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CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
CNI REVIEW - Brain
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CNI REVIEW - Brain

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  • 1. COLORADO NEUROLOGICAL INSTITUTE S U M M E R 04 Tumors CNI Center f or Brain and Spinal Tumors CNI REVIEW
  • 2. CNI REVIEW Official Publication of the Colorado Neurological Institute Contents Medical Editor John H. McVicker, MD Neuro-oncology: The Promiscuous Discipline 2 CNI Board of Directors Edward Arenson, MD Dan Weyland Chairman John H. McVicker, MD Vice Chairman Neurosurgery for Brain Tumors: 5 R. Donald Johnson Treasurer Same Goal, New Technology Walter R. Berger Timothy Fullagar, MD Assistant Treasurer Peter E. Ricci, MD Secretary Luanne M. Williams, CFRE Gamma Knife Radiosurgery 8 Executive Director at Swedish Medical Center Cynthia Acree Theron Bell D. Marshall Davis, MD Norman Dyer Barbara Farley Lucille Gallagher, ARM David C. Kelsall, MD Douglas Kerbs Artemis Khadiwala Neuropsychology’s Evolving Role in the Modern 10 Dennis O’Malley Barbara Lynne Phillips, MD Management of Patients with Central Nervous Roselyn Saunders Richard E. Schaler, MD System Tumors Michael M. Schmidt Melody Staffen Nancy Powers, PsyD and Kevin Reilly, PsyD Marc M. Treihaft, MD Mary White World Wide Web Address: www.TheCNI.org Role of the Patient Care Coordinator 13 About the Colorado Neurological Stacey Per, LCSW Institute (CNI) The Colorado Neurological Institute (CNI), a not-for-profit organization, enhances neurologic patient care through its education, research and outreach activities. As the largest, most Chemotherapy for Brain Tumors: 17 comprehensive neuroscience center in the Rocky Mountain area, CNI Current Status and Controversy provides extensive interdisciplinary programs throughout the region. Edward Arenson, MD This medical review journal is one of CNI’s many educational offerings to the medical community. All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted, in CNI REVIEW Online 19 any form or by any means – electronic, mechanical, photocopying, recording, or otherwise — without the prior written permission of the Colorado Neurological Institute. CNI Programs and Services 20 © Colorado Neurological Institute, 2004. Graphic Design: TheParksGroup, Boulder, CO
  • 3. From the Editor This edition of the CNI REVIEW highlights the CNI Center for Brain and Spinal Cord Tumors. The CNI is justifiably proud of this remarkable program. Although a relatively unheralded community resource, it provides one of the most coordinated, successful interdisciplinary programs in the country, addressing both the physical and spiritual needs of our brain and spinal tumor patients and their families. Ed Arenson introduces the CNI Center for Brain and Spinal Cord Tumors by highlighting the relatively new field of neuro-oncology. Arising in response to a surge of interest in brain and spinal cord tumors, this field focuses on the care of patients with central nervous system tumors. The neuro-oncologist assumes responsibility for the care of patients following surgery, especially those with malignant or partially resected tumors. Patients with benign tumors complicated by ongoing issues such as seizures, functional impairment, or other significant co-morbidities may benefit from the care of the neuro-oncologist who often acts as the primary care physician for issues related to the tumor. Tim Fullagar next describes the evolving role of the neurosurgeon in the optimal management of central nervous system tumors. The principle mandate and responsibility of the neurosurgical oncologist is and always has been simple — to remove the tumor. Dr. Fullagar details the technology facilitating how this is achieved with greater safety and certainty. Innovation is also apparent in how the neurosurgeon functions within the context of a multidisciplinary neuro-oncology team. Rather than making unilateral management decisions, our philosophy at CNI identifies a principle neurosurgeon as a member of a team which includes other neurosurgeons, neuro-oncologists, radiation oncologists, neuropsychologists, nurses, social workers, and other professionals. These dedicated individuals meet regularly to insure a team approach to patient management. Nancy Powers and Kevin Reilly expand on this theme with their description of the multidisciplinary team, providing care for our patients in this diverse, complex medical and supportive environment. They highlight the role of the neuropsychologist who insures a balanced approach to the needs of each patient, a role which continues to evolve as newer approaches to treatment extend the survival of our patients. Marsh Davis then describes one of the more important tools used to precisely target residual or recurrent tumors with highly focused radiation, which allows a radiation dose to be deposited within the tumor, minimizing dose deposition in surrounding non-targeted brain tissue. Finally, Stacey Per outlines the important function of the Patient Care Coordinator, who provides a bridge between the medical and the supportive services at CNI. The results of this coordinated, multidisciplinary approach are seen both in the remarkable statistics of survival and in our patients’ sense of well-being. For too long, brain tumors have been synonymous with a death sentence. We have found that our aggressive and supportive philosophy simply translates into better patient outcomes. I hope you enjoy this issue of the CNI REVIEW. John H. McVicker, MD, FACS President Colorado Neurological Institute Summer 2004 1 CNI REVIEW
  • 4. Neuro-oncology: The Promiscuous Discipline Edward Arenson, MD The relatively new field of neuro-oncology has arisen in response to the long overdue surge in interest in central nervous system (CNS) tumors by health care professionals. Since this field has no history or tradition, its definition remains elusive. What is clear is that the field concerns itself with the care (mostly postsurgical) of patients with CNS tumors. A neuro-oncologist typically assumes full responsibility for the care of patients with CNS tumors following surgery if ongoing care is necessary. Certainly all patients with malignant CNS tumors, low-grade or high-grade, completely or partially resected, should be followed by a neuro-oncologist. In addition, patients with benign tumors complicated by ongoing issues such as seizures, functional impairment, or significant comorbidities frequently benefit from the care of a neuro-oncologist who essentially becomes the primary care physician for issues related to the tumor. Introduction. The relatively new field of standard training or board exam). The neuro-oncology has arisen in response to the current legion of neuro-oncologists includes Dr. Arenson was long overdue surge in interest in central physicians with subspecialty training in graduated from Cornell nervous system (CNS) tumors by health care oncology (both pediatric and adult), University and Hahnemann Medical professionals. Since this field has no history neurology (both pediatric and adult) and College. He completed a or tradition, its definition remains elusive. neurosurgery (both pediatric and adult). residency in pediatrics at What is clear is that the field concerns itself Interestingly, many pediatric neuro- the University of Colorado with the care (mostly postsurgical) of oncologists (including myself) have become Health Sciences Center and patients with CNS tumors. A neuro- increasingly involved in the care of adult Denver Children’s oncologist typically assumes full patients because of a shortfall of committed Hospital. Over the past responsibility for the care of patients with adult neuro-oncologists. This conspicuous decade, Dr. Arenson has CNS tumors following surgery if ongoing “promiscuity” in the discipline of neuro- focused his attention on care is necessary. Certainly all patients with oncology has had a major impact on the children and adults with malignant CNS tumors, low-grade or high- other area of ambiguity in the definition of central nervous system grade, completely or partially resected, neuro-oncology, the question of what tumors. Dr. Arenson, should be followed by a neuro-oncologist. In constitutes a standard of care for the patients along with Dr. Timothy addition, patients with benign tumors that neuro-oncologists treat. Fullagar, has developed a complicated by ongoing issues such as My own perspective on this question of multi-modal treatment strategy for adults with seizures, functional impairment or significant a standard of care is that there is none and high-grade gliomas with comorbidities frequently benefit from the will not be one until, and unless, the curative intent, and has care of a neuro-oncologist who essentially background and training of those that call helped organize the CNI becomes the primary care physician for issues themselves neuro-oncologists’ becomes Center for Brain and related to the tumor. standardized. I have observed a major Spinal Tumors Team. What is not clear is what the standard difference in approach to care dependent of care should include for patients with CNS upon whether the neuro-oncologists tumors and what professional training and background is in neurology/neurosurgery or background is most appropriate (there is no oncology and whether they practice in an CNI REVIEW 2
  • 5. academic or private practice model. such as nurse practitioners and physicians’ For example, patients treated by neuro- assistants. The attending physician is oncologists with oncology backgrounds are responsible for the care, but most of the care more likely to be offered aggressive treat- is provided by others. Secondly, academic ment regimens that may involve substantial clinicians are bound to conduct clinical risks, but offer the possibility of better and/or basic research. While such research is results. This is based on both a higher necessary in order for progress to be made, it comfort level with aggressive treatment, is also relatively inflexible, and to a certain especially chemotherapy, as well as the extent, limits the creativity of the treating principle that the cancer itself is a bigger physician as well as his ability to threat to the patient than aggressive therapy individualize care when appropriate. both in terms of survival as well as preserva- tion of function. Additionally, oncologists Private Practice. An alternative to the understand that treatment approaches that academic model, at least in theory, is the seek to palliate cancer essentially never cure private practice model in which care is cancer, and that when cancer is cured, it is delivered directly by the clinician without a nearly always through the use of aggressive, hierarchy of subordinates and/or extenders. but rational combinations of individually This approach optimizes care by allowing for effective treatments. Neuro-oncologists the development of a more intimate with a background in neurology or relationship with each patient. The system neurosurgery, while comfortable with the allows greater flexibility in modifying or neurologic and anatomic aspects of CNS selecting treatment and more creativity in tumors, are less likely to achieve a comfort treatment protocol development. For level with the oncologic concepts necessary example, in our Program, patients who fail for aggressive treatment. our standard frontline therapy are frequently offered and benefit from second and third Settings of Care. Academic. The next treatments, usually both chemotherapy and major determinant of the standard of care is biological therapy. Many hours of time are the setting of care; academic or private. My required to obtain approval to provide such own career has evolved from an academic to innovative treatments. The private practice private practice over the span of 30 years. model potentially suffers from a reduced level While I have observed and participated in of peer input and criticism and from a lower what certainly was a very high standard of commitment to research and data-based care in academia, there is no question in my treatment. These problems are minimized, mind that neuro-oncologic care in academia however, if the neuro-oncologist practices in is very different from what I have experienced a setting where a privately supported since going into private practice a decade institute provides the means of creating a ago. The academic model emphasizes comprehensive and multidisciplinary research and “protects” the physician from program in which there is both the being overwhelmed by clinical care demands opportunity and the logistical support in order to allow research to be performed. necessary to conduct clinical research. This Continuity of care is insured by the presence approach is exemplified at the Colorado of fellows in training and physician extenders Neurological Institute where the Center for Summer 2004 3 www.thecni.org
  • 6. 1. Cowna J, et al. The impact of provider Brain and Spinal Tumors is a Program with a Address comments and questions to: volume on mortality mandate to provide multidisciplinary care to Edward B. Arenson, MD after intracranial tumor resection. Neurosurgery. its patients, track its clinical outcomes, Co-director, CNI Center for Brain 2003:52;48-54. provide an active educational program for its and Spinal Tumors members as well as the lay community and 701 E. Hampden Avenue, Suite 370 perform credible and significant research. Englewood, CO 80113 While these lofty goals have not been fully realized, there is every reason to expect that they will be in time. Conclusion. Herein are described distinctly different approaches to the care of patients with CNS tumors dependent upon the background of the neuro-oncologist and the medical environment in which the patient is treated. Finally, an even larger problem, beyond the scope of this article, is the fact that many (most?) patients with CNS tumors never see a neuro-oncologist, but instead are managed by a general medical oncologist or no oncologist at all. Experience from MD Anderson Cancer Institute and other respected centers clearly indicate that patients are harmed by the latter approach and should be referred to centers, academic or otherwise, which provide a comprehensive program for a critical mass of patients with CNS tumors.1 The issues outlined in this article are ones of major concern for any patient diagnosed with a central nervous system tumor. The resolution of the critical questions of who is a neuro-oncologist and what the standard of care should be will not occur until those who are currently most active in the field, including members of the Society for Neuro-Oncology, recognize that these are problems of sufficient importance to be addressed and acted upon. CNI REVIEW 4
