Neuro-Oncology Program
Diagnosis and Treatment
Most often neurosurgery patients are diagnosed following pathologic examination after surgery or biopsy. Definitive diagnosis requires tissue examination whenever possible and is planned in any patient where the danger does not outweigh the risks. Many patients come to the Neuro-Oncology Clinic having already received a diagnosis and are coming to us for a second opinion or for additional treatment options. We review all slides and radiographic studies as well as assess other areas of functional and psychological function to design a customized treatment plan.
About Brain Tumors
Malignant Brain Tumors: Malignant brain tumors represent the single most common class of primary brain tumors (tumors arising in the brain from brain cells), constituting approximately half of all newly diagnosed tumors. Malignant brain tumors arise from the supportive or structural class of brain cells known as glia or glial cells. These glial tumors are referred to as gliomas or may be further classified by tumor subtype, such as astrocytoma, glioblastoma, anaplastic astrocytoma, oligodendroglioma and ependymoma. Medulloblastoma and primitive neuroectodermal tumors (PNET) are rare in adults and mostly found in children.
Pituitary Tumors: Pituitary tumors are generally benign tumors that arise from the pituitary gland, a structure located at the base of the brain that is critical for normal hormonal functioning. Some of these tumors secrete hormones that can cause changes such as abnormal growth, breast milk production, skin and hair texture changes, loss of sexual potency or drive, or alteration in menstruation and infertility in women. As these tumors enlarge, they can press on surrounding structures, particularly the optic nerves. Pituitary tumors that secrete hormones may be suppressed and stabilized or decreased in size by medication therapy. Tumors that are not responsive to hormone suppression by medication will often need surgical removal.
Meningioma: Meningioma is the most common benign brain tumor and constitutes 30% to 40% of all brain tumors. Meningiomas arise from the coverings of the brain, called meninges, and do not invade the brain but rather push on it and cause problems by compressing the normal brain and its collection of neurons.
Acoustic Neuroma: Acoustic neuroma, also known as vestibular schwannoma, is a benign tumor arising from the eighth cranial nerve. Symptoms of acoustic neuroma often include dizziness, hearing loss or imbalance. This type of tumor is extremely common and can grow to a very large size.
Metastatic Brain Tumors: Metastatic or “secondary” brain tumors occur when cancer cells break away from a primary tumor elsewhere in the body, and spread to the brain via the bloodstream. Metastatic brain tumors are more common than primary brain tumors and represent more than half of the tumors seen in a neuro oncology setting. Cancers that metastasize to the brain include lung, breast, colon, melanoma and kidney cancer, and other less common tumors. Sometimes a person’s primary cancer is discovered only after the metastatic tumor is diagnosed, but it is also possible that cancer can metastasize long after the primary cancer occurs.
A pathologist can examine the tumor cells to determine whether the tumor started in the brain or metastasized from another location. The cells in a metastatic brain tumor that began as breast cancer, for example, will be composed of breast cells (not brain cells).
Treatment depends on the type of primary cancer, the size and location of the metastasis, the patient’s age and general health, the types of treatments the patient has had in the past, and their response to those treatments.
About Spinal Tumors
Spinal tumors include those that are metastatic from other sites (lung, breast, prostate, etc.), and involve the bony (vertebral) elements or primary tumors arising from the neural (spinal cord and nerve tissue) elements (meningiomas, schwannomas, astrocytomas, ependymomas). Both types of tumors can compress the spinal cord. Comprehensive care, including spinal reconstruction, is provided using a team approach.
We offer state-of-the-art spinal stabilization for metastatic spine tumors to preserve neural function and improve quality of life. We emphasize minimally invasive techniques, such as retropleural thoracotomies, short segment fusions and the use of cages, to enhance fusion. For tumors of the spinal cord, we emphasize intraoperative monitoring and stimulation of the spinal cord to maximize the safety of the resection. Procedures such as kyphoplasty and vertebroplasty are available to reconstruct compressed vertebral bone, restore alignment or remove pressure on a nerve.
About Skull Base Oncology
The skull base is located between the brain and the structure of the face and neck. Cranial nerves, major arteries and veins cross the skull base and are affected by both benign and malignant tumors that arise in, occupy or extend to the base of the skull. Although skull base tumors are outside of the brain, they can affect many important functions, such as taste, vision, hearing, swallowing, facial movement and hormonal balance. Because most tumors grow slowly, symptoms may be present for years before the correct diagnosis is made. Major breakthroughs in surgical and imaging techniques, together with advances in molecular biology and gene therapy, help us to better understand skull base tumors and provide new and better ways to treat them.
