Transcription:
The Latest Multidisciplinary Approaches for Treating Brain Tumors

Prakash Chandran (Host): Brain cancer is relatively rare. But it’s one of the more challenging forms of cancer to manage. Finding a medical team that can provide a clear cut diagnosis and a personalized treatment plan is an important step to managing a complex condition like this. Which is why we are joined today by Dr. Navid Redjal. He’s the Director of Neurosurgical Oncology at Capital Health’s Center for Neuro-oncology, part of Capital Institutes for Neurosciences, a fellow of the American Association of Neurosurgical Surgeons and he’s a board-certified Harvard trained neurosurgeon. Dr. Redjal, it’s a pleasure to have you today.

Navid Redjal, MD, FAANS (Guest): Thank you for having me.

Host: I want to start with the basics around understanding what the symptoms of a brain tumor might be.

Dr. Redjal: So, that’s a great question. We all get headaches and things like that, but signs and symptoms of a brain tumor usually are persistent and progressive. What I mean by that is tumors, they don’t get smaller and their symptoms usually get worse over time and they are usually persistent and progressive.

For instance, headache that continues on and does not get worse, it continues to get worse and it gets progressively worse would be considered to be concerning for a possible underlying lesion. Usually headaches associated with brain tumors get worse when lying down, so it’s associated with increasing intracranial pressure. So, the kind of common headache associated with a brain tumor is worse when you wake up. It’s not always typical, but that could be associated.

Brain tumors also may affect certain locations in the brain and certain functions associated with those locations in the brain. For instance if a brain tumor is located in the speech area; then the patient would notice worsening speech difficulty that would be getting progressively worse. If the tumor is located in the visual cortex; then the patient would notice one side of vision can be more difficult to see. And then as you guys know, the brain is kind of hard wired such that the left side of the brain controls the right sided functions and the right side of the brain controls left sided functions. So, if you have a right sided brain tumor located in the motor cortex; then you would start to notice some left sided weakness.

Also, sometimes the brain tumors are located near cranial nerves. A very common brain tumor known as a vestibular schwannoma could affect hearing and dizziness. So, it always depends on where the location of the tumor is, but again, these symptoms are usually persistent and progressive.

And another common sign of a possible brain tumor is new onset seizures. But overall trying to emphasize symptoms that are persistent, progressive and progressively getting worse are more associated with a tumor rather than things that are transient, for instance I had a headache for a day or two and they got better, that wouldn’t be consistent with a brain tumor.

Host: You keep coming back to this whole persistent and getting more progressively worse. So, if I am waking up and that headache is getting worse and worse or my vision is getting blurrier and blurrier; there may be something that I may want to look into or get diagnosed. Is that correct?

Dr. Redjal: Exactly. So, that would lead you to get an imaging study like a CAT scan or an MRI in order to assess. Usually tumors, they don’t regress by themselves. They continue to grow and cause more swelling and over time, symptoms continue to get worse. They usually don’t get better.

Host: So I would go over to my primary care physician. They would probably refer me over to a specialist. Talk to me a little bit about the process of getting that MRI and then once for example, a tumor is detected; talk to me about some of the different treatment options.

Dr. Redjal: Sure. So, initially there’s different ways that brain tumors present. So, sometimes it’s like you said, having bad headaches, it’s not getting better and you kind of show up to your primary care and they get either a CAT scan or an MRI and they find a lesion. They send you to a specialist. The other way a lot of these lesions are discovered is a patient continues to get worse or has a seizure and comes to the emergency room and we see on the scan a lesion and what happens after that depends on especially the location. Sometimes it’s in an outpatient setting, sometimes an inpatient setting.

But the first thing we do is – usually what happens is a patient gets a CAT scan. A CAT scan provides information about swelling and hemorrhage and size of a lesion and then the scan that you really need to get fine detail of what the tumor looks like is an MRI of the brain with contrast. After that happens, there is a differential based on how that scan looks. So different types of brain tumors have different types of characteristics.

One thing I kind of want to clarify is differentiation between brain tumor and brain cancer. So, you can have a tumor. So a tumor is an abnormal growth of cells that continues to grow. And what differentiates a tumor from cancer is a cancer cell can invade and spread in the brain. So, for instance, there’s a lot of brain tumors that are considered relatively benign because they don’t grow and spread into the brain so that’s not considered cancer. There’s a very common brain tumor known as a vestibular schwannoma or acoustic neuroma is a brain tumor of the hearing nerve. That’s not considered cancer because it can’t spread into the brain.

