1. Brain Tumors David A. Sun, M.D., Ph.D. Neurosurgery

2. Disclosures I have no relevant personal financial relationships I do not intend to discuss off- label/investigational use of commercial products/devices

3. Types of Tumors Primary brain tumors Brain tissue origin Secondary brain tumor Non-brain origin

4. Secondary brain tumors Non-brain origin = Cancer metastasis –Most common –25-45% of cancer patients Lung: >50% of all; most common in men Breast: Most common in women Melanoma: Highest propensity for brain –50% of melanoma patients develop brain mets; Multiple Renal Cell Colorectal Any primary can metastasize to the brain

5. Primary brain tumors Meningioma (35%) Glioma (30%) –Astrocytoma Glioblastoma –Oligodendroglioma –Oligoastrocytoma –Ependymoma Pituitary Adenoma (13%) –Within skull –Beneath brain Skin Skull Meninges Brain Neuron Astrocyte Oligodendrocyte Ependyma

6. Is this cancer?

7. Benign Slow growing Non-invasive Does not spread Less likely to recur Malignant Fast growing Aggressively invasive May spread distantly More likely to recur

8. Is this cancer? Meningioma Glioma BenignMalignant

9. Is this cancer? Meningioma Grade 123 92% 6%2% BenignMalignant

10. Is this cancer? Meningioma Grade 123 92% 6%2% Glioma Grade 1234 BenignMalignant

11. Is this cancer? Meningioma Grade 123 92% 6%2% Glioma Grade 1234 BenignMalignant Pilocytic astroctyoma (surgically curable) Glioblastoma (15 month median survival)

12. How do brain tumors cause problems? Mass effect –Tumor pushes on normal brain Local invasion –Tumors invade normal brain Microscopic Edema –Swelling of normal brain

13. Presentation Generalized symptoms and signs → Elevated intracranial pressure Headaches (50%) –New or different –Worsening over time –Worse on awakening, them improve –Other symptoms Seizures (30%) Cognitive change (30%) Personality change (25%) Nausea/vomiting (15%) Blurred vision/papilledema Lethargy

14. Presentation Focal symptoms and signs → site specific to location

15. Presentation Focal symptoms and signs → site specific to location; Personality Cognitition Expressive language Receptive language Incoordination Balance Vision Weakness Incoordination

18. What are our options? Surveillance –Serial MRI scans

19. What are our options? Surveillance –Serial MRI scans – Watch it

20. What are our options? Surveillance –Serial MRI scans Surgery –Biopsy Diagnose the tumor –Resection Diagnose the tumor Remove as much of tumor as possible

21. What are our options? Surveillance –Serial MRI scans Surgery –Biopsy – Pick a few weeds out Diagnose the tumor –Resection – Pull as many weeds as possible Diagnose the tumor Remove as much of tumor as possible

22. Surgery

24. Where is the tumor? What bone is in the way? What brain is involved? –What does that brain do? What arteries/veins are involved?

25. Surgery Where is the tumor? What bone is in the way? What brain is involved? –What does that brain do? What arteries/veins are involved?

27. X

28. X

32. Transnasal Trans- sphenoidal

35. Primary motor cortex X

36. Primary motor cortex Awake Crani

38. Biopsy

39. Surgical tools - Microscope Improves visualization –Increased light –Increased magnification Improves surgeon comfort –Adjust scope angle, instead of bending/twisting

40. Surgical tools - Navigation GPS system for the OR –Pre-plan surgical approach –Confirm anatomic position Brings radiology data into the OR Functional MRI White mater tracks

41. Surgical tools - Robotics Navigation systems with built in surgical assistant –Pre-plan surgical approach –Utilize the robot to align the instruments Minimally invasive –Single stitch incision –Maximizing precision

42. Surgical tools – Laser Ablation Minimally invasive –Single stitch incision Pass a probe into the tumor –Reduced risk to normal brain Utilize heat to destroy tumor cells Pre-op 1 year post-op

43. Radiation Therapy No clean margins Can never pull every single weed Whole brain radiation –Multiple small doses to entire brain Stereotactic radiosurgery (SRS) –High dose to a small area –Limits exposure to normal brain SRS

44. Team Approach Neuro-oncology Radiation oncology Behavioral oncology Neurosurgery Neuro-radiology Neuro-psychology Neuro-pathology Nurse Navigator Research Nurse PT/OT/SLP Support services Make the diagnosis Deliver individualized treatment Provide clinical trials Provide support for our patients and families Maximize quality of life

45. Questions?