon, radiation oncologist, medical physicist, radiation therapist and dedicated nurse.
For many patients, radiation therapy (RT) rather than stereotactic radiosurgery (SRS) will be preferred. These include patients with newly diagnosed high grade gliomas and those with more than four metastatic brain tumors. State-of-the-art RT, while treating larger tumors than SRS and over more sessions, also strives to limit radiation delivery to the areas of the brain necessary to achieve tumor control.
For some patients, stereotactic radiation therapy (SRT) affords the advantage of a full course of RT — the avoidance of side effects afforded by fractionating the treatment — combined with the precise delivery of stereotactic technique. The Novalis system is uniquely designed to offer the full gamut of SRS, SRT and RT, as determined by the needs of each individual patient.
Surgical Treatment Options
Surgery is often the first step in the treatment of brain tumors. The goals of brain tumor surgery are to:
- Confirm the diagnosis by obtaining a specimen of the tumor (biopsy) for a neuropathologist to analyze, and
- Remove as much of the tumor as is safely possible (resection). Brain tumor surgery can be done via craniotomy or stereotactic biopsy.
This minimally invasive procedure can be used to obtain a diagnosis in certain patients, either before proceeding with a craniotomy or instead of a larger procedure. For patients with tumors deep in the brain or for those for which a craniotomy and resection (surgical removal) is otherwise not indicated, stereotactic biopsy is an ideal choice to identify the exact type of tumor. Biopsy can be done using a stereotactic frame or surgical navigation. Intraoperative MRI has some unique advantages for stereotactic biopsy, including the ability to confirm that:
- the biopsy is taken from the desired target
- critical structures are avoided, and
- no intracerebral bleeding has occurred during the procedure
A craniotomy (temporary opening of the skull) is done when the plan is to remove the tumor. The goals of surgery are to:
- confirm the diagnosis
- remove as much of the tumor as can be safely done, and
- cure the patient of his or her tumor, if possible, by surgery alone.
This can be done for certain persons who have benign tumors, especially those that press in on the brain rather than grow within it (such as certain schwannomas, meningiomas and pituitary adenomas).
Preservation of neurological function is facilitated by technical advances such as functional MRI (fMRI). This imaging technique processes data acquired while patients perform simple tasks, such as finger tapping. Different areas of the brain, such as the primary motor or visual cortex, Broca’s area and Wernicke’s area can thereby be imaged. This information can be used to plan brain tumor surgery in advance or during the procedure itself. Diffusion tensor imaging (DTI) uses a different MRI technique to identify white matter tracts; this data can be used in the same fashion as fMRI.
When language function is at risk during surgery, it is possible to perform brain tumor resection (surgical removal) with the patient awake. Local anesthesia and intravenous sedation are used as the incision and skull are opened and closed. Since the brain has no pain sensation, the patient can be completely awake during the tumor resection. Brain mapping, done with a neuropsychologist, identifies areas of the brain where surgery can be done without risk of impairing a patient's language function. The precision of brain tumor surgery has been greatly increased by the use of surgical navigation technologies, in particular intraoperative MRI.
In addition to maintaining neurological function, craniotomies are planned with cosmetic appearances in mind. Brain tumor surgery aims to return the patient to a normal, active life as soon as possible.
Continuing Research Efforts
The internationally renowned experts at the Brain Tumor Center are constantly pursuing new avenues of clinical research that will improve the patient's lives. Underway is the further development of tools to ensure that laser fibers can be inserted with the highest accuracy through small incisions in order to treat the tumors. Extensive research in stereotactic radiosurgery focuses on using this technique to treat metastatic tumors, avoiding whole-brain irradiation and subsequent memory loss, as well as defining the ideal dose and treatment schedule for patients with benign brain tumors. Combined with iMRI, these methods represent state-of-the-art excellence in brain tumor surgery and exemplify the important link between research and surgical applications for better treatment.
Make an appointment at our Brain Tumor Center
Cushing Neuroscience Institute’s Brain Tumor Center makes it easy for you to take the first steps in ensuring the best neurological care for yourself or your family. Simply email us at firstname.lastname@example.org, call us at (516) 941-1260 or fill out our Request an Appointment form.