Current and Future Treatment Options: Neurosurgery

1. Current and Future Treatment Options: Neurosurgery Paul L Grundy Consultant Neurosurgeon Wessex Neurological Centre www.braintumoursurgery.co.uk

2. Introduction • NICE guidelines • Current management • Gliomas • Cerebral metastases • The future • Day-case surgery • Enhanced resection • Decommissioning of services? www.braintumoursurgery.co.uk

3. NICE IOG: key recommendations • Care coordinated through MDTs • Every pt with imaging suggesting tumour is rapidly discussed at N-MDT • Neuropath and radiology comply with guidelines and cancer wait times • Communication and information • CNS / key worker roles defined • Palliative care on MDT • Data collection (web) in place www.braintumoursurgery.co.uk

4. NICE IOG Brain & CNS Tumours 2006 NICE IOG brain & CNS tumours • All patients with suspected diagnosis of brain/CNS tumour should be referred to specialist neuro-oncology MDT • All neuro-oncology surgery should be performed by designated specialists www.braintumoursurgery.co.uk

5. Neurosurgical Oncology Neurosurgical oncology • “All specialist neurosurgeons treating patients with CNS tumours should be core members of the N-MDT” • Minimum attendance at N-MDT of 50% • “A specialist neurosurgeon who spends >50% of clinical PAs in neuro-oncological surgery and is regularly involved in dedicated specialty clinics caring for these patients” www.braintumoursurgery.co.uk

6. Controversy 1: biopsy LGG? • Low-grade glioma management options • Surveillance alone • Surgery (to be discussed) • Radiotherapy – timing and dose • Chemotherapy www.braintumoursurgery.co.uk

7. Biopsy of LGG • Reliability of diagnostic imaging? • Will biopsy change management? • How does tumour type influence prognosis? • Risks of biopsy? www.braintumoursurgery.co.uk

8. Reliability of diagnostic imaging • CT/MRI - 60-70% • Contrast enhancement unreliable • Tumour grade (esp II v III) – poor • Tumour type – poor predictive value • DTI – unreliable (Magalhaes et al. Acad Radiol 2005) • PWI – unreliable (Fayed & Modrego. J Neurooncol 2005) • MRS – best available • Specificity & sensitivity 80% (low v high-gde) • Can’t differentiate GBM v met www.braintumoursurgery.co.uk

9. Prognosis of gliomas • Glioblastoma – 6-14 months • Anaplastic astrocytoma – 24-36 months • Grade II astrocytoma – 60-120 months • Anaplastic oligodendroglioma • 1p19q loss – 80-150 months • 1p19q intact – 7-45 months • Metastases – 8-10 months www.braintumoursurgery.co.uk

10. So, should we biopsy ? • YES…….. • NICE: Improving Outcomes in Brain and Other CNS Tumours. 2006: “The diagnosis is confirmed by surgical biopsy, though in a few cases biopsy is either not feasible or clinically inappropriate” www.braintumoursurgery.co.uk

11. Stereotactic biopsy www.braintumoursurgery.co.uk

12. EM frameless pinless biopsy www.braintumoursurgery.co.uk

13. Biopsy? Resection? Biopsy vs resection Controversy 2: Glioma - biopsy or resection? • Benefits • Risks www.braintumoursurgery.co.uk

14. Extent of resection? www.braintumoursurgery.co.uk

15. Resection or Biopsy? Resection or biopsy? • Biopsy • No prognostic benefit • No Gliadel • No benefit of temozolomide • QOL often worse • Steroid dose higher • Resection • Improves prognosis • Gliadel • Temozolomide • QOL often better • Steroid dose less www.braintumoursurgery.co.uk

16. NICE TA - Gliadel NICE TA - Gliadel • Pre-op discussion in MDTM after MRI • Specialist neuro-oncology surgeon • Neuronavigation • Intra-op diagnosis of HGG • >90% resection • Ventricle not widely open www.braintumoursurgery.co.uk

17. Gliadel Implantation Gliadel implantation www.braintumoursurgery.co.uk

18. NICE TA - Temozolomide NICE TA - Temozolomide • Histology confirmed as GBM • WHO performance status 0/1 • Age <70 • (resection?) www.braintumoursurgery.co.uk

19. Median survival for GBM Median survival of GBM? • Best supportive care – 1-2/12 • Biopsy + RT – 6/12 • Resection + RT – 12/12 • Resection + Gliadel + RT – 14/12 Westphal • Resection + RT + temozolomide – 14/12 Stupp • Resection + Gliadel + RT + temozolomide – 21/12? McGirt et al, J Neurosurg 2009, 110(3), 583-8 Affronti et al, Cancer 2009, 115(15), 3501-11 www.braintumoursurgery.co.uk

20. Consensus Consensus • Most patients should be offered tissue diagnosis • Aim for macroscopically complete resection if safely feasible • Otherwise may partially resect if significant mass effect www.braintumoursurgery.co.uk

21. Maximise EOR Neuronavigation ALA Intra-op USS Intra-op MRI Specialist neurosurgeon Minimise risk Awake surgery Neurophysiology Specialist neurosurgeon Surgical goals www.braintumoursurgery.co.uk

22. How we do surgery Pre-op MDT discussion Steroids Minimal access craniotomy Image-guidance Awake surgery En-bloc resection Day-case or short stay surgery How we do surgery www.braintumoursurgery.co.uk www.braintumoursurgery.co.uk

23. Awake craniotomy • Simple technique • Conscious sedation – “full-awake” • Stealth AxiEM – “pinless” • Cortical / sub-cortical stimulation • Clinical testing • No additional neurophysiology www.braintumoursurgery.co.uk

24. Controversy 3:Cerebral metastases • Surgery or SRS? • Post-op WBRT? • Follow-up? www.braintumoursurgery.co.uk

25. Primary tumour type www.braintumoursurgery.co.uk www.braintumoursurgery.co.uk

26. RCT evidence • Patchell et al. NEJM 1990. 322:494-500 • Vecht et al. Ann Neurol 1993. 33:583-590 • Randomised prospective trials • Surgery + WBRT > WBRT alone • Mintz et al. Cancer 1996. 78:1470-6 • No advantage to surgery www.braintumoursurgery.co.uk

27. Surgery or SRS? www.braintumoursurgery.co.uk www.braintumoursurgery.co.uk

28. Gamma knife radiosurgery www.braintumoursurgery.co.uk

29. Radiosurgery results SRS for metastases www.braintumoursurgery.co.uk www.braintumoursurgery.co.uk

30. Surgical results Surgical results • PG Image-guided 121 0.8%96 / 4 4.1% No patients died as result of surgery 2 patients developed severe deficits www.braintumoursurgery.co.uk www.braintumoursurgery.co.uk

31. Survival after surgery www.braintumoursurgery.co.uk www.braintumoursurgery.co.uk

32. Summary • All suspected tumours referred to MDT • Biopsy minimum standard for most • Resection where safely feasible (awake) • Multimodality treatment of GBM • Surgery or SRS for selected patients with metastases • Minimal access navigated surgery • Short hospital stay www.braintumoursurgery.co.uk

33. Patient with suspected brain tumour Neurosciences neuro-oncology MDT meeting MRI likely high-grade glioma? Treat according to tumour type no yes Tumour operable & surgery indicated yes no Surgical resection Possible to resect >90% & ventricle not wide open & specialist neurosurgeon (PG/JD) & frozen section HGG Not possible to resect >90% or ventricle wide open or non-specialist neurosurgeon or frozen section not HGG IGS biopsy No gliadel Insertion of gliadel Neurosciences neuro-oncology MDT meeting Histology = GBM Treat according to tumour type no yes Age >70 yrs or PS 2/3/4 Age <70 yrs & PS 0 or 1 RT + temozolomide RT or palliative care www.braintumoursurgery.co.uk

34. The Future • Biopsy • LA, frameless, pinless, day-case procedure • Histology, molecular analysis, individualised therapy • Resection • Improved safety – awake surgery, specialist surgeon • Enhanced resection – IGS, USS, iMRI, ALA • Multimodality treatments www.braintumoursurgery.co.uk

35. ALA guided resection www.braintumoursurgery.co.uk

36. iMRI www.braintumoursurgery.co.uk

37. However • Beware • Major cost saving strategies of PCTs • Cost effectiveness analyses • Surgical procedures may be easy target • Some procedures may be decommissioned • Patients with cancer will suffer www.braintumoursurgery.co.uk

38. Conclusion • Complex, controversial field • What does the patient want? www.braintumoursurgery.co.uk

39. Thank you ? www.braintumoursurgery.co.uk