Brain, Skull Base & Pituitary Tumors Programs

INCIDENCE AND PREVALENCE

According to the National Cancer Institute, approximately 23,880 adults will be diagnosed with a primary malignant brain tumor in 2018.1 Metastatic brain cancer will affect a larger number of individuals, though estimates widely vary.2 While approximately 13,000 individuals in the U.S. are diagnosed with pituitary tumors annually, fewer than 1% of these are malignant.3

PROGRAM OVERVIEW

Hoag Family Cancer Institute, in collaboration with Hoag Pickup Family Neurosciences Institute, offers unique multi-modality diagnostics and treatment services for patients suffering with primary brain tumors, metastases to the brain, pituitary tumors and other neoplasms and invasive tumors of the complex skull base region. This program aligns neurosurgeons, ENT surgeons, neurologists

neuro-ophthalmologists, neuro-oncologists, radiation oncologists and physicists, neuro-radiologists, pathologists and endocrinologists who are committed to providing the latest and most effective diagnostic imaging studies, surgical techniques, clinical research and coordinated management strategies for each patient. The program is comprehensive, offering both craniotomy and stereotactic radiosurgery, minimally invasive surgical approaches, access to advanced therapeutics, as well as Gamma Knife and Cyberknife stereotactic techniques.

The Brain Tumor Program is led by Medical Director Christopher Duma, M.D., F.A.C.S., a board-certified neurosurgeon and a fellow of the American College of Surgeons. Robert Louis, M.D., who is boar d-certified in neurosurgery and fellowship-trained in complex cranial surgery and minimally invasive skull base and pituitary surgery, leads Hoag’s Skull Base and Pituitary Program.

DIAGNOSTICS

Hoag Pathology provides full support for intraoperative evaluation and diagnosis of brain, pituitary and skull base tumors as well as brain metastases. A dedicated pathologist provides specialized expertise to the program. Tumor molecular genomic profiling is available for patients with gliomas to help clinicians select the most effective treatment. Patients’ brain cancer samples are sent for genomic profiling and bioinformatic analysis to Caris Life Sciences, and the results of the genomic testing are presented and discussed for clinical relevance at the Neuro-Oncology Tumor Board.

MR brain demonstrates enhancing mass at the site of prior treatment indeterminate for recurrent cancer versus radiation necrosis while PET/MR reveals increased FDG activity within this mass confirming pr esence of recurrent cancer.

The full range of advanced imaging options are available to patients with brain, pituitary and skull base tumors through Hoag Radiology. Hoag is the first hospital on the West Coast to routinely offer PET/MR to patients. The revolutionary hybrid imaging technique is being utilized for patients with brain tumors who have had surgery or radiation to evaluate and differentiate between necrosis of tumor versus recurrent disease. PET/MR offers significant advantages over MRI alone in the differentiation of tumor recurrence and post therapy changes.

TREATMENT

Tumor Board

Hoag Neuro-Oncology Tumor Board is designed for all practitioners to present and discuss patient cases. It is attended by neurosurgeons, ENT surgeons, neurologists, neuro-ophthalmologists, neuro-oncologists, radiation oncologists, neuroradiologists, pathologists, endocrinologists, and the specialized nurse navigator.

The Neuro-Oncology Tumor Board is held every Friday at 11:30 a.m. at the Patty & George Hoag Cancer Center in Newport Beach and via videoconferencing at Hoag Cancer Center Irvine. It is moderated by Christopher Duma, M.D., F.A.C.S.

To submit a case for the Neuro-Oncology Tumor Board, contact Brain, Skull Base & Pituitary Tumors Nurse Navigator, Lori Berberet, R.N., M.S., at 949-764-6656 or [email protected] or Rosana Figueroa at 949-764-7044 or [email protected] Surgery Hoag’s neurosurgeons employ image-guided preoperative surgical planning as well as intraoperative navigational equipment to minimize impact on parts of the brain critical for motor, sensory, speech, visual and memory functions. The team also specializes in awake craniotomy.

Surgery

Hoag’s neurosurgeons employ image-guided preoperative surgical planning as well as intraoperative navigational equipment to minimize impact on parts of the brain critical for motor, sensory, speech, visual and memory functions. The team also specializes in awake craniotomy.

Whenever possible, Hoag’s neurosurgeons use minimally invasive surgical techniques employing some of the most advanced technology available including biomedical electronics, sophisticated neuronavigation systems, neuroendoscopic equipment and microsurgical tools. The majority of pituitary and skull base surgeries at Hoag are done through tiny incisions or utilizing naturally occurring orifices such as the nostrils.

