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The Wake Forest Baptist Approach Brain Tumor Center  of Excellence ------------------------------- View Brain Tumor Center Video ------------------------------- A multidisciplinary clinic for brain cancer treatment ------------------------------- Gamma Knife -------------------------------- Gamma Knife versus Cyberknife important differences in capabilities -------------------------------- The Leading Edge of Treatment -------------------------------- The Brain Tumor Center of Excellence of Wake Forest University was formed in June 2003 -- the realization of a dream of three of our leading physicians and the chair of the Department of Neurosurgery. With the goal of being a national leader in patient care and research, the Center has built its program with three basic components:  an excellent group of clinicians, a world-class researcher to direct the Center, and a mission to grow the clinical and basic research programs to a magnitude that would place Wake Forest among the top six brain tumor centers in the United States. Patients come from all over North Carolina, the Southeast and beyond to seek care from this team of highly experienced, nationally recognized experts in all facets of brain tumor treatment and study. Significant strides have been made in our research goals. The Brain Tumor Center of Excellence has three areas of research focus: ·      Novel therapeutics – identifying innovative treatments that will improve outcome. ·      Bioanatomic imaging – identifying the unique signatures of a cancer through non-invasive imaging of tumor biology, chemistry and physiology, thus allowing individual treatment planning. ·      Radiation-induced brain injury – understanding the mechanisms of injury and ways to prevent and treat side-effects of brain tumor therapy. Each year, approximately 17,500 primary brain tumors and 150,000 to 250,000 metastatic brain tumors are diagnosed in the United States.  Brain tumors are the most common cause of death from childhood cancers, and the cure rate in adults is 1 percent to 5 percent. It has been said that if a cure could be found for brain cancer, it would solve the mystery of all human cancer.  Our goal is to solve that mystery. Gamma Knife Stereotactic Radiosurgery Gamma Knife versus Cyberknife – important differences in capabilities Since Wake Forest University Baptist Medical Center opened North Carolina’s premiere Gamma Knife sterotactic radiosurgery center in 1999, patients have come from across the nation to benefit from this non-invasive, state-of-the-art treatment.  Our Center boasts one of the most experienced radiosurgical treatment teams in the United States, and is one of the most active Gamma Knife Centers in the country. The Gamma Knife is a method of delivering an ultra-precise dose of radiation to treat a variety of benign and malignant lesions and conditions in the brain, including brain metastases, trigeminal neuralgia, acoustic neuroma, vascular malformations, meningiomas, malignant gliomas, pituitary adenomas, and skull base lesions.  All patients undergo multidisciplinary evaluation with neurosurgery, radiation oncology, and where appropriate medical oncology, pediatric oncology, neurology, otolaryngology, and interventional radiology.  On a weekly basis, a Gamma Knife conference is held by the entire team at which our own cases as well as sent-in consultations are reviewed. 3D Conformal and Intensity Modulated Radiation Therapy Among the newer treatment options for cancer of the prostate, brain, lung, and head and neck are two methods of focusing radiation on the tumor and surrounding at-risk tissues while optimally sparing nearby normal tissues, 3-dimensional (3D) conformal radiation therapy, and intensity modulated radiation therapy (IMRT).  This approach uses anatomic computed tomogrphic and/or magnetic resonance images of the patient, computer-generated radiation dose calculations, and a computer-controlled linear accelerator to conform or “paint” the radiation dose very precisely to match the shape of the tumor to be treated, avoiding critical structures that may be only millimeters away. When the linear accelerator radiation beam intensity is varied, or modulated, over space and time during the patient’s treatment, hence the term “Intensity Modulated” radiation therapy. In combination with advanced imaging techniques like magnetic resonance spectroscopy and positron emission tomography that image both tumor anatomy and biology, IMRT holds great promise for improving local tumor control and survival, even in the most resistant and aggressive human cancers.  Brachytherapy Brachytherapy, which literally means “short therapy”, involves the implantation of radioactive sources in or near a tumor, a procedure which typically involves the collaboration of a surgical oncologist and radiation oncologist.  A full range of brachytherapy treatment options are available for treating cancers of the prostate, breast cervix, uterus, vagina, head and neck, soft tissues, brain, and eye.  In fact, with the availability of both high dose rate (HDR) and low dose rate (LDR) brachytherapy technology and expertise, virtually any area of the body can be implanted if appropriate.  Brachytherapy is often used as a “boost” in conjunction with external beam radiation, particularly for locally advanced cancers.   