  • 7. Neurosurgery for Brain Tumors: Same Goal, New Technology Timothy Fullagar, MD The role of the neurosurgeon in the optimal management of a patient with a central nervous system tumor has evolved in some ways, particularly the new standard of being a member of a multidisciplinary neuro-oncology team. This team includes other neurosurgeons as well as neuro-oncologists, radiation oncologists, neuroradiologists, neuropsychologists, nurses, social workers and other professionals who meet regularly to insure a team approach to patient management. However, there has been no change in the principle mandate and responsibility of the surgical neuro-oncologist, to remove the tumor. What has changed is how this is achieved more safely and more often. This article will address these improvements and explain the technology that has facilitated this progress. Introduction. The role of the following an injection of the agent Dr. Fullagar is Co- neurosurgeon in the optimal management of gadolinium (gadolinium enhancement) Medical Director of the CNI Center for Brain and a patient with a central nervous system surrounded by an area, often much larger, of Spinal Tumors Program (CNS) tumor has evolved in some ways, abnormal signal that is not enhanced by and a neurosurgeon at particularly the new standard of being a gadolinium (T2 signal). This area can be Rocky Mountain member of a multidisciplinary neuro- tumor, swelling, or both, but standard MRI Neurosurgical Alliance. oncology team. This team includes other scanning cannot distinguish between them. He received his training at neurosurgeons as well as neuro-oncologists, Newer scanning techniques such as MR the University of Tennessee radiation oncologists , neuroradiologists, spectroscopy or PET scanning with dopa as is a Commander in the neuropsychologists, nurses, social workers (investigational) frequently can determine U.S. Naval Reserve. Dr. and other professionals who meet regularly to whether there is tumor in the nonenhanced Fullagar is Co-Principle insure a team approach to patient area and where the likely edge of grossly Investigator for a federally management. However, there has been no detectable tumor is located. This knowledge funded clinical trial change in the principle mandate and can lead to the removal of tumor which studying the use of responsibility of the surgical neuro- otherwise would have been left behind to photodynamic therapy as oncologist, to remove the tumor. What has bedevil the patient in the future. We have adjunctive treatment for patients with high grade changed is how this is achieved more safely seen cases where patients came to us for gliomas. He has particular and more often. This article will address consultation from another center where they expertise in the use of these improvements and explain the had undergone what appeared to be an pre-operative and intra- technology that has facilitated this progress. adequate (gross total) resection of their tumor operative functional brain only to discover through MR spectroscopy mapping to expedite Neuroimaging. First, and perhaps most that a substantial volume of resectable tumor optimal resection of brain important, are the continuing advances in had been left behind. In many cases, it was tumors. neuroimaging, which allow neurosurgeons to possible, subsequently, to remove much or all better understand what the full extent and of this residual disease without any harm to location of the tumor is. For example, most the patient. high-grade CNS tumors consist Another issue we often encounter in radiographically of an area of bright signal our desire to optimize tumor removal is the Summer 2004 5 www.thecni.org
  • 8. functional outcome for the patient. Many determine which areas are responsible for the tumors, unfortunately, are located in areas of speech. Patients may also be awakened eloquent brain where tumor removal might during the surgery itself, without discomfort, result in devastating deficits such as aphasia and repetitively tested by the neurologist and/or hemiplegia. Technology, largely and/or neuropsychologist as the operation developed from epilepsy surgery, now proceeds in order to inform the neurosurgeon allows us to better define the relationship if speech is being affected and thus greatly between tumors and areas of eloquent facilitate the safety of the surgery. functional brain. Thus, a combination of greatly For example, functional MRI (FMR) is improved neuroimaging and the ability to a technique whereby an MRI scan can be determine where eloquent functions are modified to reveal areas of motor and more located in relationship to tumors can allow a recently sensory and language functions much greater likelihood of achieving the goal situated on the cortex. Currently, we are able which is so critical to the chances of long- to use FMR at Swedish Medical Center for term survival, the complete and safe removal localization of the primary motor cortex. of all grossly detectable tumor. Patients are asked to tap their finger repetitively during an MRI scan which Adjuvant Treatments. Despite these results in visibly detectable change in advances, it is well known that all malignant cerebral blood flow and in the area of cortex CNS tumors invade the brain microscopically where the primary motor neurons are located. and cannot be cured by surgery alone; there is The neurosurgeon can then determine if always microscopic disease left behind. Most removal of the tumor will or will not leave of the microscopic disease is located within the patient with a major deficit. This can one inch of the edge of the surgical cavity. help the neurosurgeon in planning an Recent research has focused on strategies to approach which will minimize risk of injury. eradicate this residual disease where 90 Another important test, frequently percent of all recurrences occur. These used in our own Program, is the Wada test in approaches include two techniques now which selected injection of the short-acting available in our Program, photodynamic anesthetic, sodium amytal, sequentially into therapy (PDT), and Gliasite. each carotid artery allows the definitive determination of which side of the brain is Photodynamic Therapy. PDT is a dominant for both language and memory. technique in which a light sensitive chemical The neurosurgeon then decides if it is (photophryn) is given to the patient necessary or not to map the precise location intravenously 24 hours before surgery in of language on the side where the tumor is order to allow its selective uptake by tumor located. Mapping of language can be cells. After removal of the tumor, a laser light accomplished either preoperatively by source is placed into the surgical cavity. This surgically placing a grid of electrodes on the intense light penetrates 1 to 2 cm into the surface of the brain on the dominant side, surrounding brain and converts photophryn returning the patient to the floor, and into a poison which can destroy the tumor subsequently using the grid to electrically cells but is minimally toxic to normal brain stimulate areas of brain during speech to cells. A federally funded investigational trial CNI REVIEW 6
