Neuro-oncology Resources

• Neurosurgical Oncology
• The MGH Brain Tumor Center
• Adult Brain Tumors
  • Referral material will be evaluated promptly
  • Medical Neuro-oncology Attending Staff
  • Active treatment protocols (including proton beam radiosurgery, interstitial photoelectron therapy, gene therapy , and boron-neutron capture therapy -- in conjunction with Brookhaven National Laboratories)
• Pediatric Brain, Spine, and Peripheral Neuroblast Tumors
• Neuropathology and the Neuropathology Consultation Service
• Proton Beam Stereotactic Radiosurgery Homepage
• Benign brain and spine tumors such as meningioma, epidermoid, dermoid, hemangioblastoma, subependymal giant cell astrocytoma, pleomorphic xanthoastrocytoma, and craniopharyngioma.
• Acoustic neuroma and other cerebellopontineangle (cpa) and skull base tumors
• Pituitary tumor (adenoma, carcinoma) information
• Neurofibromatosis (type I, Von Recklinghausen's disease) information
• Tuberous sclerosis resources
• Von Hippel-Lindau disease resources
• Links to other neuro-oncology information and support resources
• Return to the MGH Neurosurgery Homepage

Neurosurgical Oncology

The neurosurgical oncology group specializes in using modern neuroimaging techniques such as positron emission tomography (PET scanning) and functional magnetic resonance imaging (fMRI) to ensure the most accurate diagnostic biopsies and maximal resection of benign and malignant primary and metastatic tumors of brain, spine, and peripheral nerves. Both PET and many advaneces in MRI were initiated at MGH and are under current development here. In addition, these techniques are supplemented by intraoperative functional mapping and physiologic monitoring when these techniques are appropriate to ensure maximal tumor removal. Active surgical research protocols include interstitial photon irradiation technology developed as MGH and clinical trials of the implantation of chemotherapy releasing biopolymers at the time of surgical tumor resection . Addresses and telephone numbers of the members of the neurosurgical oncology staff can be obtained at their homepages by selecting the highlighted names.

• Fred G Barker II, M.D . (benign and malignant brain tumors)
• Griffith R. Harsh, IV, M.D. Director of Neurosurgical Oncology
• Robert G. Ojemann, M.D. (special interests include hemangioblastoma, ependymoma, vestibular and other intracranial schwannomas, and meningiomas)
• Brooke Swearingen, M.D. (pituitary and skull base tumors)
• E. Antonio Chiocca, M.D., Ph.D. (research in genetic and viral anti-tumor therapies)
• William Butler, M.D. (computer-assisted minimally-invasive neurosurgery)
• G. Rees Cosgrove, M.D., F.R.C.S. (C.) (interstitial photoelectron therapy of metastatic brain tumors)
• Paul Chapman, M.D. (pediatric neuronocology and proton beam stereotactic radiosurgery)
• Stephen Tatter, M.D., Ph.D. (benign and malignant brain tumors)
• Lawrence F. Borges, M.D. (spinal tumors)
• See also the MGH/MEEI Cranial Base Center (including acoustic neuromas and other cerebellopontine angle lesions)
• See also the MGH Neuroendocrine Center (pituitary tumors, pituitary adenoma, acromegaly, Cushing's Disease)

Massachusetts General Hospital Brain Tumor Center

Background

The Brain Tumor Center at the Massachusetts General Hospital provides dedicated multidisciplinary care to individuals with primary and metastatic cancers of the brain and spinal cord and nerve roots. A dedicated team consists of members of the Services of Neurosurgery, Neurology and Radiation Medicine along with members of the Medical Oncology staff, Social Services, Nursing Services and Pharmacy. Members of the Center participate in protocols provided by the National Cancer Institute, the New Approaches to Brain Tumor Therapy (NABTT) consortium of the NCI, and the Brain Tumor Collaborative Group (BTCG) and the Pediatric Oncology Group (POG). In addition we are members of the CALG-B, and on the coordinating committees of the American Brain Tumor Association and the Central Brain Tumor Registry. Dr. Hochberg , as well, is consulting neuro-oncologist at the Dana Farber Cancer Center. Patients are seen during multi-disciplinary clinics by members of the Center. Referral problems are reviewed at formal conferences held on Monday and Tuesday mornings of each week. These conferences provide expedited review of neurologic history, radiographs and pathologic materials. Results of the clinical discussions and treatment plans are provided to referring physicians or to patients and their families.

