Delicate brain surgeries—
high-tech equipment, new approaches
The future of neurosurgery is arriving now at the Health Science Center.
Minimally invasive brain surgery performed with sophisticated computer and imaging systems and radical resections (removal) of malignant brain tumors, followed by delivery of radiation therapy with pinpoint accuracy, are among the numerous clinical and research projects of the division of neurosurgery.
At a recent conference on "Surgery at the Dawn of the 21st Century," Alexander G. West, MD, PhD, assistant professor of neurosurgery, outlined some of the new minimally invasive approaches for surgical treatment of brain tumors. Surgeons in the past, explained Dr. West, used a standard approach to operate on pituitary gland tumors—going through the skull—a procedure called a craniotomy. Within a year, Health Science Center surgeons will be able to approach such tumors through the nose (since the pituitary is located behind the sphenoid sinus) with a new high-tech imaging system known as flaneless stereotaxy.
With the flaneless stereotaxy system, to be housed at University Hospital, a pointer tool is inserted surgically in the brain or spine, and the tool transmits three-dimensional images of its exact location onto a computer screen.
"Flaneless stereotaxy is a very sophisticated computer and imaging system where you can guide surgery by using minimally invasive techniques to arrive not only at the pituitary gland, but practically any lesion, and be very confident that you have resected the tumor and provided the least amount of perturbation of normal tissue," Dr. West explained. "It’s like a guidance system, almost; like being in a simulator for fighter pilots—you’re aware of where you are anywhere in space." He added that neurosurgery is probably the only surgical subspecialty with a system that provides three-dimensional images.
Another multidisciplinary approach at the Health Science Center has given new hope to patients with malignant brain tumors.
In October 1997 Dr. West operated on 42-year-old Elizabeth Mallory. A resident of Fort Walton Beach, Fla., she had emergency surgery at an area hospital to remove a malignant brain tumor. Surgeons there were able to remove about 40 percent of the orange-sized mass (glioblastoma), and told her she had a few months to live.
Mallory, who wanted very much to live a long life with her husband, children and grandchild, sought a second opinion and was referred to Pamela Z. New, MD, clinical assistant professor of medicine at the Health Science Center.
When Mallory arrived at the Health Science Center, she learned that in addition to Dr. New a team of physicians and researchers would be assisting with her case, including Dr. West; Bill J. Salter, PhD, assistant professor/research of radiology; Terence S. Herman, MD, clinical professor of radiology; and James M. Hevezi, PhD, director of medical physics at the Cancer Therapy & Research Center (CTRC).
Mallory was advised to have another resection—this time with greater than 95 percent of the tumor to be removed and radioactive seeds to be implanted around the rim of the resection cavity.
"We know that by reducing a malignant tumor by the greatest amount provides the best prognosis," said Dr. West. "The problem we have is trying to get control of the tumor since there are always tumor cells left behind that infiltrate the surrounding normal brain. The prognosis is abysmal in the usual sense, with just surgery and radiation; however, by using radical resection assisted by intraoperative mapping and implanting iodine 125 seeds around the rim of the resection cavity, the results are probably the best to date in terms of local control of the disease.
"We’re not talking about cure," Dr. West cautioned. "We’re trying to provide the longest quality life available for these patients with such a devastating disease."
After surgery, Mallory had several weeks of radiation therapy delivered by the new Nomos Peacock system housed at the CTRC. Capable of delivering radiation with pinpoint accuracy, CTRC’s new Peacock system is one of only 16 worldwide.
"The Peacock system allows us to treat patients we couldn’t treat before because we could not pinpoint radiation," added Dr. Salter, a medical physicist. "If you get close to the mid-brain and to critical structures, you risk doing more damage than good. Elizabeth’s is a very difficult-to-deal-with situation—we’re very excited that we have a tool like the Peacock system that allows us to approach it in novel and more effective ways."
Mallory returned to Florida in January following her radiation therapy. She is scheduled to visit the surgical team at the Health Science Center every few months.
"Everybody at the Health Science Center is just wonderful," said Mallory. "The doctors here had a plan and knew what to do."
Dr. West works in the division of neurosurgery along with Dennis G. Vollmer, MD, associate professor of neurosurgery and division head; Willis E. Brown, Jr., MD, professor of neurosurgery; and Micam W. Tullous, MD, clinical assistant professor of neurosurgery.
