Ask Us Anything About… Brain Tumors

Nearly 78,000 new primary brain tumors are expected to be diagnosed this year. There are more than 100 distinct types of primary brain and central nervous system tumors. What treatment options are available?

We get answers to your questions from Dr. Heath Mackley, Radiation Oncologist and Dr. James McInerney, Neurosurgeon.

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Transcript

Description – The video begins inside a waiting room where three men are standing next to each other. From left to right is Dr. Jim Mcinerney, Dr. Heath Mackley and Scott Gilbert holding a microphone.

Scott Gilbert – Thing about brain tumors. I’m Scott Gilbert. Thanks for joining us. Nearly 100,000 brain tumors are diagnosed each year in the United States. That’s almost enough people to fill Beaver Stadium up at Penn State. Here to talk with us today about brain tumors and to answer any of your questions are Dr. Jim Mcinerney and Dr. Heath Mackley. They’re both the co-directors of Gamma Knife Radiosurgery Program here at the Milton S. Hershey Medical Center. Thanks for being here today, guys. I understand that most brain tumors are malignancies that actually started elsewhere in the body. Can you talk about some of what those most common areas are?

Dr. Heath Mackley – Sure. Cancer can arise from pretty much any part of the body, but for cancers that start somewhere else and go to the brain, the most common would be lung cancer, breast cancer, melanoma.

Scott Gilbert – Now, when we talk about cancer, we often think about benign versus malignant. But Dr. Mcinerney, I understand that even a benign tumor in the brain can be dangerous. Why is that?

Dr. Jim Mcinerney – Sure, well, part of the reason we think a malignant tumor that goes to the brain is bad is because your brain’s obviously pretty important. And anything that gets damaged up there is potentially going to affect your life. So a tumor, even though it’s benign, even though it’s slow-growing, could be in a spot where it’s going to affect, say, a nerve or, you know, other structures that make you incapable of doing something. So it could make you deaf or it could give you trouble with balance or walking or something like that. So even a tumor that, you know, is behaving benignly, growing slowly doesn’t seem like it’s that big a deal, if it gets big enough can become life changing and not in a good way.

Scott Gilbert – As we continue our conversation, we welcome your questions for Dr. Mcinerney and Dr. Mackley. You can just add a comment to the comment field below this Facebook post, and we’ll pose that question to them live. If you’re watching this video on playback, feel free to pose your question, and we’ll get an answer for you as well. What do we know about the causes of brain cancer? And for that matter, what do we not know?

Dr. Heath Mackley – Sure Well, there’s a few things that we do know, and then there’s things that we’re still working on. So one of them is environmental exposures. We do know that radiation exposure can lead to the creation of brain tumors, especially meningiomas. We also know about specific hereditary disorders that are tied to certain jeans, so we know there are certain groups of people where in their family, certain brain tumors run. And what we’ve really been learning a lot about more recently over the past decade is most people don’t have brain tumors in their family. It’s not an identified hereditary disorder. Instead, it’s a serious of genetic errors that ultimately leads to the brain tumor. We’re really starting to learn all of those steps, and hopefully that will lead to targeted therapies that go after those genetic mutations.

Scott Gilbert – And Dr. Mcinerney, what are some symptoms of a possible brain tumor? Keeping in mind that if you have one or two of these symptoms, it doesn’t necessarily mean a sure diagnosis.

Dr. Jim Mcinerney – Sure. And that’s probably the thing. Everybody always says I have a headache. I must have a brain tumor. And obviously, most of the time, headaches are not. But the way I like to characterize it is if you have a really bad headache like the worse headache of your life or a headache that’s not going away and keeps staying around, you know. The headache that comes and stays, rather than the headache that comes and goes. If you have a neurological problem with that headache, you know, your eye is drooping or you can hear or you’re weak or off balance or something like that. If you have a seizure, so you know, a neurologically cursed headache. Those are the kinds of headaches that we worry more about. So you know, the one that comes and stays. The ones that causes other problems. And all those other problems, obviously, can happen without a headache too. And so when people have neurological problems, you know, specific things that aren’t working right. Especially, you know, focal things. Not just I don’t feel right. But you know, I can’t hear well. I can’t, you know, I can’t walk right. Those are the kinds of things that really make us, you know, sit up and take notice.