Brain cancer on the other hand, these lesions are able to spread within the brain. Usually cancer in the brain doesn’t spread elsewhere; it basically continues to grow in the brain and cause massive effect and symptoms there. So, that’s one thing I want to initially just kind of differentiate. Having a brain tumor doesn’t mean you have brain cancer. Brain cancer is when a tumor can spread within the brain.

Host: I’m so glad that you made that distinction because that was actually the next question, I wanted to ask you. When you hear that someone has a brain tumor; you basically think oh my God, this is extremely fatal, and I’ve always made the assumption that it is cancerous. So, it’s kind of nice to hear that a lot of them like the ones that you are mentioning are benign. So, I want to get a little bit into when you do detect a brain tumor that is not cancer or that is not cancerous; how do you go about removing it? Is it a surgical option? Is it other types of treatment? Talk a little bit about that.

Dr. Redjal: So, that’s a great question. So, again, now we are falling into the class of tumors that are benign and so the first initial thing is when you find a lesion in the brain, and if it’s not causing symptoms; just like, I tell patients, just like a new mole you find on the skin; we sometimes initially follow these lesions. The options usually are to follow these lesions to make sure they are not growing. But if it has characteristics that are concerning; then we think about treating the lesion.

And treatment has come a long way in terms of where we were maybe 30-40 years ago. We have the ability to do surgery very minimally invasive approaches here at Capital and also, we have the capability of doing what’s called stereotactic radio surgery. And the system we have here at Capital is the CyberKnife system where you can kind of do focused radiation meaning right to the tumor. And this is in the benign case.

But in a case where we are concerned about cancer, for instance let’s say a patient comes in and has a new lesion with a lot of swelling and has concerning symptoms; our approach here at Capital is initially if there is a suspicion of brain cancer, we have a multidisciplinary approach here. I’m involved as a neurosurgeon. A radiation oncologist is involved. A medical oncologist is involved. The most common brain tumor that’s malignant in the brain is actually metastatic cancer. It’s a lesion that has come from elsewhere, from lung cancer, from breast cancer.

So, the first initial step when you are concerned about a malignant, a cancerous brain tumor, is to verify that it is not coming from somewhere else. So, as a team, we get everyone involved, the medical oncologist, radiation oncologist and we get scans of the chest and abdomen and pelvis. And for instance, if a lung lesion is found; sometimes we end up finding out if that’s a specific type of lung cancer and we treat based on that lung cancer. Sometimes the patient requires surgery. Sometimes the patient requires radiation. Sometimes the patient requires chemotherapy or targeted immunotherapy.

So, it really depends on the imaging study and the symptoms and kind of background.

Host: One of the things that you were saying there that is a relief to hear about what Capital Health offers is the multidisciplinary treatment and just the fact that you get a team together to rule out certain things or to really just figure out where in the body might be causing this brain tumor. So, we kind of briefly touched on what would happen if the tumor is benign. But let’s say that you detect something that isn’t benign. Talk a little bit maybe about what steps a patient might go through to treat it.

Dr. Redjal: So in the setting of brain cancers; the most common type of brain tumor brain cancer is metastatic cancer from elsewhere. For instance a lung cancer that’s gone to the brain. So a brain metastasis. Other types of common types of malignant brain tumors are glioblastoma which is also considered a brain cancer and in addition to that; CNS lymphoma. So, a great example of how these patients are treated differently is for instance in the news you probably heard that Jimmy Carter had brain cancer, but his cancer was he had melanoma and he had the melanoma go to the brain. So, his treatment was based on radiosurgery, so they did – they shot small radiation beams, targeted radiation beams to tumors and he was place also on systemic immunotherapy. And he made a good recovery.

So, that’s a setting where the multidisciplinary group based on the primary diagnosis of melanoma; the best treatment right now is to do radiosurgery which is the CyberKnife shooting it with radiation beams in a very focused, minimally invasive approach in combination with immunotherapy.

Host: Yeah, I’ve actually heard a lot of great things about the CyberKnife system. So, can you talk a little bit more about it?

