Progress in Surgery, Radiotherapy and Chemotherapy

The Last 30 Years

Dr. Rolando Del Maestro co-founder of Brain Tumour Foundation of Canada
By Dr. Rolando F. Del Maestro, co-founder of Brain Tumour Foundation of Canada

In the 30 years since Brain Tumour Foundation of Canada formed, there have been major changes in patient treatment. In my opinion the most significant advance over the past three decades has been the development of the specific medical specialty called Neuro-Oncology, focused on both research and care of patients with brain or spinal cord tumours. By having a specific practice devoted to this unique community of patients, it opens doors to more personalized medical care.

Surgical Advances

The modern neurosurgical suite is a co-operative and integrated community of health care specialists including anesthesiologists, surgeons, and specially trained nurses and technicians, all focused on giving patients the best care possible.

As surgery is such an integral part of the diagnosis and treatment planning, it is critical that not only enough tissue be removed for correct diagnosis and testing, but that removal of the tumour itself be as safe as possible for the patient.

The last 30 years have seen tremendous advances in the neurosurgical equipment used to carry out safe, operative removal of tumours.

Today’s neurosurgical operating room has incorporated the magnetic resonance (MR) scanners developed in the 1980s, used originally for diagnosis, into intraoperative, 3D systems that allow surgeons to know and continually monitor the position of instruments during operations. New devices such as ultrasonic aspirators, like the Cavitron®, have allowed for more careful removal of tumours with less injury. Additionally, recent high-powered microscopes have extended the quality of surgeons’ vision to see abnormal tumour tissue in the brain.

Operations in what doctors consider eloquent (speech, motor and sensory) areas of the brain have been enhanced by the ability of the surgeon to operate on patients who are “awake.” While under neuroleptic anaesthesia, a lighter form of anesthetic where the patients themselves can provide immediate feedback on whether there have been any injuries during surgery.

A small number of hospitals now have MR scanners incorporated into the operating room. These can help surgeons decide on how much tumour has been removed. In the future, intraoperative MR scanners will become more common, robotic tools will aid in surgical tumour removal, and the ability to reconstruct and operate on a patient’s tumour in a virtual reality environment will be standard practice.

Radiotherapy Treatment

The major change in radiotherapy has been a shift from giving whole brain radiation or radiotherapy to larger regions of brain, to what is known as Intensity Modulated Radiotherapy (IMRT) – a form of stereotactic radiosurgery. IMRT allows for delivery of radiation to smaller areas within the brain, with much less injury to the surrounding normal tissues and other brain structures like the cranial nerves.

Advances in robotics and computer technology have led to the development of the Gamma Knife® (a specialized unit that delivers targeted single, high-dose radiation), stereotactic radiosurgery delivered by linac machines, and the implementation of the CyberKnife® (a robotic radiosurgery system that is image-guided).These innovative systems have all proven useful in the treatment of acoustic neuromas, meningiomas and metastatic disease.

Chemotherapy

The major advance in the treatment of brain tumours has been the usefulness of temozolomide (Temodal®) and the importance of specific genetic changes in a patient’s tumour that determine their response to the drug.

Only two treatments are presently approved for individuals with the most aggressive glial tumour, glioblastoma multiforme (GBM): radiation and temozolomide. Both treatments are given together, and molecular profiling of GBM tumour tissue has determined that changes in a molecule, called O6-methylguanine-DNA methyltransferase (MGMT), within the tumour, can predict improved response to treatment with temozolomide.

Treatment Advances

Additionally, the effectiveness of anti-angiogenic drugs that modify the blood vessels of brain tumours, such as bevacizumab (Avastin®), will soon be known. Two large trials assessing the use of this compound given during the initial treatment of GBM or at the time the tumour recurs will be reported in the fall of 2012 and help guide treatment in the future. Newer approaches, like the use of a specific vaccine that targets specific molecules (epidermal growth factor receptor mutation, EGFRVIII), are now being assessed, as are anti-invasion drugs targeting the movement of brain tumour cells.

Although implemented in all trials for the treatment of brain tumours, the era of personalized medicine will soon be common neuro-oncology practice. Genetic changes such as 1p and 19q loss of heterozygosity (loss of a portion of the 1st and 19th chromosome) in oligodendroglial tumours, the presence of genetic changes in MGMT (promoter methylation), mutations in other proteins (EGFRVIII, IDH-1, IDH-2) will soon be used to develop specific treatments for specific tumours.

While progress has been slow over the last 30 years, a new understanding of brain tumour biology focused on the genetic changes present in each person’s tumour will lead to improved patient survival and may one day result in cures for those diagnosed with a brain tumour.

About the Author

Dr. Rolando F. Del Maestro is the Director of the Montreal Neurological Institute’s Brain Tumour Research Centre. One area of his research is focused on understanding the invasiveness of malignant brain tumour cells. Failure to control these invading tumour cells may be the key reason for recurrence after radical resection, and may contribute substantially to the failure of other modalities of treatment such as radiotherapy and chemotherapy.

The development of virtual reality systems (NeuroTouch) holds great promise for the teaching and improvement of safe surgical procedures. Dr. Del Maestro works with many national and international collaborators and is at the forefront of this initiative.

The goals of Dr. Del Maestro's research are:

  • To define the genetic and biochemical determinants of invasive brain tumours
  • To develop novel chemotherapeutic approaches to target malignant brain tumour cells
  • To implement virtual reality technology to improve patient safety during surgical operations

Dr. Del Maestro also co-founded Brain Tumour Foundation of Canada in 1982, alongside Pamela Del Maestro and Steve Northey. You can learn more about the evolution of the Canadian brain tumour community over the past 30 years at www.BrainTumour.ca/30YearsofHope.


Dr. Del Maestro was the keynote speaker at the London Brain Tumour Information Day Conference. This article was published in September 2012. Dr. Del Maestro is Professor Emeritus, Department of Neurology and Neurosurgery, McGill University.

 

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