Scott Gilbert – So not a headache for a day or two. It goes a little beyond that.

Dr. Jim Mcinerney – Right, exactly.

Scott Gilbert – You’re watching Ask Us Anything About Brain Tumors from Penn State Health. I’m Scott Gilbert alongside Dr. Mackley and Dr. Mcinerney. Feel free to let us know if you have any questions. Just post them in the comment field below this Facebook post. And also we ask you to, if you’re enjoying this video, you’re finding it informative, please share it as well on your Facebook page and help to get the word out about this good information. I’d like to ask you a little bit about how brain tumors are diagnosed, including how you determine whether it’s malignant or benign. How does that process begin?

Dr. Heath Mackley – Sure. Well, there’s generally two things you can do. The first one is you get imaging. And so often that’s an MRI. Occasionally, it’s just CT scans, instead because there are people that cannot have MRIs. And then the other second thing is usually getting a biopsy. Now there are times when we will occasionally not do a biopsy because it’s either a very bad location or we are almost certain it’s a benign tumor based on how it looks in the MRI. But for most people, it’s imaging and biopsy. Those are the two ways that we figure out exactly what kind of brain tumor it is.

Scott Gilbert – So we all know the brain does a lot of different things. There are many different parts to it. So I imagine part of the severity of a diagnosis, I would imagine, depends on where that tumor’s located, correct?

Dr. Jim Mcinerney – Sure, absolutely. And there are, you know, all different types of tumors that can give you all different types of problems, obviously. A lot of the benign tumors that we see will often, like I said before, give sort of focal problems, where all of a sudden you can’t hear or your balance is off or your vision is off for something like that. There are other tumors that can be more diffuse, and they can attack larger areas of the brain. And so people have trouble thinking or, you know, planning or participating and things like that. so there’s a lot of different, you know, kinds of symptoms that you can have.

Scott Gilbert – A lot of different treatments too. Chemo, surgery, radiation are all options. So how do you determine the best treatment plan for a particular patient? Where do you start?

Dr. Heath Mackley – Well, it starts with a team. And so besides seeing the individual physicians, the physicians will get together into a meeting called a tumor board. So we’ll have neurosurgeons there, radiation oncologists, neuro oncologists, radiologists, and we’ll all put our head together to say for this individual patient, what’s the best plan of care for them?

Scott Gilbert – Dr. Mcinerney?

Dr. Jim Mcinerney – Sure. Yeah, one of the things you need to know is what are you taking care of, right? And as we’ve said, there are an awful lot of different types of tumors and problems. You know, some things are going to be, again, very focal in one location. If it’s, you know, if it’s something we can identify and take out, we love to be able to operate on something and make it go away forever. But there are other things where that’s not possible. There are some tumors where they are diffusely growing within normal brain cells that are doing important jobs, and we can’t just cut them out and make them go away. And so in those situations, sometimes we have to do something that’s going to target those bad cells without hurting the good ones as best as we can. And that’s where things like radiation and chemotherapy come into play. And so obviously knowing what you’re dealing with is what you have to start with anytime you’re trying to make these kinds of judgment calls and decisions.

Scott Gilbert – And the most targeted type of radiosurgical [phonetic] of radiation is Gamma Knife radiosurgery. We’ve been doing that here in Hershey for many years. But just recently upgraded to the Gamma Knife Icon. So let’s talk a little bit about that machine, which is just down the hall from us right here where we’re standing. So when does that come into play?

