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NewYork-Presbyterian Hospital is at the forefront of neuro-oncology, providing state-of- the-art care through interdisciplinary teams at both NewYork-Presbyterian Hospital/Columbia University Medical Center and NewYork-Presbyterian Hospital/Weill Cornell Medical Center. The hospital's neurosurgeons, interventional neuroradiologists, neurologists, neuropsychologists, medical oncologists, and radiation oncologists are pioneering the latest surgical and nonsurgical techniques to improve survival and preserve neurological function for people with cancers of the central nervous system. These cancers include primary brain tumors, such as gliomas, and metastatic or secondary brain cancer.

In addition to a long established neurosurgery program at NewYork- Presbyterian/Columbia, the Hospital has expanded its neurosurgery program at NewYork-Presbyterian/Weill Cornell with the creation of a neuro-oncology division led by one of the few physicians in the nation trained in neurology, neurological surgery, and neuro-oncology. The new division offers world-class research and treatment for cancers affecting the brain and spine, among other areas. Therapeutic interventions include the full spectrum of traditional as well as new and innovative treatments, including surgery, radiation therapy, stereotactic radiosurgery, chemotherapy, immune therapy, and complementary therapies.

Diagnostic Innovation

NewYork-Presbyterian Cancer Centers maintain an arsenal of state-of-the-art diagnostic techniques magnetic resonance imaging (MRI), computed tomography (CT) and positron emission tomography (PET) scans and sophisticated monitoring systems designed to identify critical problems. The hospital's expertise and resources include advanced MRI technology, MR spectroscopy, diffusion MRI, and functional MRI, making it possible to make precise diagnoses and develop more effective interventions for tumors of the brain. The Hospital is a world leader in minimally invasive endoscopic surgery, including the use of intracranial endoscopy for use with intraventricular and pituitary tumors. In addition, the Hospital has installed an intra-operative MR and several frameless stereotactic systems for localizing brain tumors, for stereotactic biopsy, or volumetric removal.

NewYork-Presbyterian's clinical neurophysiology division maintains one of the most advanced intraoperative neurophysiological monitoring systems in the world. Continuously monitoring the electrical activity of the brain and spinal cord during surgery diminishes the risk of neurological injury by helping the surgeon clearly identify and avoid portions of the brain and spinal cord that control key functions, such as movement and sensation. In addition, monitoring in real time allows physicians to detect and possibly reverse injury to the brain and spinal cord.

Intraoperative neurophysiological monitoring involves the use of one or a combination of several techniques to detect abnormal electrical patterns in the brain; to evaluate the sensory areas of the brain, brainstem, and spinal cord; and to observe the areas of the central nervous system that control movement. NewYork-Presbyterian Hospital, which pioneered the use of motor evoked potentials (MEPs) to monitor the areas of the central nervous system that control movement during surgery to correct spinal deformities, is one of a handful of medical centers that routinely uses this monitoring technique during surgery.

NewYork-Presbyterian Hospital also has the world's most extensive computer network dedicated solely to monitoring central nervous system function in critically ill patients. Fiber-optic connections provide a seamless link between adult and pediatric operating rooms, intensive care units, epilepsy monitoring units and the clinical neurophysiology laboratory. This comprehensive system provides physicians with a continuous flow of accurate information that may be critical to preventing and reversing neurological damage.

Therapeutic Excellence

Advances in Surgery

Skull Base Surgery
The skull base defined as the anatomic region separating the neurocranium from the facial has been referred to as "terra incognita" and a "no-man's land." Historically, the complexity of the region rendered many tumors there inoperable. NewYork-Presbyterian Hospital is helping lead the refinement of techniques and technology in this surgical specialty. Using a team approach, neurological surgeons, otorhinolaryngologists, plastic surgeons, vascular surgeons, interventional neuroradiologists, and pediatric surgeons develop multimodal approaches that optimize care for each patient.

Many skull base surgeries are now performed endoscopically, allowing surgeons to treat most patients without facial incisions. In additio, doctors at NewYork- Presbyterian/Columbia are researching minimally-invasive, stereotactic radiological techniques.

