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Treatment Options for Aggressive Brain Tumors

Glioblastomas are the most common – and most aggressive – type of brain tumor.

What treatment options are available for patients with these fast-growing tumors?

Dr. David Schiff discusses the comprehensive treatment options available at UVA Health System, including Gamma Knife surgery, TomoTherapy, chemotherapy and clinical trials investigating potential new treatments.
Treatment Options for Aggressive Brain Tumors
Featured Speaker:
Dr. David Schiff
Dr. David Schiff is the co-director of the UVA Neuro-Oncology Center. His specialties include clinical trials for malignant brain tumors and the management of neurological complications of cancer and its therapies.

Organization: UVA Neuro-Oncology Center
Transcription:

Melanie Cole (Host): Glioblastomas are the most common and most aggressive type of brain tumor. What treatment options are available for patients with these fast-growing tumors? My guest is Dr. David Schiff. He is the co-director of the UVA Neuro-Oncology Center. Welcome to the show, Dr. Schiff. Tell us what is a glioblastoma, and what makes this tumor so harmful to patients?

Dr. David Schiff (Guest): Melanie, glioblastoma is a type of cancer that originates in the brain substance] itself. Many brain tumors are secondary, meaning they've spread from other organ sites in which the tumor originated. For example, people with lung cancer, breast cancer, kidney cancer can have tumors spread to the brain, and we call that brain metastasis. But glioblastoma is a cancer that arises from the supporting cells in the brain itself. There's roughly 10,000 to 12,000 diagnosed each year in the United States, and there is a number of things that make them very tough to treat. One, of course, is the real estate, the location in the brain, because there are many parts of the brain that are absolutely crucial to our functioning. Another very important reason these are such difficult tumors is that even when the tumors look well localized or circumscribed on the brain, and if they're favorably located, perhaps the surgeon can remove the visible tumor, the problem is that these tumors invariably put out little microscopic fingers or tentacles into the surrounding healthy brain. These tentacles are invisible, the surgeon can't see them. And unlike some other parts of the body where the tumor can take some extra tissue around the tumor—a margin, as we say, try to be on the safe side—it's just not feasible on the brain. So even when these tumors are favorably located and the surgeon is able to do a great job with it, there's always tumor cells left behind after surgery.

Melanie: Now, Dr. Schiff, people, they get headaches, and right away this is the kind of thing that they worry about when they get headaches. Tell us some of the symptoms, something that might send somebody to the doctor to check for such a thing. It's pretty scary, and people want to know what might they feel.

Dr. Schiff: Well, fortunately, almost everybody in the world has had a headache at one time or another, and many of us get headaches pretty frequently. Fortunately, only a miniscule fraction of all the people with headaches have headaches related to brain tumors. Probably about a third of patients with glioblastoma initially come to medical attention because of headaches. So headaches certainly can be a sign of brain tumor, though as I said, in the world of people with headaches, brain tumor's a very uncommon cause. I think the big thing to keep in mind is that a change in a long-standing headache pattern or the new development of headaches in an adult, particularly someone who's middle aged or elderly, may warrant some attention. Headaches are one symptom. Other symptoms include things like personality change. People just sort of losing interest in their favorite activities and kind of being a little bit like a bump on a log, withdrawn. Sometimes people present to medical attention because of some weakness or clumsiness on one side. They may have some facial drooping or slurred speech. They may start dropping objects with a hand. Sometimes vision on one side is impaired so that people may bump into objects on one side or the other. These can all be -- and occasionally, related to that, people may start to have driving accidents because they're not seeing things on one side of the road. Those are the sorts of stories that patients in our clinic typically come in with.

Melanie: So maybe loss of vision and changes in personality, behavior. So now they've come to see you and you've diagnosed them. Now, what are some of the treatment options that are available—surgery, chemotherapy, radiation? Because you've described those fingers, and maybe margins are not able to be gotten. Explain what the surgeries are like and then what they can expect after.

Dr. Schiff: Right. The first thing is typically, as a patient, by the time he or she comes to us, they've had a CAT scan or an MRI that shows something that looks like a lump in the brain, and they come to me and my neurosurgical colleagues and we have to figure out what the next step is. Sometimes we suspect that the lump is a glioblastoma. Sometimes we're honestly not sure. We usually have an idea whether it's a tumor or not, but there are other types of tumors, as I mentioned. So the first step is to make sure there's no obvious sign of tumors elsewhere in the body. So if somebody has a history of cancer, we examine them, and sometimes we may get a chest x-ray or a CAT scan of the chest and abdomen to make sure we don't see any tumor there, to make sure that isn't, what with the lump in the brain, it doesn't represent spread from elsewhere in the body. Once we've done that—and we are assuming we don't see anything suspicious below the neck—then the next step is to make a diagnosis to get tissue from the lump in the brain. And there, it really boils down to should the surgeon make an attempt to remove as much of the tumor as can safely come out, or is the tumor located in such a delicate place that only a biopsy can be done. That's a decision ultimately that's up to the surgeon in discussion with the patient, because sometimes, if there's potential risk of doing a more aggressive surgery, obviously, patients need to be involved in the discussion as to how much risk they're willing to tolerate.

Melanie: So at the UVA Neuro-Oncology Center, what treatment options are you offering?

Dr. Schiff: Well, the tumor neurosurgeons and the medical neuro-oncologists like myself, we don't do surgery but choose from the other therapies available. We generally see the patients together at the same time in-clinic, and we figure out first what the surgical approach should be. Now, if the patient has undergone total or partial removal of their tumor or has only had a biopsy, the next step, we generally have to wait a few days for the pathologist to do their work with the specimen to render a diagnosis, and then we meet together with the patient and the family to discuss the diagnosis and to discuss treatment options. A couple of things about the surgery, there are some bells and whistles that can be done to make the surgery safer and more effective. Among the things we do at UVA include, first of all, we have an operating room suite that has an MRI in it so that during the surgery, the surgeons can have the patient undergo an MRI to see if they've gotten everything that they want to get out of the brain before putting the skull back on and closing the skin and sending the patient to recovery. That can be very helpful in maximizing the amount of tumor that's safely removed. The other thing our tumor neurosurgeons do is they do functional mapping of the brain so that they can record signals from the brain while the patient is asleep in the operating room to make sure they're not taking out areas that are important for movement or sensation. They also have the ability to do what we call awake craniotomy—in other words, a surgery where the patient is put to sleep initially to have the skull opened, but the patient can be awakened for parts of the surgery so that the surgeon and psychologist and physiologist can test the patient while the patient is awake to make sure that areas of brain tissue that the surgeons would like to remove are not performing vital functions that the patient is not going to be happy about missing when he or she wakes up.

Melanie: Now, Dr. Schiff, in just the last 20 seconds, if you would, wrap it up about the center and give some hope out there to people listening.

Dr. Schiff: Right. Well, while glioblastomas are very aggressive tumors, our clinical focus has been on doing clinical trials of novel therapies to improve the outcome. In fact, two of the therapies tested here in the last five or six years, one of them being a vast.. one of them being the Novocure TTF device, have been approved by the FDA, so we have seen some real progress during our time here.

Melanie: Thank you so much. You are listening to UVA Health System Radio. For more information, you can go to uvahealth.com. This is Melanie Cole. Thanks for listening.