  • 9. of this treatment is currently active in its relationship to critical areas of normal our Center. brain. In addition, the neurosurgeon is able to offer patients new techniques to attack Gliasite. A second technique, Gliasite, tumor cells which persist beyond the surgical allows the placement of a balloon into the margin. Finally, surgery for recurrent tumors, surgical cavity following tumor removal with or without adjuvant treatment such as which conforms to the shape of the cavity. photodynamic therapy, has made an impact. This balloon is connected to a reservoir As technology continues to develop, we which is left under the scalp. Following expect that an increasing number of patients sufficient time for recovery from surgery, a will benefit from surgical outcomes which radioisotope (I125) is injected into the balloon open the door for longer and better survival and left there for long enough to provide an and, for some, cure. effective dose of radiation therapy to the margins of the cavity where most of the Address comments and questions to: residual tumor is located. Timothy Fullagar, MD Despite these newer techniques, and Co-director, CNI Center of Brain despite better tumor removal up front, and and Spinal Tumors despite better postsurgical treatment such as 701 E. Hampden Avenue, Suite 510 radiation, chemotherapy and biological Englewood, CO 80113 therapy, most patients ultimately relapse. In the past, these patients were essentially abandoned medically and died rapidly. Most recently, for patients with good residual neurological function and quality of life, we have offered re-operation followed by newer postsurgical treatments. Although this is not always beneficial, many patients have had significant benefit in extension of survival and quality of life; a few have had long-term survival and might be considered cured. This approach is not unique to our Program, but is used much less commonly in most other centers. Conclusion. The role of the surgical neuro-oncologist (neurosurgeon) in the management of patients with CNS tumors remains crucial to the prospects of these patients for longer and better survival. The neurosurgeon’s role, principally to remove the tumor, is greatly expedited by the development of new technologies to identify the true extent and location of the tumor and Summer 2004 7 www.thecni.org
  • 10. GammaKnife Radiosurgery at Swedish Medical Center D. Marshall Davis, MD Stereotactic radiosurgery (SRS) utilizes therapeutic radiation in a novel fashion by combining many narrow “pencil” beams arrayed from multiple directions, precisely focused on a small target. This allows the absorbed radiation dose to be deposited at this focal intersection point while simultaneously minimizing dose deposition in surrounding non-target tissues. Dr. Lars Leksell initially developed this technology in Sweden and the first dedicated device to perform SRS was the GammaKnife in 1967. Initially devised to substitute for standard neurosurgery within inaccessible regions of the brain, it is now considered a standard therapy option for a variety of medical conditions. Dr. Marshall Davis is a Introduction. Stereotactic radiosurgery medical conditions. board-certified radiation (SRS) utilizes therapeutic radiation in a novel The indications for radiosurgery oncologist and has been a fashion by combining many narrow “pencil” continue to expand, with a list that includes member of the CyberKnife beams arrayed from multiple directions, both benign and malignant tumors of the team at Newport precisely focused on a small target. This brain, encompassing primary gliomas as well Diagnostic Center since allows the absorbed radiation dose to be as metastatic lesions, arteriovenous 1994. After earning his deposited at this focal intersection point malformations and functional conditions medical degree from the while simultaneously minimizing dose such as trigeminal neuralgia. Although SRS University of Nebraska, deposition in surrounding non-target tissues. was not widely accepted in the United States Dr. Davis completed his internship at Denver Dr. Lars Leksell initially developed this until the late 1980’s, it has been incorporated Presbyterian Medical technology in Sweden and the first dedicated rapidly into the armamentarium of treatment Center and his residency at device to perform SRS was the GammaKnife options for these medical conditions. Swedish University of California, in 1967. In its current configuration, the Medical Center has had an established San Francisco Medical GammaKnife deposits radiation utilizing a radiosurgery program for 5 years utilizing a Center. His extensive fixed arrangement of 201 isocentrically linear accelerator based technology. This X- experience includes serving positioned, non-opposing 60Co y-beams, Knife incorporates our standard 6 MV energy as clinical assistant each with a nominal energy of 1.25 MeV. The linear accelerator outfitted with special professor at the University distribution of these is in a hemispheric equipment mounted to the gantry head in of Southern California fashion such that a halo or “crown” of order to perform the SRS procedures. With School of Medicine. He radiation is deposited resulting in dose this system, the radiation is deposited within was also department clouds with a roughly spherical or ellipsoid a precisely determined collection of director for radiation shape. These small clouds of dose, referred to intersecting arcs distributed around the oncology at Century City as “shots” are adjusted for volume by varying targeted region. Again, the optimizing Hospital and Sonora Cancer Center. the size of standard available collimators and process strives to conform radiation dose can be clustered together so as to create dose tightly around the intracranial target. distributions that conform tightly around The majority of radiosurgical devices small targets. Initially devised to substitute use an invasive fixed head frame for for standard neurosurgery within inaccessible immobilization to achieve the accuracy regions of the brain, it is now considered a necessary for treatment delivery, although standard therapy option for a variety of newer technologies utilize implanted CNI REVIEW 8
  • 11. fiducials which can be tracked in real time by mean of 4 to 6 months, with the use of cameras, robotically manipulated small linac corticosteroids and standard whole brain beams which track skull position in real time radiotherapy. This contrasts with the recent (CyberKnife ) or relocatable headframes experience gained at multiple radiosurgical which typically utilize a bite block system. centers in which patients with good With all these technologies, the treatment performance status are approached with SRS goal is typically to deliver a single, large or surgical metastasectomy followed by radiation dose to the target so as to take whole brain radiotherapy, or in specific advantage of the radiobiological advantages instances, observation without radiation in inherent in this strategy (the explanation of the hopes of sparing toxicity. Selected which is beyond the scope of this article). patients followed in this fashion have The GammaKnife is still considered survivals of 18 to 24 months or longer. The the “gold” standard for radiosurgery delivery, goal is to maximize control of central nervous and we at Colorado Neurological Institute system disease for the lifetime of the patient and Swedish Medical Center are fortunate to and with the advent of newer and improved soon have this device available for our systemic therapies for metastatic cancer, we patients. We look forward to building on the project ever-increasing survivorship of these initial experience of