When you hear about advancements in brain surgery, it’s often a report of a new technology, surgical approach, or technique. But just as important are new ways of thinking that lead to shifts in how we care for patients.
My colleagues and I at UT Southwestern have participated in research and thought leadership advancements that have transformed standards of patient care.
Four advancements strike me as the most profound in the treatment of brain tumors.
“More brain tumors can now be removed through the nose without having to open the skull. Harkening back to the Egyptian mummification process of organ removal through the nose, this minimally invasive technique may seem simple, but endoscopic brain surgery is actually a complex procedure that was years in the making."
1. Stereotactic radiosurgery
Not long ago, patients who had a pituitary tumor, acoustic neuroma, or meningioma had limited treatment options: undergo traditional craniotomy to remove the tumor, followed by fractionated radiation. Traditional radiation typically is delivered to the tumor and surrounding tissue, which can lead to hair loss, damage to healthy tissue, and skin changes.
Stereotactic radiosurgery changed all that. Two of the better known types are CyberKnife and GammaKnife. Stereotactic approaches deliver highly focused radiation directed solely to the tumor, which spares more healthy tissue and markedly reduces side effects. Perhaps the biggest benefit is that treatment usually can be completed in just one session, saving patients time and the hassle of traveling.
We are regularly finding more applications to use stereotactic radiosurgery alongside other traditional approaches, so patients with a wider range of brain tumors likely will be eligible as time goes on.
Using the GammaKnife to make brain surgery safer
UT Southwestern was the first hospital in Texas to use the GammaKnife, a cutting-edge tool that paves the way for safer and more convenient radiation treatments for brain tumor patients. The machine gives doctors the ability to combine precision treatment and increased protection, without the need for halo-style head restraints.
2. Endoscopic brain surgery
More brain tumors can now be removed through the nose without having to open the skull. Harkening back to the Egyptian mummification process of organ removal through the nose, this minimally invasive technique may seem simple, but endoscopic brain surgery is actually a complex procedure that was years in the making.
The biggest hurdle was that, frankly, the nose and sinuses are natural receptacles for germs and debris. We now have techniques to effectively seal off the brain from the nasal cavity to prevent infections and leakage of spinal fluid.
Additionally, technological advances for surgical visualization – our ability to see what’s going on in the brain and nasal cavities – have become much more advanced. And we now have sleek, slender tools to enter the nostrils, disturbing less surrounding healthy tissue.
Endoscopic techniques require fewer and smaller incisions, resulting in quicker recovery and less scarring than craniotomy. And by approaching pituitary adenomas, meningiomas, and chordomas from the bottom of the brain via the nasal cavity, we don’t have to move the brain nearly as much as we had to during craniotomy. This reduces the risk of damaging healthy tissue and aids in quicker recovery.
Removing tumors with innovative techniques
UT Southwestern's Skull Base Program takes a multidisciplinary and minimally invasive approach to treating patients. Advances in technologies and surgical techniques have made it possible to remove tumors through the nose or ear canal.
3. Laser interstitial thermal therapy
Laser interstitial thermal therapy (LITT) is a state-of-the-art surgical technology that can ablate (destroy with heat) a tumor through a tiny incision in the skull.
In this minimally invasive procedure, the surgeon inserts a laser fiber into the incision and directs it to the tumor. The laser transfers heat, destroying the tumor while sparing healthy tissue surrounding it. We monitor the patient’s brain using real-time MRI visualization to watch and see if areas of the brain get warm. If they do, we can reduce the heat to avoid tissue damage.
LITT usually takes around 4 hours, and most patients can go home after a few days. Today, we use LITT to ablate tumors that are difficult to access or extract, or for metastatic tumors. However, the procedure is showing promise for glioblastomas, which are aggressive brain tumors – recent research suggests it can extend patients' lives compared to standard treatments. LITT can also be an option for patients with radiation necrosis, a lesion that can develop as a result of traditional radiation.
NeuroSphere 360 - Voyage into the Brain
The Peter O’Donnell Jr. Brain Institute takes you on a journey deep into the brain to see what the forefront of neuroimaging looks like.
4. Emphasis on quality of life
In the last 20 years, brain surgeons have begun to analyze how we gauge success. We used to focus mostly on thing like how many tumors we removed, the extent of resection and median survival rates, etc. Of course, the number of tumors extracted is still important for us to track and for patients to understand. Typically, the higher-volume the center, the better the surgical outcomes.
But today, one of our most important goals is to improve or maintain our patients’ quality of life after surgery. To achieve this at The Peter O’Donnell Jr. Brain Institute, we take a team approach to recommending treatments for patients with brain tumors. Doctors, nurses, specialists, and therapists meet regularly to discuss every case and consider all potential therapies and find the least invasive, most effective therapy for each patient.
As minimally invasive surgical options continue to expand, we can offer more patients improved quality of life without reducing the effectiveness of their treatments. In some patients, we can avoid procedures altogether through active monitoring (regularly checking for tumor changes) or medical management.
What will the next 20 years bring?
So much has changed in just two decades of brain surgery. I’m eager to see what advancements will transform patient care over the next 20 years. I anticipate that a focus on quality of life will continue to be just as important as it is today, if not more so. And, even as technology advances, the team approach to care is likely to remain a vital part of brain surgery.
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