Referral Reviews

Patients can be referred for the development of a treatment plan in conjunction with their primary physician, for a second opinion, or for ongoing management by the Brain Tumor Center physicians. Patients are seen during multi-disciplinary clinics by members of the Center. Referral problems are reviewed at formal conferences held on Monday and Thursday mornings of each week. These conferences provide expedited review of neurologic history, radiographs and pathologic materials. Results of the clinical discussions and treatment plans are provided to referring physicians or to patients and their families.

Go to the BTC for directions on how to request a referral to the Brain Tumor Center at Massachusetts General Hospital

Medical Neuro-oncology

Attending Staff

• Dr. Fred Hochberg - clinical interests in oligodendroglioma and mixed oligo-astrocytoma, primary lymphoma of the nervous system, newly diagnosed and recurrent malignant glioma as well as the complications of previous radiation and chemotherapy.
• Dr. John Henson- clinical interests include recurrent benign and malignant primary tumors as well as metastatic cancer of the brain and spinal cord. (Tel: 617 726 5510) Dr. Henson also studies the genetic basis for brain tumors in the Molecular Neuro-oncology Laboratory .
• Dr. Tracy Batchelor- clinical interests in metastatic cancer and the remote effects of cancer on the brain and spinal cord and nerves.
• Dr. Lloyd Alderson- clinical interests oligodendroglioma and mixed tumors as well as tumors of the pineal area, cerebellum and brain stem (pinealoma, ependymoma, medulloblastoma). Dr. Anderson also studies mutations in brain tumors in the Molecular Neuro-oncology Laboratory .
• Dr. Asha Das- clinical interests in the Protein A therapy of paraneoplastic neurologic syndromes (the remote effects of cancer on the nervous system) including opsoclonus-myoclonus, cerebellar degeneration, encephalitis of cancer, myelitis of cancer, Eaton-Lambert syndrome. In addition she provides care for patients with cancer of the meninges (carcinomatous meningitis).
• Dr. L. Kim- clinical interests include the use of topo-I inhibitors (Topotecan and 9-Aminocampto) as therapy for newly diagnosed and recurrent gliomas. In addition Dr. Kim utilizes fast (echo-planar) MRI and deoxyglucose PET scans for the identification of localized malignant degeneration within benign gliomas and necrosis within malignant gliomas.

Nursing Service

• Mrs. Barbara Rattner provides quality of life assessment for patients with cancer. In addition she coordinates support groups for these patients and aids in coordinating in-patient care. Social Service and rehabilitation services are also available.

Radiation Medicine

• Dr. Alan Thornton- clinical interests include the use of fractionated and "single" dose proton therapy for newly diagnosed and recurrent low grade and malignant gliomas. In addition he uses "STAR" technology for the treatment of metastatic cancer to the nervous system. A subgroup of patients treated include those with skull base lesions (chordoma, chondrosarcomas) with Drs. Munzenrider and members of the Neurosurgical Skull-base Unit.

ACTIVE THERAPIES FOR ADULT CNS TUMORS

Therapy for primary and metastatic tumors of the brain, spine, and of peripheral nerves is determined on an individual basis by informed agreement of patient, family, and the members of the Brain Tumor Center. The following treatment protocols are examples of those currently enrolling patients (except where noted) at the MGH. State of the art therapies are also available for tumors of other histologies. These examples are listed by tumor type as follows:

• Oligodendroglioma and Mixed Oligo-Astrocytoma --Benign and malignant
• Benign Astrocytoma :--The low grade glioma
• Glioblastoma-Malignant Glioma-Anaplastic Astrocytoma
• Paraneoplastic Neurologic Syndromes
• Complications of Cancer (Pain, radiation necrosis, leukoencephalopathy, neuropathy, myelopathy)

Primary Lymphoma of the Nervous System

• High dose methotrexate therapy in the absence of irradiation. Currently 18 patients are on-study with 85% complete responses.
• High dose methotrexate induction of response followed by radiation therapy. Thirty five patients have been treated with median duration of response now in excess of 38 months.
• Methotrexate-CHOD chemotherapy has been provided to 17 patients with 80% response.