our linear accelerator- patients. The recurring theme in treatment is based program. To ensure the success of this to maximize and maintain quality of life, endeavor, our effort will include active function, and, when possible, longevity. marketing as well as extensive education to surrounding communities and physicians Conclusion. The cost of GammaKnife both to increase awareness of the potential compares favorably with other modalities utility of the GammaKnife as such as standard surgery, conventionally well as to illustrate how this device has delivered radiation and other anti-cancer changed the paradigm in which we think of therapies. It is also the most cost effective particular illnesses. SRS system as compared to an adapted linear There is abundant literature describing accelerator, providing the volume of patients the use of GammaKnife to treat benign seen is adequate. We anticipate build out and tumors including acoustic schwannoma, construction to begin with installation by the meningioma, craniopharyngioma and both end of October, 2004. Acceptance testing secreting and non-secreting pituitary will follow and with this in mind, we will adenomas. Within the CNI Brain Tumor look forward to the planned dedication of our Program we are excited about its potential GammaKnife facility later this year. Please utility in treating astrocytoma and join us at that time. oligodendroglioma, both primary and recurrent. The “paradigm shift” I discussed is Address comments and questions to: particularly evident for brain metastasis D. Marshall Davis, MD which makes up between 50 percent and 70 Swedish Medical Center percent of individual GammaKnife Department of Radiation Oncology treatments worldwide. Historically, the 799 E. Hampden Avenue, Suite 100 overall survival for patients with brain Englewood, CO 80113 metastasis was as little as 2 months with a Summer 2004 9 www.thecni.org
  • 12. Neuropsychology’s Evolving Role in the Modern Management of Patients With Central Nervous System Tumors Nancy Powers, PA-C, PsyD and Kevin Reilly, PsyD The standard of care for patients with central nervous system (CNS) tumors includes a multidisciplinary team of professionals who provide for diverse complex medical and supportive care to insure a balanced approach to care of the needs of each patient. The role of a neuropsychologist continues to evolve as newer approaches to treatment extend survival. In this article, the current role of the neuropsychologist on the brain tumor team will be highlighted. Introduction. The standard of care for Outpatient Neuropsychological Testing. patients with central nervous system (CNS) Neuropsychological testing may be tumors includes a multidisciplinary team of recommended on an outpatient basis to professionals, who provide for diverse provide a baseline prior to brain surgery. Dr. Powers received her complex medical and supportive care to Testing also provides post surgical serial doctorate in clinical insure a balanced approach for the needs of measurements of brain function pre and post psychology from the University of Denver, each patient. The role of the neuro- radiation and/or chemotherapy. Testing is followed by a fellowship at psychologist continues to evolve as newer used to pinpoint deficits to facilitate the Harvard Medical approaches to treatment extends survival. rehabilitation and, ultimately, return to work School in the Neuro- In this article, the current role of the neuro- or school. Testing is used to define which psychology and Behavioral psychologist on the brain tumor team will compensatory strategies may be most Medicine Programs. She be highlighted. effective for rehabilitation. received a Master's of Testing is always requested by Social Science in Pediatrics from Neuropsychology Defined. A neuro- Security Disability Insurance or by private the University of psychologist is a doctoral level clinical companies to objectively define if a patient Colorado Health Sciences psychologist with specialty training and has deficits and document when patients are Center, as part of her clinical expertise in evaluation and rehabili- Physician Assistant’s tation of patients with brain tumors, as well training. She specializes in as other types of medical problems affecting adult and pediatric brain function. A neuropsychologist typically neuropsychological uses a number of standardized intellectual evaluation and treatment tests which scientifically measure thinking for patients with brain skills, behaviors, and emotions related to tumors, traumatic brain injuries and other cognitive brain dysfunction. The neurological aspect of disorders. She is the the neuropsychologist’s job involves Director of Neuro- measuring all aspects of the brain tumor’s psychology at the Colorado effect upon the patient’s day-to-day Neurological Institute functioning. Center for Brain and Spinal Tumors. CNI REVIEW 10
  • 13. unable to return to work. Testing maximizes information about size, location, and makeup the patient’s quality of life by providing a of a brain tumor. Imaging, however, provides better understanding of how the tumor only limited information about day-to-day affects all aspects of their lives. Neuro- cognitive, behavioral and/or emotional effects psychological testing is considered a of the tumor. Imaging studies primarily neurodiagnostic procedure which is covered show tumor location relative to the patient’s by most medical insurance companies. cognitive abilities. Functional magnetic Neuropsychologists are particularly helpful resonance imaging (FMRI) is currently used in teasing out organic from psychological at Swedish Medical Center to determine problems. For example, patients with frontal location of motor and sensory cortex. lobe tumors may present with decreased Neuropsychological testing and/or a Wada initiation, apathy, impulsivity and test may help determine whether language is inappropriate behavior. Others may in the left, right, or both hemispheres. Prior misinterpret the patient’s behavior as to an awake craniotomy, the patient practices laziness, lack of motivation and/or with the neuropsychologist the same visual depression. However, a patient may be and auditory stimuli used during surgery. unable to behave in any other way due to There is minimal discomfort during surgery, brain based tumor deficits. as the potentially painful part of the Dr. Reilly obtained his Neuropsychological evaluations are operation is performed when the patient is Doctorate in Clinical particularly useful for patients because brain under general anesthesia. Language areas are Psychology from the tumors often affect complex and unique located during surgery by the neurologist University of Denver in aspects of the individual’s functioning. The using EEG electrical stimulation on a grid. 1988. He has been in type of dysfunction which testing can The part of the brain identified as a potential private practice as a identify varies depending upon tumor language area is stimulated by the Clinical Rehabilitation location, size and grade. In addition, neurologist at the same time the patient is and Clinical Neuro- chemotherapy, radiation and brain surgeries cognitively tested by the neuropsychologist. psychologist since 1990. often compromise brain function because The neuropsychologist’s role during surgery His practice is primarily normal brain tissue is interrupted at a is to assess if language is interrupted