Dr. Jim Mcinerney – So anytime we’re treating, maybe a little bit off from what I just said, but when we’re treating something focally, but we’re trying not to do a traditional operation, right? So we can target anything in the brain with radiosurgery. The difference is basically that when we do radiosurgery, we sort of mean that as we’re going to do it once or maybe, you know, occasionally we’re divide that up into two or three treatments. But for the most part, we’re trying to do a one-time radiation treatment to, you know, obliterate, you know, to kill whatever it is that’s causing the trouble. And so there are a lot of different tumors and other conditions too that we can target that way.

Scott Gilbert – And tell me how that works. I mean, how are you able to target a part of the brain in such a non-invasive way. I guess it all involves a lot of beams of radiation that basically meet in one place, right?

Dr. Jim Mcinerney – Exactly. So it’s sort of, I like to think of it as a geometric solution, right? The trick with radiation is how do you hurt the thing that you want to hurt and not hurt everything else? And with the Gamma Knife, we take 192 low-dose beams and point them at the same spot. And so that each individual beam is not powerful enough to really be damaging, but where they come together, that energy summates and it increasing exponentially. And so what we target, what we put at the focal point where all those beams are meeting gets damaged. But as we get away from that central point that that dose of radiation goes down exponentially so that even though everything sees radiation, doesn’t see enough to be damaged by it. We see radiation when we walk outside, and we don’t get damaged by it. So we see radiation all the time. And that’s what we have to do is to make sure that everything that’s normal that we don’t want to have damaged by this doesn’t get enough radiation to be damaged by it. We want to hurt the thing that we want to target, you know, the tumor or whatever else that we’re going to put there.

Scott Gilbert – Makes good sense.

Dr. Heath Mackley – I think it’s important to add with the actual planning process that it’s a team approach as well. So you have a neurosurgeon and a radiation oncologist develop the plan together. And then at that point a medical physicist will then review the plan to make sure that all of the safety and quality parameters have been achieved. So it’s really a team effort also in creating an individual plan for each patient.

Scott Gilbert – A lot of people behind each of those procedures.

Dr. Heath Mackley – Yes.

Scott Gilbert – And tell me a bit about the importance of the recent upgrade to Icon. Why is that an important step?

Dr. Heath Mackley – Well, I’m really excited about the Icon. And that’s because it takes the strength of the Gamma Knife, which Jim just described very well, but it adds a few things that gives us a few more capabilities. And so one thing we’re able to do now is to treat with a mask instead of a framed system. Now, we still use the frame system a lot. It’s a very good system. But there are patients that can’t have a frame and the mask gives us an alternative for those patients. Additionally, the mask system allows us to treat patients in more than one treatment. Jim had also eluded to that. There are patients where there is an advantage to treating two, three, up to five times. And it’s generally patients that have tumors that were too big for traditional single treatment Gamma Knife. So the mask allows us to do that. Besides that, we also have a motion management system. Because the mask isn’t quite as tight as a frame is. However, we’re still able to individualize the plan for the patient because we will do a motion study to see exactly how much the patient moves during the time that they’re laying under the mask. And then we can take that into account in our planning process so that way we don’t miss the target at all. And then the last thing is we have a cone beam CT which gives us a lot of flexibility. For the people that don’t know what that means, basically, we’re able to get a mini-CT scan while the patient’s on the table right before we treat them. That is a quality assurance check for patients with frames. But it also gives us the flexibility of being able to plan off of MRIs that weren’t done that day.

Scott Gilbert – So it really allows you to be a precise as possible.

Dr. Heath Mackley – Yes.

Scott Gilbert – All this really amounts to. Great, well thank you for the good information. And if you have any questions, even if you’re watching this video on playback, we encourage you to share them in the comment field. We’ll track these guys down and get an answer for you. We also encourage you to share this video as well to get the word out about this information about brain tumors. This has been Ask Us Anything About Brain Tumors from Penn State Health. My thanks to Dr. Jim Mcinerney, Dr. Heath Mackley, and my thanks to you as well for tuning in.

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