Winter 2007

Brain Tumors Require Diverse Team and Technology

Nalin Gupta, M.D., Ph.D.

Successfully treating brain tumors in children requires a team approach, says UCSF neurosurgeon Nalin Gupta, M.D., Ph.D. "You need to bring together many pediatric specialties: surgery, radiation oncology and oncology."

Surgery itself requires collaboration among many specialties. Before surgery begins, radiologists use many sophisticated imaging methods to precisely locate the tumor and its invasion into surrounding tissues. Modern imaging techniques also can identify areas of the brain that have important function and may be at risk during surgery. The availability of advanced techniques such as functional MRI, MRI spectroscopy and diffusion tractography significantly aids the surgical planning process, Gupta says.

During surgery itself, extensive experience with functional brain mapping by experts like Mitchel Berger, M.D., further improves outcomes and lowers the risk of disability. "It's the coordination of imaging, mapping and surgical procedures that preserves eloquent function, reduces risk and increases safety," Gupta says.

Daphne Haas-Kogan, M.D.

Skull base tumors usually require close cooperation between neurosurgeons, plastic surgeons, ear, nose and throat surgeons and other specialists. "The fact that we have all these specialists in one place — and their experience working with pediatric patients — is part of what makes us the strongest program in Northern California for brain tumors," Gupta says.

Complementing the multidisciplinary surgical approaches available at UCSF are the varied tools to apply radiation in a focused, precise way. Thanks to recent advances in radiation treatments, young children are surviving many brain tumors that would have been incurable a decade ago. The Gamma Knife has long been the gold standard for care in treating certain head and neck tumors. The basic approach utilized by the Gamma Knife — multiple, calibrated beams of radiation that converge in the tumor — has evolved into many advanced technologies.

UCSF has recently acquired the latest version of the Gamma Knife, called Perfexion, which reduces machine preparation time, treatment time for the patient and the need for awkward positioning — all especially beneficial when working with children.

Intensity-modulated radiation therapy (IMRT) is a relatively new approach made possible only through recent advances in imaging and computer technology. IMRT planning starts with target and normal tissue definition, then dose prescription and then inverse planning. Using computer optimization, multiple small fields are designed to give a complex and conformal radiation dose distribution. Physicians at UCSF have used IMRT to treat cancer patients since 1997, garnering more experience with IMRT than those at most other places in the country.

Since the mid-1980s, radiation oncologists at UCSF have been pioneering the use of intraoperative radiation therapy (IORT) for tumors throughout the body, including the head and neck. UCSF is one of the few medical centers nationwide at the forefront of advancing this mode of treatment. IORT delivers a concentrated beam of radiation to cancerous tumors while they are exposed during surgery. This allows physicians to administer high doses of radiation to tumors without exposing nearby healthy organs, lessening the risk that healthy tissue will be damaged.

The CyberKnife, a robotically controlled linear accelerator, offers another approach for precisely applying radiation to any area in the body. "All these techniques can be used to target tumors as precisely as possible and spare normal tissue," says radiation oncologist Daphne Haas-Kogan, M.D. "This is especially important in children, who are more prone to long-term effects of radiation."

Finally, UCSF boasts a large pediatric oncology program. Innovative clinical and basic science research programs, such as those in the newly established Pediatric Brain Tumor Institute, create opportunities for enrollment in clinical trials offering advanced, cutting-edge treatments.

"If you take the stance that you want to be able to treat all children, you have to have a large repertoire of skills and technologies available," Gupta says.

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