Neuro-oncology

The neuro-oncology program at Westchester Medical Center is a comprehensive program for both adults and children and emphasizes a multidisciplinary approach. Management decisions are made in a tumor board setting for both adults and children with malignant brain and spinal cord neoplasms. The department also has expertise in treating complex spinal tumors and peripheral nerve neoplasms.

Primary brain tumors account for approximately 1.4% of all cancers and 2.4% of all cancer-related deaths. About 35,000 new cases of primary brain tumors are diagnosed in the United States each year. The average age at diagnosis is about 57 years. No clear etiologic factors are known to cause primary brain tumors at this time, however, certain correlations are known. For example, there is a higher incidence of meningiomas in women with breast cancer. Similarly, there is also a higher incidence of meningiomas after prolonged survival in patients receiving cranial radiation for some other disease, such as leukemia. Glioblastoma multiforme (GBM) accounts for approximately half of all primary brain tumors. Secondary or metastatic tumors of the brain are also extremely common, especially from primary sources, such as lung and breast. Primary central nervous system lymphomas have become more common and currently accounts for approximately 3% of all brain neoplasms. Examples of benign brain tumors include meningiomas, acoustic neuromas, pituitary tumors, and pilocytic astrocytoma in children. Posterior fossa tumors are more common in children and examples include medulloblastoma, ependymoma, and cystic astrocytoma.

Diagnosis

The diagnostic procedure of choice for many patients with brain neoplasms is a MRI scan. Such a scan should be performed with and without administration of a contrast, such as gadolinium.

At WMC, we also have a 3 tesla magnet. This high-field-strength magnet allows us to perform advanced MRI techniques, such as spectroscopy, diffusion tensor tractography, and functional MRI tensor and perfusion studies. The 3 tesla magnet also outlines a lesion with exquisite anatomical detail which helps the surgeon in choosing a safe trajectory to the tumor.

MR spectroscopy often helps us differentiate tumors from other tumor like lesions, such as stroke and abscess.

Functional MRI scan allows us to precisely delineate important areas, such as the motor, sensory and speech areas of the brain.

Diffusion tensor tractography reveals how important tracts such as the pyramidal tract fibers are related to the tumor. This is of great importance to the surgeon while resecting these tumors without damaging such important structures.

Tumors with a rich blood supply and also those related to important blood vessels such as the carotid artery can be studied by using MR angiography.

In very vascular tumors or tumors where embolization is feasible, catheter cerebral angiography is carried out in a biplane neuro interventional suite. This advanced suite allows preoperative embolization of tumors to reduce vascularity and aid the surgeon during resection. A dedicated neuropathology team carefully analyzes these tumors with special stains and molecular methods to precisely define the nature of these tumors and their grading with regards to malignancy.

Treatment

A wide array of treatment strategies are offered in a customized fashion to best treat patients with these complex tumors. Depending on the nature of the tumor, it's location, and the age of the patient an appropriate sub-specialist is available to tackle the problem in the best possible manner.

Surgical treatment is carried out in a state-of-the-art operating room with complex and costly technologies that can only exist in a major tertiary care health center. We routinely employ computerized image guided navigation and interoperative ultrasound to safely resect these tumors in a as complete a fashion as possible. We have dedicated neurosurgeons and skull base neurosurgeons for dealing with tumors in these areas.

Some deep tumors may need a framed stereotactic biopsy followed by adjuant radiation or chemotherapy. On the other hand, certain benign skull base tumors can undergo complete resection by a team of neurosurgeons and otolaryngologists through complex skull base approaches, lasting many hours.

Intraoperative cerebral monitoring and cranial nerve monitoring is utilized to preserve function. A neurophysiologist is present in the operating room while operating on the brain to monitor motor function, sensory function, brain stem function, and cranial nerve function. Dedicated neuro-anesthesiologists provide the best possible conditions to safely operate on the brain with maximal preservation of function. Minimally invasive and endoscopic procedures are routinely performed for pituitary tumors and deep seated tumors, especially within the ventricular system. A separate team of specialists exist for dealing with children with brain tumors in a dedicated modern children's hospital with facilities rivaling any in the world.