by the focused on the psychological cellular level. Testing is helpful for patients EEG electrical stimulation. Once the and neurobehavioral and professionals when resolving issues about mapping is complete, the neurosurgeon can aspects of medical/ neurological condition. treatment possibilities and combinations. make decisions regarding how much of the He has been a member of Decisions regarding which treatments will be tumor can be resected safely by avoiding or the CNI Center for Brain utilized and possible complications are made minimizing damage to the patient’s receptive and Spinal Tumors with the patient and their families, who and expressive language centers. Program since 2001. ultimately make all final decisions. Role of Neuropsychology in Cognitive Inpatient Testing. Awake Craniotonomy. Rehabilitation. The ultimate goal is Another important role of the neuro- returning patients to their previous life psychologist is to assist the neurosurgeon in activities. If complete return to previous identifying eloquent areas of brain function, activities is not possible, another goal is to such as language, to be avoided if possible return the patient to as close a level of during brain surgery resections. Physical functioning as possible. Patients are offered imaging studies provide a wealth of psychological support to facilitate coping Summer 2004 11 www.thecni.org
  • 14. Conclusion. The role of the neuropsychologists at the CNI Center for Brain and Spinal Tumors is to define and treat emotional and organic consequences of the brain tumor and its treatment. We contribute to the Program Team in a variety of ways including cognitive and psychological evaluations, treatment, rehabilitation and disability determination. Our ultimate goal, in concert with the goals of the Program, is to maximize the quality and quantity of the lives of the patients we care for. with lifestyle changes. A patient may require a short-term leave of absence from work or even a permanent leave. Patient support Address comments and questions to: groups are also an integral part of the CNI Nancy Powers, PA-C, PsyD Center for Brain and Spinal Tumors Program 701 E. Hampden Avenue, Suite 370 to insure maximum emotional functioning Englewood, CO 80113 and quality of life. The family is encouraged Kevin Reilly, PsyD to attend the support groups as well. 7800 S. Elati Street, Suite 104 Cognitive rehabilitation may be Littleton, CO 80120 recommended to facilitate physical, vocational and psychological functioning. Cognitive rehabilitation frequently involves retraining the patient’s thinking skills by developing compensatory strategies. These strategies are uniquely designed for each patient using their strengths to help compensate for weaker skills. Learning to use these strategies not only helps them compensate for an impaired cognitive ability, but may help rebuild the skill itself. For example, using a checklist may actually improve attention skills. There are rehabilitation strategies for most areas of intellectual functioning, ie, memory, attention, problem solving, organization, impulsivity and many others. CNI REVIEW 12
  • 15. Role of the Patient Care Coordinator Stacey Per, LCSW The Patient Care Coordinator provides a bridge between the medical and the supportive services at the Colorado Neurological Institute’s Center for Brain and Spinal Tumors. The medical component is comprised of the various physicians and the medical intervention they prescribe. The supportive care component encompasses the Patient Care Coordinator, the Program Assistant, and the Neuropsychologists as well as the menu of programs offered to our patients and families. Introduction. The Patient Care discharged from the hospital with only a Coordinator provides a bridge between the follow up from their neurosurgeon. As a medical and the supportive services at the program ambassador, I meet with these Colorado Neurological Institute’s Center for patients during their admission to introduce Brain and Spinal Tumors. The medical our various programs and other services. I component is comprised of the various then assess their needs and facilitate the physicians and the medical intervention they appropriate referrals. These patients may prescribe. The supportive care encompasses benefit from supportive services such as Stacey Per received her the Patient Care Coordinator, Program meeting with a neuropsychologist or Master’s Degree in Social Assistant, and neuropsychologists, as well as attending our support group. After they are Work with a concentration the menu of programs offered to our patients discharged from the hospital, they have the in health care from the and families. The Patient Care Coordinator benefit of many different programs, as well as University of Denver. She has many different roles. I am the program being acquainted with the Coordinator if worked at Denver Health ambassador and advocate for patients and future needs arise. Medical Center in the families in my care. In addition, I maintain In my role as program ambassador, I Emergency Department, existing programs and create new ones to have worked hard to build a relationship where she was awarded a offer our patients and families different with the neurology floor at Swedish Medical certificate in Excellent choices to meet their special needs. Center where most of the Program patients Patient Care .She went on are housed during part of their hospital to co-found Namaste Program Ambassador. In the role of admission. Through this relationship, I have Comfort Care Hospice, where she developed ambassador, I move back and forth between given in-services to promote a sense of good numerous innovative the clinics in the physicians’ offices and will between our team members and the programs. In 2003, she Swedish Medical Center. I speak with the hospital staff. was appointed the acting patients, their nurses, the physicians, the In the role of ambassador, I am an secretary and social chair social workers and other support staff approachable liaison between the patients of the Colorado Chapter of members. I attend various rounds and and medical professionals who may be less the National Association communicate with everyone involved in accessible. I bring homemade cookies to of Social Workers. patient care. I introduce the Program to new patients’ families in the surgical waiting patients and educate the hospital community room, and bring patients handmade blankets about the services offered to the patients in once they reach the floor. Patients are given a the Program. friendly face to talk with during their For example, patients with benign difficult medical crisis. Brain tumor patients brain tumors may have an operation and be show a fear and uncertainty that stems from Summer 2004 13 www.thecni.org