Since 2015, minimally invasive neurosurgery has been guided utilizing the Surgical Navigation Advanced Platform (SNAP), by Surgical Theater, a system for planning and performing brain surgery that was developed and based on flight simulator technology for F-16 fighter jets. It allows for Virtual Reality 360-degree reconstruction, planning, rehearsal and navigation for complex neurosurgical procedures. Virtual Reality “fly-throughs” performed on each case, allow Hoag’s neurosurgeons to practice an operation in 3-D before ever picking up the scalpel. The tool optimizes minimally invasive approaches, smaller incisions, fewer complications, and better overall outcomes. In the two years since Surgical Theater was introduced at Hoag more than 700 surgical cases have been performed utilizing this innovative technology.

Surgery planning using Surgical Theater 3D Virtual Reality

Building upon the same platform, in 2017, EndoSNAP was introduced at Hoag. This provides the additional capabilities of Augmented Reality for endoscopic cases. The split screen view provided by the EndoSNAP gives the surgeon a “heads-up display” and allows for pinpoint accuracy and improved visualization of critical structures. Hoag remains the only center in California and ranks as the second highest volume center in the nation to use Augmented Reality in Neurosurgery.

Medical Oncology

Medical oncologists affiliated with the program have a specialized focus on brain, pituitary and skull base tumors and stay up to date on the newest research and therapies. Hoag was an early adopter of Optune, a wearable device that creates low-intensity, wave-like electric fields for the treatment of glioblastoma multiforme (GBM). Specialized training is required for physicians to administer the treatment; Hoag implemented the use of Optune soon after its FDA approval for patients with recurrent GBM and as first line therapy in combination with chemotherapy.

The implementation of reflex tumor molecular genomic profiling for brain tumor patients has resulted in the identification of molecular targets to help oncologists direct therapy in cases of disease progression. In some cases, off-label immunotherapies including pembrolizumab and nivolumab are being used to treat recurrent disease.

Radiation Oncology

Hoag offers all three radiosurgery options for the treatment of brain tumors – Gamma Knife Radiosurgery, Cyberknife®, and TomoTherapy® – ensuring patients receive the most appropriate and effective treatment for their unique case.

Hoag offers Gamma Knife® Perfexion, which is the most advanced radiosurgical device available and targets brain tumors with half a millimeter accuracy. An expanded and specialized treatment area in Hoag’s Marilyn Herbert Hausman Advanced Technology Pavilion optimizes the patient experience. Hoag’s Gamma Knife team includes neurosurgeons, radiation oncologists, physicists, and specially trained nurses.

Stereotactic radiation therapy can also be delivered in fractionated form using Hoag’s advanced technologies in cases where single treatment radiosurgery is not indicated. Hoag radiation oncologists meet weekly to discuss the most appropriate treatment modalities and have expertise in utilizing both radiosurgery and stereotactic radiation therapy techniques.

CLINICAL RESEARCH

Through Hoag Family Cancer Institute’s Developmental Therapeutics Program, in alliance with USC Norris Comprehensive Cancer Center, patients have access to clinical trials not typically offered at community hospitals. For an up to date list of open trials, please contact Leila Andres, M.S., at 888-862-5318.

SCREENING AND HIGH RISK SERVICES

It is estimated that up to 10% of all brain tumors (malignant and benign), occur because of a hereditary syndrome. In contrast to other hereditary cancer conditions, those involving brain tumors/brain cancer almost always involve more than a single tumor diagnosis. Conditions involving hereditary brain tumors include: Li Fraumeni syndrome, Lynch syndrome, familial adenomatous polyposis, neurofibromatosis types 1 and 2, Cowden syndr ome, von Hippel-Lindau and tuberous sclerosis. Hoag Family Cancer Institute’s Hereditary Cancer Program offers genetic counseling and genetic testing.

SUPPORT AND EDUCATION

Hoag’s Brain Tumor Support Group offers education and support for anyone diagnosed with a primary brain tumor or metastatic disease. The group meets monthly and is beneficial for patients, family, and friends.

The Program’s specialized nurse navigator, Lori Berberet, R.N., M.S., is a vital member of the team, providing guidance and navigation to patients with brain, pituitary, and skull base tumors throughout their treatment.

Hoag Family Cancer Institute’s range of Integrated Cancer Support Services help patients address the emotional, physical, spiritual, social, and financial challenges that accompany a cancer diagnosis.

Hoag is also designated as a teaching center for Stereotactic Radiosurgery for the UCI Neurosurgical Residency Program annually. It is a three-month rotation, approved by the Board of Neurologic Surgeons. The program director is Christopher Duma, M.D.

1 Surveillance, Epidemiology, and End Results Program of the National Cancer Institute, https://seer.cancer.gov/statfacts/html/brain.html
2 National Brain Tumor Society, Braintumor.org
3 Cancer.net, The American Society of Clinical Oncology (ASCO)

For more information call: 949-722-6237