Operating Room Imaging
At NewYork-Presbyterian Hospital, neurosurgeons employ the "stealth system" in operating rooms. This involves taking MRI or CT scans the night before a surgery and projecting a 3-D image onto a screen in the operating room. The image, which can be manipulated, provides surgeons with a map for "neuronavigation" as they perform surgery on a tumor. For example, the vascular anatomy can be superimposed on 3-D reconstructions of the skull base itself. The technique means a safer and more complete resection with improved outcomes. Recently, NewYork- Presbyterian/Weill Cornell obtained a real-time imaging and magnetic resonance unit for the operating room that can assess the extent of resection as a procedure is performed.

Radiation Therapy

Stereotactic Radiosurgical Procedures
NewYork-Presbyterian Hospital has long been a leader in this arena and as a result offers patients a full spectrum of radiosurgical services. These noninvasive techniques target brain lesions while minimizing radiation exposure to noncancerous tissue, resulting in fewer complications and shorter hospital stays. Radiosurgical methods can also penetrate areas of the brain that could not be reached with conventional surgery or other techniques. Patients undergoing these procedures are put in a stereotactic headframe on the day of surgery, which allows for precise localization of the tumor and provides a reference for imaging and treatment throughout the procedure. Other stereotactic treatments offered to patients at NewYork-Presbyterian Hospital are gamma knife radiation surgery, linear accelerator-based stereotactic radiation surgery and 3-D conformal intensity modulated radiation therapy.

Gamma Knife Radiation
NewYork-Presbyterian Hospital is one of only 100 sites worldwide to have this 20-ton radiosurgery system. Using a three-dimensional approach, it is capable of directing up to 201 beams of gamma radiation to converge, with pinpoint accuracy, on a target within the brain. The gamma knife technology allows for the highest level of precision in positioning radiosurgical beams, minimizing damage to surrounding healthy tissue and increasing effectiveness. Unlike traditional open skull procedures, which can require several days in the hospital and weeks or months of recuperation, patients treated with the gamma knife can often go home the same day and return to work or school immediately. Recently, NewYork-Presbyterian Hospital treated its 1,000th patient with the gamma knife. Patient satisfaction ratings for the past year were over 98 percent based on 98 percent of patients responding.

Intensity Modulated Radio-Therapy (IMRT) This sophisticated stereotactic technique is being utilized for large, irregularly shaped lesions surrounded by healthy tissue that is especially sensitive to radiation. This system, which can also be given with fractionation, employs beam-intensity modulation technology that shapes the radiation to conform to the target site.

Linear Accelerator-Based Stereotactic Radiosurgery
This technique is suitable for larger targets. This method provides radiation in the form of a single, highly focused beam applied in multiple sweeps around the brain lesion. It also allows multiple smaller-dose, or fractionated, stereotactic radiotherapy, which is advantageous in selected patients.

Brachytherapy
At NewYork-Presbyterian/Weill Cornell, the first liquid brachytherapy for metastatic brain tumors in New York City was performed. Using the GLIASITE implantable balloon, a percutaneous injection of radioactive iodine was temporarily placed in the cavity after the tumor was removed to treat microscopic cells in the surrounding brain.

Chemotherapy

GLIADEL Wafers
The implantation of dime-sized GLIADEL wafers in the brain cavity following surgical removal of the glioma tumor was recently shown to extend the lives of patients in the early stage of this deadliest form of brain cancer. Patients treated with the FDA-approved chemotherapy agent lived, on average, 26 percent longer than patients given traditional intravenous therapy. Both treatments contain the same chemotherapy agent, but unlike intravenous chemotherapy, which has difficulty crossing the blood-brain barrier, GLIADEL achieves superior drug concentration on the tumor without the toxicity and side effects associated with systemic treatment. Two physicians at NewYork- Presbyterian Hospital will launch the first clinical trial using magnetic resonance spectroscopy to study how GLIADEL affects the tumor and the surrounding brain anatomy.

Mannitol
NewYork-Presbyterian Hospital is a pioneer in the delivery of mannitol, a sugary substance that kills tumor cells without destroying healthy tissue. The agent may be delivered to the tumor site via a catheter and may be used alone or in conjunction with surgery.