  • 16. 1. Miller L. The other brain the diagnosis of cancer as well as its impact injuries: Psycho- Support Services. The CNI Center for therapeutic issues with on daily functioning.1 As a patient ambas- Brain and Spinal Tumors holds a monthly stroke and brain tumor sador, I am able to “humanize” the medical patients. Cognitive support group for both patients and their Rehabilitation. process so that patients feel they are not just caregivers. It is critical that both patients and 1991:9(5);10-16. brain tumor patients, but individuals who caregivers feel they are not alone with this 2. Fawzy FI, Fawzy NW, Canada AL. still have dreams and hopes for the future. disease. The therapeutic benefits of Psychoeducational discussing the unique problems of having a intervention programs for patients with cancer. Patient Advocate. In my role as patient brain tumor are immeasurable. Both patients Psychologische Betrage. advocate, I meet with patients and assess and caregivers need a safe place to 2000:42(1);95-117. 3. Salander P. Brain tumors their needs. I may assist patients with grant decompress and brain storm about coping as a threat to life and requests or provide resources for community strategies. Patients benefit from sharing their personality: The spouse’s perspective. Journal of programs and resources. I have helped stories and not feeling as if they are the only Psychosocial Oncology. patients and their families with information ones embarking on this difficult journey. 1996:14(3);1-18. 4. Branka AM, Jakovljevic on topics that range from finding assisted So often the caregiver’s needs are M, Branimir M. living to deciding which breed of dog may be overlooked. We address this need by splitting Depression, cancer and religiosity. Psychiatria best for them. I help patients with disability the group into patients and caregivers. This Danubina.2002;June, applications and make referrals to hospice provides the caregivers the ability to share 14(1-2);9-18. and home health agencies. Most importantly, their own stories and to get support through I am a sounding board, a confidant. I am a their process. Spouses should be viewed as person they can share their frustrations with separate people with their own needs.3 at times, and offer a shoulder to cry on at In our support group, we start out as a other times. I gauge patients’ moods and may larger group of both patients and caregivers offer an encouraging word, a joke, or a tissue. to discuss general issues. We then split up into a group of patients and a group of Support Program Coordinator. In my caregivers. This gives both groups the ability role as support program coordinator, I oversee to express the very different frustrations that and facilitate a monthly support group. I they are facing. In the different groups, the attend the monthly healing service, plan and members can get validation and support in a oversee a quarterly fun activity, “match” non-threatening environment. newer patients with more experienced The group addresses issues of coping, patients and oversee the Heartstrings depression, isolation, dealing with friends volunteers. It is paramount for patients to and families. The group takes a solution- have several choices to obtain emotional focused approach to these and other issues support. Based on a review of the literature identified by its members. Physicians who and authors clinical and research experience, are affiliated with the Program, as well as cancer patients may benefit from a variety of outside service providers may attend to give a psychological intervention programs.2 brief in-service to the group. Both patients Finally, I keep statistics about how and caregivers are given the opportunity to many patients we are treating, what type of learn more about different treatment options tumors they are diagnosed with, and what related to brain tumors. services they may be receiving. This enables the Program to track its growth and let us Healing Service. The CNI Center for evaluate how our services are being utilized. Brain and Spinal Tumors addresses more than CNI REVIEW 14
  • 17. just the physical and the psychosocial aspects not have seen one another for a period of of having a brain tumor. The interfaith time to reacquaint themselves with the Healing Service addresses the spiritual Program and its current activities. This component as well. Traditionally, the medical service includes candle lighting, live music model does not address issues of spirituality and sentiments of patients, caregivers, and or religion. By holding a monthly Healing team members. Service, the Program acknowledges the importance of spirituality and fellowship Heartstrings Program. The CNI Center within the community it is treating. A large for Brain and Spinal Tumors is fortunate to portion of published empirical data suggests have a team of volunteers to add warmth and that religious commitment may play a heart to our program. This is facilitated beneficial role in preventing depression and through the Heartstrings Program. We have physical illness, and facilitate recovery.4 As volunteers who knit and quilt blankets. Patient Care Coordinator, I encourage These blankets are given to patients post patients and their family members to connect surgery. Our volunteers wanted to address the with their spiritual source. I work closely need for support for families while patients with the chaplain intern from Swedish are undergoing surgery. We have a loyal Medical Center, and encourage patients to troop of cookie bakers who supply our get spiritual support. families with fresh, homemade cookies while in the family waiting room during their Quarterly Leisure Event. Our patients loved ones surgery. Heartstrings is able, and their families have identified the need to through funds donated to CNI, to help many have group recreation activities as a patients with the financial burdens of mechanism to interact with other patients battling a brain tumor. and families in a relaxing, enjoyable manner. To address this issue, we have created Peer Support Coaches. Patients may not quarterly “fun” activities, such as watching feel comfortable going to a group or social movies, having picnics and casual gatherings. activity. They may prefer to speak with an The patients and their families are given the individual on a one-to-one basis, someone creativity to decide what they want to do in who has already undergone various treat- the future. One family reported they wanted ments and has been dealing with the same to make scrapbooks around having a brain disease for a longer period of time. The tumor. Another family is interested in concept of having a peer coach is helpful not planning a retreat for couples so they can only for the patient being coached, but for have some relaxing time together to enjoy the coach as well. The peer support coach is life and not have to worry about being a helped by being able to “give back.” The patient for a few days. coaches are able to share their success story and to internalize their unique process. Reflecting the Light. The CNI Center The patient is able to see that they are not for Brain and Spinal Tumors has a spring alone in this disease process. They are able ceremony to reaffirm life and to remember to identify with the longer term survivor those who have not been as fortunate in the and gain a sense of hope through the Program. This is a time for people who may outcome of another. Summer 2004 15 www.thecni.org
  • 18. Conclusion. The Patient Care Coordinator plays a pivotal role in a unique program at the Colorado Neurological Institute. This role will grow and evolve as the needs of the Program continue to expand. As medical treatments become more complex and more successful, more emphasis will be placed on supportive care. As demonstrated in this article, our Program recognizes this need, and through the Patient Care Coordinator has sought to continue to balance our outstanding medical care with a strong supportive care program. Address comments and questions to: Stacey Per, LCSW 701 E. Hampden Avenue, Suite 330 Englewood, CO 80113 CNI REVIEW 16
