Scott Webb: The East Side Neuroscience Institute is a partnership between Evergreen Health and Over Lake Medical Center to provide world class care right here on the east side. Today we're here with top experts from the East Side Neuroscience Institute to discuss how physicians create individualized care for the surgical management of tumors involving the brain and spine. Today we have neurosurgery specialists, Dr. Amitoz Monhas, Ryder Gwinn and Dustin Hayward on the program. Doctors, thanks so much for your time today. I was just mentioning that we're gonna talk about brain tumors and treatment options and all this really interesting stuff. So it's so great to have your time. Great to have your expertise. And Dr. Monhas, I'm gonna start with you. What are the technological advances in brain tumor surgery?

Dr. Amitoz Manhas: To talk about technological advances is first to recognize that a lot of what we do in brain surgery has not changed conceptually. We are still looking to do what we can to preserve and hopefully improve neurological functioning and to establish diagnoses for conditions that need to be treated. But some of what has improved over time is our visualization and our ability to access, , different pathologies through smaller opening. So one example is being able to use an endoscope. We have traditionally used microscopes. We now can use endoscopes to enter small corridors, through what we call either the skull base or through small openings over the skull into fluid spaces in and around the brain.

And that allows us to get up close and able to basically attack some of these conditions through the use of an endoscope. So that's one advancement that has happened, and has become more widespread over the last few years. Another, approach is through tubular retractors. That is something that is still not as commonplace, but, , that is a way to access pathology is deep in the brain, through working channels, very much like is being used in the spine. So that's another way of accessing. Another interesting way to visualize tumors is through the use of markers that can be picked up by the tumors.

So, , for example, fluorescein. A type of chemical that can b e injected into the body , and can be absorbed by the body. And it can accumulate in parts of the brain where brain tumors exist, and that can be visualized under the microscope. So those are some examples. , we also have some interesting technologies coming our way. I know Dr. Gwinn is utilizing laser interstitial thermal therapy and he could probably talk to you more about that. We do awake craniotomies in our system. This is something that has been done for a long time, but it's using real time feedback from patients.

And we use neuro electrophysiology to monitor critical structures in the brain during brain tumor resection. It allows for maximal safe removal of tumors, so there's a lot of exciting things being done , in terms of surgery. There's also a lot of molecular genetics that. Have evolved and that has led to, treatments on the medical side of things after tumor surgery, after we've either done a biopsy or resection, we've been able to target tumors and treat them effectively based on their molecular genetics. So that's another technological advancement.

Scott Webb: Yeah. And Dr. Gwinn, Dr. Monhas mentioned their lasers, so that always gets my attention. Anytime one of our experts talks about lasers, I'm all in for that. So let's talk about lasers and other things, but basically, how has treatment evolved over the past 10 years or so?

Dr. Ryder Gwinn: Things have been evolving in tumor surgery over more than 10 years, really a hundred years. But like Dr. Monhas said that the goals are still the same., but I would say the biggest. Kind of innovations beyond the technology, and we'll talk more about that is, one that, you know, we're really taking a team approach now to, both diagnosing and treating tumors. We know that as surgeons we're an important part of the team, but there's really just a whole host of other folks involved.

From radiologists to medical oncologists, to radiation oncologists and we have nurse navigators who can help kind of guide people throughout the whole process and help a lot of the coordination that has to happen with follow up visits and everything. So team approach is very, very important. Dr. Monhas talked about the genetics, , understanding of tumors that have really been helpful in both predicting how likely a tumor is to recur and also how likely it is to respond to an individual chemotherapy agent or type of treatment, whether it's surgery or radiation or chemotherapy. Really there's been advancements in anesthetic protocols.

So we're much more comfortable operating on patients, who might have swelling in the brain. , from their brain tumors or in particularly if we want to help protect their vital functions like speech or vision or memory or motor functions. We can now much more easily have them awake and be comfortable in the operating room and be able to map out these functions in the operating room so that we can then protect them as we're going in to get that tumor out.

As Dr. Monjas had mentioned this laser interstitial thermal therapy is one pretty large advance in terms of both minimizing the footprint of our surgery and also accessing parts of the brain that were not easy to access at all if even possible in the past. And this is a really neat. Technology where we can make a very small hole in the skull, maybe three millimeters wide, about a pencil head. And then introduce a laser fiber into the brain, and then we can then take them to the MRI suite and then turn on that laser energy and watch where the brain is heating with that laser energy.

And so we can make sure that we're treating exactly the right area and to the exact extent that we want to. And this has now given us access to virtually any part of the brain to treat tumors with tumors that were thought to be inoperable in the past. Now we have a tool that can help us do that. , and then I think just personal expertise has really been developing, particularly at Eastside Neuroscience Institute over the past five years or so. We have three tumor surgeons that each have a little bit of a different, expertise and. interest that contribute to getting the best outcome for our patients.

Dr. Hayward does a lot of cerebrovascular surgery, so he operates on people with aneurysms in addition to tumors and really knows how to take out a tumor that might be wrapping around a blood vessel that it would be very dangerous otherwise. He also can approach tumors using the arteries of the body to place catheters up to where the tumor is, and then fill those tumors with agents that cut off the blood supply. And that makes the surgery much faster and much safer. If we can go in there knowing that the vast majority of that blood supply, the tumor has already been taken away.