Dr. Redjal: So, the CyberKnife system is a type of stereotactic radiosurgery and to kind of just back up and kind of explain what stereotactic radiosurgery is. So, in the past; a person would get a good dose of radiation to normal structures because of how the technology of radiation was. Stereotactic radiosurgery came into play such that beams of radiation can be focused to the exact site of where you want to treat, minimizing the radiation dose coming in and the radiation dose coming out.

Now the CyberKnife robotic radiosurgery system is unique in the sense that it’s a system that provides extreme accuracy and it’s an outpatient procedure that is completely minimally invasive. So, there is no – so how it works is patients come in to get treated. They get a special CT scan and they get a mask that is made specifically for them. And then they come back and up to one to five days of treatment where they come to the machine. They lay down flat and this robot moves and performs a very, very precise radiation to the tumor within 30-45 minutes of a treatment and the patient can go home.

We even had patients during lunchtime, would come get treated and go back to work. It’s very friendly to the patient and it really doesn’t allow for any significant change in their quality of life during their treatment. So, as technology has gotten better and better; we’ve become more precise and in terms of the treatments and stereotactic radiosurgery in general has changed the way we treat brain tumors for a large part.

The benefit of the CyberKnife system compared to other stereotactic radiosurgery systems is it is able to treat both brain and spinal tumors. So, it has that benefit. It’s a huge kind of change in how we treat brain tumors over the last 20 years and it’s becoming more and more used based on great data that’s showing better outcomes for patients, especially in terms of their quality of life.

Host: Yeah, that’s truly incredible just to know that there is such advancement in technology that allows you to go in on your lunch break to get something like so serios treated, it’s really mind-blowing. I wanted to ask you, in addition to the doctors, who else is involved in the patient’s care?

Dr. Redjal: The people who are – the support team in the Cancer Center is huge to have the successful outcome. But here at Capital, we are lucky to have a very strong supportive care service team. we have very strong nurse navigators, physician assistants, therapists, nutritionists, all who are involved and we are unique in the sense that a lot of these partake in our weekly multidisciplinary tumor boards where we discuss patients and if there is something that the patient needs on a nutritional level, or they just need more support; we have system in place in order for them to continue with that because the most important thing is if the patient wants to have a successful outcome, they need to have that support and some patients without that support will not have a good outcome regardless of if you are giving them the best therapies. And I think that’s one of the keys here at Capital. We have a very strong supportive care team.

Host: It’s so wonderful to hear that you have that comprehensive care at Capital. I’m curious as to if I were a patient, going through this; how often would I meet with the medical team or the support team during the course of my treatment?

Dr. Redjal: So, yeah that’s a great question. So, for brain cancer patients; it’s very important to kind of approach these patients on a multidisciplinary team fashion. Such that everyone is kind of on the same page where the patient is in treatment. And here at Capital, we are lucky that our medical oncologist, our radiation oncologist, the neurosurgeons are all housed within one hospital and one system. Such that a patient can come for their appointment the same day and see the radiation oncologist, the neurosurgeon, the medical oncologist, can see the nutritionist, can see the supportive care team and we do this in order to provide them with that kind of continuous, collaborative, multidisciplinary approach such that we are kind of all working together for the same goal, maximizing their quality of life and their quantity of life.

Host: Well thank you so much for educating us here today. I’m curious if anyone listening to this wants to learn more about the Center for Neuro-Oncology at Capital Health; where might they get more information?

Dr. Redjal: So, our website www.capitalneuro.org is great to kind of give you some more information and also, I’m sure you have our number for the Capital Institute of Neuroscience which is 609-537-7300. But one other thing that we always like to provide our patients is quick access to care so here at Capital also, one of the benefits is if a patient wants to be seen by a specialist; we are able to quickly accommodate that, and our cancer team is always aware that cancer patients value – we really value their time and we want them to get into see us as soon as possible.

Host: Well Dr. Redjal, thank you so much for educating us today on brain tumors and all the different treatment options offered at Capital Health. For everyone else listening for a referral to a board certified physician, please call Capital Institute for Neurosciences at 609-537-7300 or like the doctor said, go to www.capitalneuro.org. My guest today has been Dr. Navid Redjal. I’m Prakash Chandran. Thank you so much for listening.