At Moffitt, we believe that a team approach to these complex tumors, both benign and malignant, makes a difference in clinical outcomes and patient satisfaction. In addition to the expertise of the core surgical team of neurosurgeons and ENT surgeons, the Skull Base Oncology team includes plastic surgeons, orbital surgeons, radiation therapists, neuro-oncologists, neuropsychologists, audiologists, nutritionists, psychologists and speech and swallowing specialists. These professionals are dedicated to providing the most effective and comprehensive care available to patients with complex skull base tumors.
Skull base tumors can affect different parts of the cranium. For example, tumors of the anterior skull base include carcinomas of the paranasal sinuses, esthesioneuroblastomas, angiofibromas and pituitary tumors. Tumors in the middle part of the skull base include nasopharyngeal carcinomas, adenoid cystic carcinomas and cavernous sinus meningiomas. In the posterior skull base, one finds tumors such as acoustic neuromas (schwannomas), chordomas, chondrosarcomas and glomus tumors. Although certain tumors are treated occasionally by one specialist, the majority of cases require the skills of an interdisciplinary team.
Neurosurgery
The Neurosurgery Service at the Moffitt Cancer Center routinely uses cutting-edge technologies to achieve maximal tumor removal while restoring and preserving maximal neurologic function. These include magnetic resonance imaging (MRI)-guided surgery, where MRI images are integrated into the advanced surgical microscope so the surgeon has a “roadmap” of critical structures and can avoid neural injury using the integrated imaging and microsurgery functions.
The 3-D intraoperative navigation systems enable precise location of deep-seated or small brain tumors. In addition, other technologies include: the monitoring of speech during surgical procedures where the patient is awake for critical portions of the surgery; the preoperative identification and operative monitoring of motor or visual functions during surgery to minimize postoperative deficits or changes; and the monitoring of delicate cranial nerve functions during skull base procedures for tumor removal. We specialize in neurosurgical services for oncology patients with the following benign or malignant tumors:
- Brain tumors: low-grade gliomas, astrocytomas, oligodendrogliomas, oligoastrocytomas, anaplastic astrocytomas, glioblastomas, pineal region tumors and brain cysts
- Spinal cord tumors, vertebral tumors, spinal nerve tumors, compression fractures
- Pituitary, acoustic and skull base tumors: chordomas, meningiomas, acoustic neuromas, sinus carcinomas and pituitary tumors
- Metastatic tumors to the brain and spine
The treatment plan for the newly diagnosed patients will often be a surgical procedure, either removal of the tumor or a radiologically guided biopsy to establish a diagnosis. A surgical date is usually decided upon by the conclusion of the initial visit, and patients requiring surgery will have the opportunity to ask all questions and be educated about the experience of surgery and additional treatment. Nonsurgical therapies such as radiation, chemotherapy and entry into an experimental protocol may also be recommended in addition to or in place of surgery.
Following surgery, patients generally spend the night in the Special Care Unit and then are transferred to the regular Neurosurgical Patient Care Unit the next day. Discharge from the hospital to home is usually done within 24-48 hours after surgery and follow-up visits are then coordinated by the interdisciplinary neurosurgical team. Social workers will help make arrangements for any special equipment or care that may be needed after discharge.
Radiation Therapy
A highly experienced team of radiation oncologists, physicists and therapists provide both conventional and stereotactic radiotherapy treatments for primary brain tumors, brain metastases and spinal tumors. Our treatment facilities include a state-of-the-art, shaped-beam radiotherapy system (Novalis) with intensity-modulated radiotherapy (IMRT) and intensity-modulated radiosurgery (IMRS) capabilities. This allows highly accurate targeting of tumors with maximal sparing of normal surrounding brain. We have also begun development of programs for fractionated stereotactic radiosurgery and radiotherapy for skull base and spinal tumors.
Chemotherapy
Treatments range from standard chemotherapy to antiangiogenic agents, differentiating agents, new molecular agents and numerous institutional and national clinical trials. We are active members of the NCI-sponsored brain tumor consortium, called New Approaches to Brain Tumor Therapy, or NABTT, and offer access to the most current clinical trials, including targeted tumor therapy.
Additional Team Support
The Psychosocial & Palliative Care Program offers ongoing neurocognitive, emotional and social support as well as referrals to other Moffitt and community resources for patients and their families. In addition, registered dietitians, as part of the treatment team, provide proper nutrition intervention and nutritional education and support.