Dr. Monhas has done a fellowship in skull base surgery and has very specific, small openings that he can make, including the endoscope that he was talking about to go through the nose. But tumors that are stuck to the skull base or rapped aound cranial nerves can be very, very difficult to treat unless you have a lot of expertise. And then myself, I've been taking care of patients with tumors and epilepsy for about 20 years. And really feel very comfortable around, patients that have tumors near eloquent parts of the brain. So if it's near where their language centers are or their vision, Very used to having patients awake in the operating room and being able to test those functions before removing that tumor.

,Another big advancement that I haven't really talked about yet is in imaging and our ability to figure out not just anatomically where a tumor is in the brain. But also functionally, even before we get to the operating room, we can figure out where their motor function is, their language function. And we can even look at kind of the cabling pathways in the brain that connect one area of a brain to another and know whether or not those fibers are going through the tumor or around the tumor, which really gives us a great roadmap before we go into the operating room to say, okay, this is the best avenue to get to the tumor without interrupting any vital function.

Scott Webb: I'm just over here Dr. Gwinn, I was listening to you the whole time just sort of shaking my head thinking, well, that no, you can't do that. The tumor wrapped around a, blood vessel. No. You just call it a day. What are you gonna do with that? But Dr. Hayward, you know, you're going in and you're doing biopsies, right? And you're using the technology, using your expertise, the team approach. All of this. Maybe you can tell us more about that. Talk more about the process of biopsy in treatment and who's involved to ensure the really timely care of patients.

Dr. Dustin Hayward: That's a great question and I think I'm following up, on two really excellent responses. So I'll try to bring a couple of new dimensions into the question, which I think is really kind of asking, you know, what happens after we get tissue? What happens after we get that biopsy? Or we resect that tumor and, what are the stages, that our patients can expect after that? And the networks of support that we use to make sure that they are connected with the best clinical care available in the 21st century. And our institute has a long and very close relationship with the Seattle Cancer Care Alliance.

And through them we have dedicated neuro-oncology, , doctors , who receive our patients. You know, after we've don e the operation, utilizing all the technologies that we've talked about and the expertise that we bring to the table, the patient, then will see a neuro oncologist that will design a treatment. And not just neuro oncologists, but radiation oncologists, if there's an indication for them to be involved to really put together a treatment plan that's individualized and based on the best technology that we have to offer. We also through the ACA have access to clinical trials.

If the patient meets the criteria, For a clinical trial, then a lot of times we're able to connect them with, the trial that best suits them. And then, also, directly from the operating room. We send the tumor specimen to our pathology team. And the pathologists not only use traditional techniques, like histology, meaning they look at the tissue and the cells underneath the microscope with different stains and things like that to really kind of differentiate what type of tumor it is. But then also we're using, molecular techniques and genetic profiling to really figure out exactly what this tumor is down to its most basic level and also what treatments it's most likely to respond to.

So between, you know, this network of neuropathologists, neuro oncologists and, radiation oncologists, we're really able to provide every type of service that our patients might need. In an efficient, way. It's a lot of things to keep straight and we navigate the patient through the system and we actually have dedicated nurse navigators that help take the patient, , through the system and to all these providers, to make it as easy as possible. So, in the end nobody wants a brain tumor obviously , but I think at ENI we're able to really provide the care and the services that make as stress free as it possibly can be. So, that's our system and how we have things arranged.

Scott Webb: Dr. Manhas, it's come up a couple of times here today, just that there's a diversity of neurosurgical techniques, that are available to all of you, your toolboxes, runeth over, if you will, with ways to attack brain tumors, and help patients. So maybe you can talk about some of the techniques, why it's important to consider all these different options, and that, you know, the luxury of having so many options?

Dr. Amitoz Manhas: Our goal is to maintain and hopefully improve a patient's neurological level of functioning. Help them recover as soon as possible, so that they can have further care if they need it. And then the third component is establishing a diagnosis and achieving maximal safe resection. And that's different for each patient and for each anatomical situation. So if we talk about actual techniques., our goal is to work in corridors in and around the brain where we're not as likely to harm the brain, the nerves, the vessels in the region of the brain tumor. We try not to retract on the brain.

We try to do surgery without retractors and use gravity and other naturally occurring phenomenon, to reach the tumor. And the other thing that Dr. Gwinn touched upon, is basically avoiding eloquent or areas of the brain that are very important and cannot be disrupted, or else it would lead to permanent deficits. So while that risk might still exist, we can find corridors again, even within the brain, through the brain by avoiding some of these, important fibers in the brain. So putting that all together if we can avoid any further injury to the brain or any other, problems from occurring,, those kind of summarize our techniques essentially.

Scott Webb: Yeah. Well one of the things that I've really appreciated today is having three experts like yourselves on, is that you all have a way of explaining things that even I can understand. You know, lay people can understand. You've taken us through this highly complex work that you do. , figuring out tumors and the best way to biopsy them and the best approaches and trying not to do more damage in the process, right? As small as sort of footprint like we're gonna get this tumor outta there and you'll never know we were there for the most part. It's just really amazing. Has me always shaken my head when I speak to the East Side Neuroscience Institute Docs. So thank you all. Thank you so much and you all stay well.

Dr. Amitoz Manhas: Thank you.

Dr. Ryder Gwinn: All right. Thank you very much.

Dr. Dustin Hayward: Thanks for having us. Thank you.

Scott Webb: The East Side Neuroscience Institute helps improve the quality of life for people in need of individualized care for your brain or spine tumor diagnosis. To learn more, visit eastsideneuroscienceinstitute.org.