Experimental Therapies

Convection-enhanced Chemotherapy

This new drug delivery strategy may open up whole new classes of compounds that were once thought to be useless in the treatment of brain tumors. This administration method, which is being examined in clinical trials at NewYork-Presbyterian Hospital, involves implanting a stereotactically guided catheter into the tumor or surrounding brain. The catheter is connected to a low-flow pump that administers just a few drops of a chemotherapy agent each hour. This pushes the drug through the space between the tumor cells thereby avoiding toxicity, bypassing the blood-brain barrier, and delivering high concentrations of the drug directly to the tumor. Patients also avoid the side-effects of intravenous delivery. Current trials focus on the use of several agents, including Topotecan delivered with a novel P53-related protein or a pseudomonas exotoxin linked to an antibody that targets brain tumors.

Chemotherapy

NewYork-Presbyterian/Columbia clinicians are examining the ability of Tamoxifen to increase the penetration of Taxol across the blood brain barrier in patients with primary brain tumors and metastatic lesions. So far, results show Tamoxifen causes a change in the blood brain barrier, allowing the other agent to penetrate the brain. Other chemotherapy research initiatives include the use of convection-enhanced delivery (CED) to deliver Topotecan to gliomas, a technology has been found safe in early clinical trials; multicenter trials of two CED delivery protocols in patients with recurrent malignant gliomas; a multicenter clinical trial of flemazolamide for recurrent malignant gliomas, with particular emphasis on oligodentrogliomas; and testing of two nonsteroidal anti- inflammatory drugs, which have extremely low toxicity on varying grades of glial tumor cells.

Immunotherapy

This promising new avenue of inquiry involves augmenting and amplifying the immune response to tumor cells, which generally is too mild to affect tumor growth. Researchers at NewYork-Presbyterian/Weill Cornell are examining the use of interleukin-2 (IL-2), an immune treatment currently used for kidney cancer and malignant melanoma, and lymphokine-activated killer (LAK) cells in the treatment of malignant gliomas or brain tumors. In collaboration with the Ludwig Institute for Cancer Research, clinicians at NewYork-Presbyterian/Columbia are exploring immunotherapy in the treatment of recurrent gliomas and examining immune profiles the response a person's body begins to generate at the onset of a tumor. The work is aimed at developing effective vaccines.

New York Brain Tumor Project

An initiative of the new neuro-oncology division of NewYork-Presbyterian/Weill Cornell, the New York Brain Tumor Project focuses on developing promising new treatments for brain cancer. Current research includes a study of a unique immune therapy that combines Celecoxib (Celebrex), a COX-2 inhibitor, with Temozolomide (Temodar). COX-2 is an enzyme found in most cancers. NewYork- Presbyterian Hospital/Weill Cornell is a leader in the study of COX-2 inhibitors for the treatment and prevention of cancers.

Pediatric Neuro-oncology

NewYork-Presbyterian Columbia's pediatric neuro-oncology group is studying the hormonal and reproductive effects of brain tumors and their treatment. Additional studies are underway on the neuroendocrine aspects of pediatric brain tumors. In collaboration with New York University, studies are focusing on treatment outcomes in children with germ cell tumors. The studies are examining the effects of high-dose chemotherapy with bone marrow reconstitution for patients with recurrent germ cell tumors; and chemotherapy for patients with newly diagnosed germ cell tumors of the central nervous system. At NewYork-Presbyterian/Weill Cornell, radio-labeled monoclonal antibodies are being used in a study for children with disseminated malignancies of the central nervous system. In addition, studies are being conducted on local delivery systems to treat pediatric tumors.

Research

Molecular Neurosurgery

NewYork-Presbyterian/Weill Cornell scientists are seeking to target tumor cells and shut them off with gene transfer therapy or by devising a tumor- eating cell type. Research also is underway in the use of gene therapy for functional disorders and brain tumors. Research in stem cell biology is aimed at generating cells that can seek out and destroy a tumor.

Imaging

At NewYork-Presbyterian/Columbia, researchers are investigating the usefulness of MR spectroscopy (MRS) to assess the effects of chemotherapy on brain tumors; the relative merits of MRS and MRI in the detection of tumor recurrence; and the use of combined fMRI and intraoperative brain mapping techniques to understand how neoplasms and congenital lesions affect brain organization and reorganization of language and sensorimotor pathways.