Oligodendroglioma and Mixed Oligo-Astrocytoma-benign and malignant

• Chemotherapy with PCV (Procarbazine-Vincristine-CCNU) for newly diagnosed and recurrent tumors prior to irradiation therapy. Fifty patients have experienced a 70% partial response rate. Tumors containing as little as 5% oligo component respond to therapy.

Benign Astrocytoma:-the low grade glioma

• Diagnosis of growth and malignant degeneration using co-registered Echo-planar (Fast) MRI and 18-Fluoro deoxyglucose Positron Emission Tomography (PET). Over 100 tumors have been imaged for the identification of malignant change within benign glioma or necrosis within more malignant tumor.
• Hyperfractionated proton-beam radiation therapy of gliomas to 7200 cGy.

Glioblastoma-Malignant Glioma-Anaplastic Astrocytoma

• Newly Diagnosed
  • Implantation of chemotherapy releasing biopolymers at the time of surgical resection (with Johns Hopkins).
  • Newly diagnosed therapy utilizing high dose Taxol (NABTT).
  • Newly diagnosed therapy using 9-amino-camptothecan (NABTT).
  • Newly diagnosed therapy using PCV (oligo-containing tumors)
  • Maximal resection followed by proton beam radiosurgery
  • Boron-neutron capture therapy of newly diagnosed glioblastoma (with Brookhaven National Laboratories and Dr. William Sweet )
• Recurrent Therapy
  • PCV therapy of recurrent mixed tumors (Massachusetts General Hospital)
  • 9-AC therapy of recurrent tumors (NABTT)
  • Suramin therapy of recurrent tumors (NABTT)
  • Intra-arterial cis-platin therapy of recurrent tumors (BTCG)
  • Proton beam (single dose) therapy of recurrences.
  • Implantation of chemotherapy releasing biopolymers at the time of surgical resection (with Johns Hopkins).
  • Gene Therapy
    • HSV-TK with ganciclovir therapy of recurrent glioblastoma (with Drs. Harsh , Hochberg , Breakefield , Chiocca) Open for accrual April 1995.
    • Retroviral cytochrome P-450 - Cytoxan therapy of recurrent glioblastoma (Dr. Chiocca). Likely open for accrual Feb. 1996.
    • Auto-immunization of melanoma (using Gm-CSF)-cuurently limited to non-brain metastases (with Drs. T. Lynch and G. Dranoff) Open for accrual Feb. 1995.

Primitive Neuroectodermal Tumors - Pineoblastoma, medulloblastoma, ependymoblastoma-adults (over 16 years)

• Therapy prior to radiation using VP-16/Cisplatin then Cytoxan/Vincristine.
• Craniospinal irradiation.

Protocol and non-protocol therapy for patients under the age of 16-18 with PNETs is described below .

Craniopharyngioma

Treatments available for both pediatric and adult craniopharyngiomas include complete surgical resection (first advocated and performed by Dr. William H. Sweet ), intracyst radiation therapy (with Phosphorus-32), stereotactic radiosurgery, and cerebrospinal fluid shunting procedures.

• Treatment for pediatric craniopharyngioma is coordinated through Dr. Dooling's office .
• Treatment for adult patients is coordinated through the Neurosurgical Oncology offices.

Metastatic Cancer to the Brain-all histologies (solitary or multiple)

• Interstitial Photon-radiosurgical (PRS) therapy.
• Proton beam (single dose) radiosurgeryof metastases.
• "STAR" proton beam radiosurgery of newly diagnosed or recurrent metastases.
• For evaluation and treatment of metastatic tumors to the spine or peripheral nerves see the Neurosurgical Oncology section.

