Regional Neuro-Oncology Service Information Evening

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Ethelbert Woods
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1 Regional Neuro-Oncology Service Information Evening Dr Tom Flannery Information Evening hosted by Brainwaves NI, in partnership with the Northern Ireland Regional Neuro-Oncology Multi Disciplinary Team.

2 Brainwaves NI Brain Tumour Information Evening Dr Tom Flannery Glioma surgery Stereotactic Radiosurgery Future developments

3 Presentation Outline Current practice and recent developments in neurosurgical oncology in Belfast - Improving the extent of resection in eloquent areas of the brain awake craniotomy - Mrs. Gillian Trimble, Speech & Language therapist - Stereotactic radiosurgery future developments - Fluorescence-guided resection (GALA, INGALA trials) with Gliadel Future service developments and needs

4 Gliomas Although gliomas account for <2% of all primary cancers, they are associated with high disability rate and shortened survival. Although perceived to be rare, actually commonest primary cancer in adults<40 yrs. Although surgical resection can greatly reduce tumour bulk, complete excision is virtually impossible due to the infiltrative nature of these tumours. Although adjuvant radiotherapy and chemotherapy improves survival, death is inevitable from recurrent / progressive disease (usually within 2 years).

5 Gliomas Extent of resection / debulking (whenever possible) improves patient outcome Many technological aids can be used to improve extent of resection :

6 Strategies to improve EOR in Glioma Pre-operative volumetric imaging incorporated into surgical neuronavigation systems e.g. BrainLAB Intra-operative imaging e.g. USS, MRI, fluorescence-guided resection Monitoring of function with tumours adjacent to eloquent areas - the role of electrocortical stimulation in awake patients 6

7 Eloquent sites

8 The role of Awake craniotomy in resection of tumours adjacent to eloquent areas - the importance of functional preservation and improved survival 8

9 Historical Evolution of Awake Craniotomy Early archaeological records of trephination (in neolithic graves) in Peru long before advent of GA Hypothesized reasons for trephination included: rid the body of an evil spirit to cure headaches, epilepsy and insanity to obtain roundels for good luck!!

10 Awake Craniotomy in Belfast Mrs Gillian Trimble Speech & Language Therapist Department of Neurosurgery Belfast HSCT 10

11 FLUORESCENCE-GUIDED TUMOUR RESECTION

13 Patient takes drink 4 hours pre-surgery. Pre-fluorescent drug is selectively taken up by tumour cells. Blue light filter illuminates drug to shine red/pink making it easier to surgeon to differentiate tumour looking down microscope. Gliadel wafers are used to line cavity to give boost of chemotherapy to tumour resection bed.

14 STEREOTACTIC RADIOSURGERY (SRS)

sources are focused so that they intersect at a single location (isocentre).

15 Basic Principles of SRS Plan involves sphere-packing to create a dose distribution that covers the target Inside the shielded treatment unit, the beams from 201 (192) radioactive sources are focused so that they intersect at a single location (isocentre). The result is an elliptical region of high dose with a rapid fall-off in dose outside the boundaries of the ellipse.

16 Advantages of SRS Very conformal Steep radiation fall off Ability to deliver high doses of radiation very precisely within a 3-D volume Ability to treat smallmoderate lesions close to important structures

Multiple converging arc treatments are delivered with circular collimators or multileaf collimators (a

17 LINAC-based SRS Using the beam s eye-view technique, the radiation arcs avoid critical structures whenever possible. Multiple converging arc treatments are delivered with circular collimators or multileaf collimators (a field-shaping device that uses moveable leaves made out of tungsten in order to generate arbitrary field shapes). MML allows the beam to conform to the target closely and exclude normal structures.

19 Hybrid Plans = conformal arcs + IMRT/VMAT

20 Brain Mets Meningioma Acoustic neuroma Vascular malformation

21 FUTURE DEVELOPMENTS

22 Neuro-oncology is a fast evolving specialty Advances in understanding of the molecular biology of brain tumours (pathology) Advances in understanding of how tumours behave in patients (imaging) Advances in the way tumours are being treated better control / removal but with minimal side effects of treatment Key is to provide an integrated service where local personnel work collaboratively in MDT team to provide the very best care for our patients. Underpinning improvements in service provision is research.

23 Thank You for your attention and support

Specialised Services Policy: CP22. Stereotactic Radiosurgery

Specialised Services Policy: CP22 Document Author: Assistant Director of Planning Executive Lead: Director of Planning ad Performance Approved by: Management Group Issue Date: 01 July 2015 Review Date: