Michael Sughrue, MD, Director of the Brain Tumor Center and Associate Professor of Neurosurgery at University of Oklahoma, discusses a lighting treatment for brain tumors.
Interview conducted by Ivanhoe Broadcast News in May 2017.
Tell me about this specific case.
Dr. Sughrue: He has a very aggressive form of brain cancer called glioblastoma and I met him several years ago. Initially, it’s a tumor in the language area so the first day of this kind of standard approach is called an awake craniotomy. Where essentially what we try to do is we go in with the patient awake and we stimulate parts of the brain while they’re talking to try to figure out how the language network is put together so we don’t cut out critical parts of it. I’ll never forget the case because it was just incredibly challenging, it really was right in the middle of his language area. I persisted and tried, at best I got maybe two-thirds of the tumor out. It was a very big piece left in the language area. And we just said that’s the best we could do. So we gave him the standard chemotherapy and radiation, then five to six months later this tumor was back with a vengeance. I mean it looked terrible. So we know that on average, if you just basically throw another chemotherapy drug at that the average survival of a recurrent tumor like that is three or four months. And so we sat down and I told him the facts on things and I said, you know here is your options, we could try another drug, it may work it may not. However, the problem with this tumor is it’s extremely complex. By complex, it can have up to a hundred different types of cancer cells in the same person’s tumor. They are genetically different from each other. We know that throwing a drug at it, it’s really likely that one of those clones is resistant. Option two is we can go back and try to do the same operation we did before and hope that we can get more out this time. Nonetheless, odds are we know where it’s at; it’s in your language area. For number three we could go for broke, take out the whole tumor and really do an aggressive cancer surgery with the thought that probably your language is going to be severely hurt by this. It will give you the best chance of getting a response to chemotherapy. To be honest, I pitched option three because I just try to give everyone all the options, I don’t believe in making the decision for the patients because we don’t know what’s going to happen to be truthful. Anyone who prognosticates in cancers usually you know, they’re making stuff up in my opinion. He chose option three. He said I have kids I want to live, do everything possible. So I said, okay. We went in and we went very aggressive on him. The first thing that was surprising about this case, stunning, was that he really had very few language problems. He had some, but very few and they mostly got better. Which means that his brain, in the period between surgery and now, had reorganized. It moved the language somewhere else. That’s the only explanation, because I know that I went in there before and studied him. The second thing is that, more surprisingly he’s still alive and this tumor has never grown back at that site at all. And this has been years now. We really didn’t give him anything, there was no magical drug. We did a drug that works occasionally, but isn’t really a home run ball for very many people by itself. Basically, we got the tumor down to something that was manageable. His gamble paid off in a big way and he’s still with us. Which is years past his expectant survival. It was dramatic just by that, just the fact that he rolled the dice. Gambled it and what really highlights it is that when we sit there and we tell cancer patients you have a year to live or things like that, we have no idea what we’re talking about. Once we really start to say that, admit that, we start to realize that we shouldn’t really make decisions for patients on what is the best course of action and what risks they’re willing to take. We should make a reasonably informed decision on the pros and cons and really sit back and say that, we have limits to our knowledge. The other thing about it is that a little bit later, he showed up with a spot distant and deep in the brain that tried to be a radiation burn, but you don’t know that at the time. However, the issue our thought was what do we do with this. Well I told him he lived long enough to actually see technology advance so he could have a different treatment than he would have had years before. It’s very unusual, people with those tumors live an average of you know, treated the conventional ways often live a little bit over a year. He lived long enough to see technology advance. What he had the option to have is what’s called laser interstitial therapy or LITT. What LITT basically is; instead of cutting somebody open to remove a brain tumor you make a small incision and you drop a laser down to the target, a very thin laser fiber through the brain. Then you go into the MRI suite and the MRI does a very, very fast repeated MRI over and over again. And the computer reconstructs a heat map from that. So you can actually see where the heat is being sensed in the brain and you can watch the tumor burn. It’s very precise and obviously a lot easier on the patient. There’s some pros and cons to it. You can’t do it for everything. Just like any other new technology you have to learn there’s a time and place for it. For someone like him where you see a spot show up and we want to make sure that you know, that we don’t let that grow. If there’s cancer obviously if you let it get its claws in to you cancer has a bad reputation for a reason. But what it does is it allows us to stay on top of the cancer a lot longer. Especially when you see these little spots while still doing something about it instead of just hoping for the best or hoping it’s not cancer. We could treat it so we treated him and he went home in a day, we don’t have to worry about healing the wound up. What it allows us to do is to stay aggressive with these people and our real goal with this cancer is maybe if we can’t knock it off the face of the earth, which obviously would be ideal, in the meantime turn it in to a chronic disease for people that they can just live with it and be reasonably normal people. They could live like that for years. Therefore, the point of it is, to open up a new way to say, hey listen we’re not going to quit on this cancer even though it’s bad and it’s complicated and it’s difficult. Maybe we’re not going to have a single drug that’s going to wipe it out, we’re going to try to change the goal, move the goal post.
How many times might he have this procedure?
Dr. Sughrue: As many times as he wants really. As long as we can as many times as necessary. Because each procedure is very, small for brain surgery, it doesn’t put the patient through very much to be truthful. Not to say that it doesn’t have risks, of course it has risks. Not to say that there isn’t something, its anesthetic procedure. It’s just as long as the tumor configuration is reasonable there’s really no limit to it to be truthful.
Is this a new procedure across the country?
Dr. Sughrue: Yeah, it’s been FDA approved for at most two, three years.
Are you the only one in Oklahoma doing it?
Dr. Sughrue: To my knowledge yes.
Where do you see this going? I mean, this is a breakthrough obviously, what can come of this?
Dr. Sughrue: The real boundaries of it nobody knows. We know that there are certain really big tumors that you still would be better off having an open, a traditional operation. There are some tumors you just can’t safely manipulate the laser into. Where the line is we don’t know. I taught a course with some guys a few weeks ago and they showed a type of a totally unrelated disease I never even thought about treating. I would have thought it would be dangerous and they have actually pretty good results with it. We’re interested in trying that too. The truth is that like anything we don’t know. What we’ve been surprised about is that the patients do so much better than you would expect. You expect sometimes people have a few problems. In general most people have ended up in the first category. And often times with very little signs they’ve had brain surgery at all. Again you can’t take a hammer and hit nails all over the place. You have to pick the right patient for it, then for the patient whose problem is a nail it’s a great hammer.
Since it works so well on the brain is there any other applications anywhere else on the body that this could also work?
Dr. Sughrue: Various forms of this have been done for a long time, for example in the liver. What makes this a real breakthrough with the brain is that a large percentage of the morbidity of brain surgery is getting to the target. It’s opening up the head, opening up the skull, and going through the brain. Because, if it’s deep in the brain you’ve got to get there somehow. In the past in order to get to a deep brain tumor you had to cut through brain to get there. The issue is when the fiber is so small it actually doesn’t cut brain, it mostly spreads the brain around it. I mean not to say it doesn’t do any damage, it’s just you don’t see a very big profile because the laser fiber is so thin. The truth of it is that like everything in the brain adapting a technology that worked in the liver requires a lot of finesse. There are just a lot of things that the brain won’t let you do that other organs will because it’s unique, it’s complicated and delicate.
END OF INTERVIEW
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