Metastatic Cancer of the Spinal Fluid-Meningeal cancer

• Intra-thecal administration of methotrexate, cytosine arabinoside, 4-HC.
• Craniospinal irradiation.

Paraneoplastic Neurologic Syndromes

(Remote effects of cancer on the brain- including Cerebellar degeneration, optic neuropathy, brain stem encephalitis, opsoclonus-myoclonus, limbic encephalitis and Eaton-Lambert muscular weakness)

• Protein-A (Prosorba-A) therapy of newly diagnosed and recurrent non-metastatic paraneoplastic syndromes.

Complications of Cancer (Pain, radiation necrosis, leukoencephalopathy, neuropathy, myelopathy)

• Localized injection approaches for the control of pain.
• Utilization of Echo-planar MRI and PET scanning for the diagnosis of recurrent tumor versus necrosis.
• Heparin-fragment therapy of radiation necrosis.

Proton Beam Radiosurgery Homepage at Massachusetts General Hospital

Pediatric Brain, Spine, and Peripheral Neuroblast Tumors

Pediatric brain tumors are treated by a multidisciplinary group including pediatric oncologists, pediatric neurologists, radiation oncologists, and pediatric neurosurgeons . See the MGH Pediatric Neurosurgery Homepag e for a listing of MGH neurosurgeons with special expertise in the treatment of pediatric brain tumors. Proton beam stereotactic radiosurgery is also available for the treatment of pediatric brain, and spine tumors.

Appointments may be coordinated through the MGH Pediatric Neurology Service:

Elizabeth Dooling, M.D.

Director, Pediatric Neurology

Vincent-Burnham Kennedy-7

Massachusetts General Hospital

Boston, MA 02114

phone: (617) 726-3877

Experimental treatment protocols including chemotherapy are coordinated through the pediatric oncology service. For more information or to make an appointment contact:

William Ferguson , M.D.

Director, Pediatric Oncology

Wang Ambulatory Care Center-7

Massachusetts General Hospital

Boston, MA 02114

phone: (617) 726-2737

Protocols therapy is currently available for the following tumor types. Data collection for the majority of these protocols is coordinated by the pediatric oncology group. Non-protocol therapies are available for tumors of any type.

• Low-grade astrocytoma
  • primary: POG Intergroup protocol
  • recurrent: idarubicin-based therapy and topotecan -based therapy)
• Optic pathway tumors
• Ependymomas
• Brain stem gliomas
  • topotecan -based therapy
  • taxol-based therapy
• Craniopharyngioma (see above )
  • Treatment for pediatric craniopharyngioma is coordinated through Dr. Dooling's office .
  • Treatment for adult patients is generally coordinated through one of the Neurosurgical Oncology offices.
• Supratentorial neoplasms (1. malignant gliomas: anaplastic astrocytoma, glioblastoma multiforme, malignant gliosarcoma, and malignant oligodendrogiomas; malignant small cell neoplasms with glial differentiation are also eligible. 2. Poorly-differentiated embryonal cell tumors (PDETs): undifferentiatied malignant small cell neoplasm, as well as those with pineal (pineoblastomas), ependymal (ependymoblastomas), or neuronal (primary cerebral neuroblastoma) differentiation, including cases diagosed as PNET.)
  • Topotectan-based therapy
• Medulloblastoma (infratentorial PNET)
  • POG low stage protocol
  • POG high stage protocol
  • recurrent: taxol
  • subquent recurrence: POG salvage protocol

Special protocols are also available for children under 3 years of age with tumors of various histologies.

MGH Neuropathology and the Neuropathology Consultation Service

Patholgic consultations regarding central and peripheral nervous system tumors are available from the Neuropathology Service. Prior to sending the original pathology report as well as slides (and tissue blocks if available) either of the following should be contacted:

E. Tessa Hedley-Whyte, M.D.

Department of Pathology (Neuropathology)

Warren-3

Massachusetts General Hospital

Boton, MA 02114

phone (617) 726-5156

David N. Louis, M.D.

phone (617) 726-5510

fax (617) 726-5079

Links to other on line brain and spine tumor information