Brain Tumor Program

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

Pickup Family Neurosciences Institute, in collaboration with Hoag Family Cancer Institute, offers unique multi-modality diagnostics and treatment services for patients suffering with primary brain tumors, metastases of 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.

The full range of advanced imaging options is 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

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 V irtual 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, with 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.

Upper left: MR of benign brain tumor (arrow), and surroundings, the dark zone on the MRPET color image indicating edema only, as compared to lower images of another patient showing recurrent malignant tumor with combination of edema and tumor infiltration on the MRPET

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.

Neuro-Oncology Clinic

The Hoag Neuro-Oncology Clinic provides state-of-the-art treatment for patients with cancers of the brain and nervous system. Physicians Santosh Kesari, M.D., and Jose Carrillo, M.D., provide expert care for patients that are diagnosed with malignant brain tumors and endure neurologic complications from cancer or cancer therapies.

Our team of skilled and experienced physicians participate in a multidisciplinary treatment approach working with neurosurgeons, radiation oncologists, neuropathologists and neuroradiologists to plan a course of treatment that is unique and comprehensive for each patient.

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.

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.

Surgery planning using Surgical Theater 3D Virtual Reality

Surgery planning using Surgical Theater 3D Virtual Reality

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]

Hoag Survival Rates Compared to National Average SEER 2007-2013

Hoag Survival Rates Compared to National Average SEER 2007-2013 bar charts

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.

Cyberknife is a non-invasive robotic radiosurgery system that can be used to treat both neurological sites (i.e the brain and spine) as well as tumors throughout the body. Because of its unique engineering and freely moving robotic arm, it can target tumors from hundreds of angles with submillimeter accuracy. In 2018, the Cyberknife at the Newport Beach Radiosurgery Center/Hoag Hospital (NBRC) continued to be quite busy, treating hundreds of cancer patients from referral centers across Southern California. Of these, 114 were neurosurgical cases; 101 intracranial and 13 spine. Because of the Cyberknife’s ability to treat extracranial lesions, both brain and spine tumors (malignant and benign alike) are included in these figures. Dr. Amanda Schwer, a Hoag-affiliated radiation oncologist, is the medical director for the Cyberknife at NBRC.

Clinic 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 syndrome, 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)

To learn more, visit the Brain Tumor section or call 949-764-6066.