Metastatic brain tumor The major areas of the brain have one or more specific functions. Definition: A metastatic brain tumor is brain cancer that has spread from another part of the body. Alternative Names: Brain tumor - metastatic (secondary); Cancer - brain tumor (metastatic) Causes, incidence, and risk factors: Many tumor or cancer types can spread to the brain, the most common being lung cancer, breast cancer, melanoma, kidney cancer, bladder cancer, certain sarcomas, testicular and germ cell tumors, and a number of others. Some types of cancers only spread to the brain infrequently, such as colon cancer, or very rarely, such as prostate cancer. Brain tumors can directly destroy brain cells, or they may indirectly damage cells by producing inflammation, compressing other parts of the brain as the tumor grows, inducing brain swelling, and causing increased pressure within the skull. Metastatic brain tumors are classified depending on the exact site of the tumor within the brain, type of tissue involved, original location of the tumor, and other factors. Infrequently, a tumor can spread to the brain, yet the original site or location of the tumor is unknown. This is called cancer of unknown primary (CUP) origin. Metastatic brain tumors occur in about one-fourth of all cancers that metastasize (spread through the body). They are much more common than primary brain tumors. They occur in approximately 10 - 30% of adult cancers. Symptoms: Changes in sensation of a body area Decreased coordination, clumsiness, falls Emotional instability, rapid emotional changes Fever (sometimes) General ill feeling Headache -- recent, persistent, and a new type for the person Lethargy Memory loss, impaired judgment, calculating deficiencies Personality changes Pupils of eyes are a different size Seizures -- new for the person Speech difficulties Vision changes -- double vision, decreased vision Vomiting -- with or without nausea Weakness of a body area Note: Specific symptoms vary. The symptoms commonly seen with most types of metastatic brain tumor are those caused by increased pressure in the brain. Signs and tests: An examination reveals neurologic changes that are specific to the location of the tumor. Signs of increased pressure within the skull are also common. Some tumors may not show symptoms until they are very large. Then, they suddenly cause rapid decline in the person's neurologic functioning. The original (primary) tumor may already be known, or it may be discovered after an examination of tumor tissues from the brain indicates that it is a metastatic type of tumor. A CT scan or MRI of the brain can confirm the diagnosis of brain tumor and identify the location of the tumor. MRI is usually better for finding tumors in the brain. Cerebral angiography is occasionally performed. It may show a space-occupying mass, which may or may not be highly vascular (filled with blood vessels). A chest x-ray, mammogram, CT scans of the chest, abdomen, and pelvis, and other tests are performed to look for the original site of the tumor. An EEG may reveal abnormalities. An examination of tissue removed from the tumor during surgery or CT scan-guided biopsy is used to confirm the exact type of tumor. If the primary tumor can be located outside of the brain, the primary tumor is usually biopsied rather than the brain tumor. A lumbar puncture (spinal tap) is sometimes also performed to test the cerebral spinal fluid. Treatment: Treatment depends on the size and type of the tumor, the initial site of the tumor, and the general health of the person. The goals of treatment may be relief of symptoms, improved functioning, or comfort. Radiation to the whole brain is often used to treat tumors that have spread to the brain, especially if there is more than one tumor. Surgery may be used for metastatic brain tumors when there is a single lesion and when there is no cancer elsewhere in the body. Some may be completely removed. Tumors that are deep or that infiltrate brain tissue may be debulked (removing much of the tumor's mass to reduce its size). Surgery may reduce pressure and relieve symptoms in cases when the tumor cannot be removed. Chemotherapy for brain metastases is not as helpful as surgery or radiation for many types of cancer. Medications for some symptoms of a brain tumor may include the following: Corticosteroids such as dexamethasone to reduce brain swelling Osmotic diuretics such as urea or mannitol to reduce brain swelling Anticonvulsants such as phenytoin to reduce seizures Pain medication Antacids or antihistamines to control stress ulcers When multiple metastases (widespread cancer) are discovered, treatment may focus primarily on relief of pain and other symptoms. Comfort measures, safety measures, physical therapy, occupational therapy, and other interventions may improve the patient's quality of life. Legal advice may be helpful in forming advanced directives, such as power of attorney, in cases where continued physical or intellectual decline is likely. Support Groups: For additional information, see cancer resources. Expectations (prognosis): In general, the probable outcome is fairly poor. For many people with metastatic brain tumors, the cancer spreads to other areas of the body. Death often occurs within 2 years. Complications: Brain herniation (fatal) Loss of ability to function or care for self Loss of ability to interact Permanent, progressive, profound neurologic losses Calling your health care provider: Call your health care provider if you develop a persistent headache that is new or different for you. Call your provider or go to the emergency room if you or someone else suddenly develops stupor, vision changes, or speech impairment, or has seizures that are new or different. References: Nguyen TD, Abrey LE. Brain metastases: old problem, new strategies. Hematol Oncol Clin North Am. 2007;21(2):369-388. Nguyen TD, DeAngelis LM. Brain metastases. Neurol Clin. 2007;25(4):1173-1192. Peak S, Abrey LE. Chemotherapy and the treatment of brain metastases. Hematol Oncol Clin North Am. 2006;20(6):1287-1295.

Review Date:6/10/2008 Reviewed By:James R. Mason, MD, Oncologist, Director, Blood and Marrow Transplantation Program and Stem Cell Processing Lab, Scripps Clinic, Torrey Pines, California. Also reviewed by David Zieve, MD, MHA, Medical Director, A.D.A.M., Inc.