  • 19. Chemotherapy for Brain Tumors: Current Status and Controversy Edward Arenson, MD The current status of chemotherapy for relatively homogeneous group. Therefore, if primary malignant tumors of the central only a small percentage of patients benefit nervous system (CNS) is controversial and and the rest do not, the treatment is deemed complex. Despite the fact that it is well ineffective. Suppose, however, that the known in the oncology community that disease is not homogeneous, but cancer is virtually never cured with single heterogeneous, which is almost certainly the agent chemotherapy (monotherapy), the case. For example, the prognosis for patients current “standard” treatment for with tumors that can only be biopsied, no Dr.Arenson was glioblastoma, the most lethal of all CNS matter how effective the postsurgical graduated from Cornell tumors, is single agent temozolomide (TMZ). treatment, is substantially worse than those University and This relatively new drug has the advantage of with gross total resections. Furthermore, Hahnemann Medical being an oral agent, relatively low toxicity genetic and metabolic studies indicate that College. He completed a profile and crossing the blood brain barrier. these tumors are extremely complex and residency in pediatrics at Furthermore, it is easy for oncologists to diverse. It is, therefore, naive to think that the University of Colorado give. A recent study has clearly demonstrated the majority of patients are likely to benefit Health Sciences Center and that survival is improved (3 months) if this from any single treatment or any Denver Children’s drug is given both during and after radiation combination of drugs. However, a certain Hospital. Over the past therapy.1 However, the disease remains subgroup might benefit substantially from decade, Dr. Arenson has essentially incurable with this approach. The such treatments. focused his attention on principle argument against using TMZ in In this context, it would be reasonable children and adults with combination with other drugs is that, thus to consider not one, but perhaps several central nervous system far, studies have not established the safety treatment options for each patient until tumors. Dr. Arenson, along with Dr. Timothy and efficacy of such combinations. either an effective combination is found, or Fullagar, has developed a It is unlikely that studies conducted in all options have been exhausted. There are at multi-modal treatment the classical clinical trial model will lead to least 10 drugs that have been shown to be strategy for adults with the acceptance of combination chemotherapy efficacious in treatment of high-grade high-grade gliomas with as best treatment for high-grade CNS gliomas (carmustine, lomustine, vincristine, curative intent, and has tumors. Classical therapeutic clinical trials procarbazine hydrochloride, irinotecan, helped organize the CNI must show a statistically significant carboplatinum, etoposide, paclitaxel, Center for Brain and advantage of a combination over a single vinorelbine tartrate, temozolomide, nitrogen Spinal Tumors Team. agent sufficient to justify the cost and added mustard). Further, the response rate to these risk that is inherent when additional agents drugs is not dramatically different one from are given. This experimental model assumes another. The possible combinations of these that the treatment is being given to a drugs are mathematically enormous given the Summer 2004 17 www.thecni.org
  • 20. 1. Stapp R, et al. variety available. Nevertheless, most patients Concomitant and temozolomide (TMZ) receive only one of these drugs before they and radiotherapy (RT) fail and progress to a fatal outcome. In our for newly diagnosed glioblastoma Program, much to the dismay of some of the multiforme (GBM). payers, we approach each patient as a unique Conclusion results of a randomized, phase III individual. If our current first line treatment trial by the EORTC is not successful, we change to another Brain and RT groups and NCIC clinical trials approach provided the patient wishes to group. JCO Supplement. continue and has the quality of life sufficient 2, July 15, 2004. to justify such an approach. In this manner, we have improved overall survival for the entire group and have achieved long-term survival or, perhaps cure, for some patients where such an outcome would appear to be unthinkable. Certainly our approach is controversial. It must be continued in a manner which will allow its critical scrutiny by others and have the potential to be made available to patients outside our Program. This will require much ingenuity and creativity, but it will be done. Address comments and questions to: Edward Arenson, MD 701 E. Hampden Avenue, Suite 370 Englewood, CO 80113 CNI REVIEW 18
  • 21. CNI REVIEW Online The CNI REVIEW is a medical review journal for medical professionals. Each issue focuses on a specific disease with a collection of articles written by medical experts. Full text issues — published since Spring 1998 — are available online at www.thecni.org. Abstracts are available for previous years. To order a hardcopy of the CNI REVIEW, send your requests to: npyle@thecni.org, please specify issue date and title. You may also call CNI at 303/788-4010. CNI REVIEW’s Online: Issue Year Title Fall 2003 Epilepsy Fall 2002 Peripheral Neuropathies Spring 2002 CNI: Our Story Spring 2001 Spine and Spinal Cord Injury in the New Millennium Fall 2000 Stroke Summer 2000 Sports Injuries Fall 1999 Family Practice Issues in Neurology Spring 1999 Sleep Disorders Winter 1998-1999 Movement Disorders Spring 1998 Spinal Cord Injury Abstracts Online: Issue Year Title Winter 1997 Frontiers in Traumatic Brain Injury Summer 1996 Algorithmic Approaches to Neurologic Conditions Winter 1995-1996 Frontiers in Brain Tumors Fall 1994 Low Back Pain Spring 1994 Frontiers of Movement Disorders Fall 1993 Neurologic Evaluation Spring 1993 Frontiers of Neurosurgery Winter 1992 Frontiers of Neuroimmunology Winter/Spring 1992 Neurotology Summer 1991 Stroke Winter/Spring 1991 Epilepsy Fall 1990 Diagnostic Techniques, Part 2 Spring 1990 Diagnostic Techniques, Part 1 Fall 1989 Introductory Review Summer 2004 19 www.thecni.org
  • 22. CNI Programs and Services CNI Center for Brain and Spinal Tumors Edward B. Arenson, M.D. 303/788-8675 Timothy M Fullagar, M.D. 303/788-4000 CNI Center for Hearing 303/783-9220 David C. Kelsall, M.D. CNI Epilepsy Center 303/788-4600 Barbara Lynne Phillips, M.D. Kirsten Bracht, M.D. CNI Movement Disorders Center Rajeev Kumar, M.D. 303/788-4010 Lauren Seeberger, M.D. 303/788-4600 CNI Neuromuscular & Peripheral Nerve Disorders Center 303/788-1700 Marc Treihaft, M.D. CNI Stroke Program 303/781-4485 Don B. Smith, M.D. Cranio-Facial Surgery 303/788-6632 Richard E. Schaler, M.D. Dizziness and Balance Disorders 303/788-7880 Barbara A. Esses, M.D. Head Pain Center 303/781-5505 Judy C. Lane, M.D. Interventional Neuroradiology Donald Frei, Jr., M.D. 720/493-3406 Wayne F. Yakes, M.D. 303/788-4280 Neurovascular Surgery Paul D. Elliot, M.D. 303/788-4000 Sleep Disorders Center 303/788-4600 Ronald E. Kramer, M.D. Stereotactic Radiosurgery John McVicker, M.D. 303/788-4000 Marshall Davis, M.D. 303/788-5860 Voice and Swallow Disorders 303/781-0404 Andre L. Reed M.D. CNI REVIEW 20 www.thecni.org

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