A brain tumor diagnosis can sound like a life-ending situation, but not all brain tumors are the same. With advances in research, scientists and physicians have been able to investigate the underlying mechanisms involved in how brain and spinal cord tumors develop, survive, and spread. Today our experts will discuss insights on the different types of brain tumors, the symptoms they may cause, and the types of therapies to treat them. And we'll answer your questions coming up right now on At the Forefront Live.

And we want to remind our viewers that today's program is not designed to take the place of a visit with your physician, so we're going to start off going to each one of you introduce yourselves to our audience and tell us a little bit about what you do here at UChicago Medicine. But I do want to point one thing out before we get going. We actually have a guest on set for the first time in a long time, and we're very happy about that. We are doing the social distancing and we also-- we're mindful of the new CDC guidelines that came out this week. So we are being safe. We've both been vaccinated. But I do want to stress that. So Dr. Das, I'm going to start with you, since you are on set, if you can tell our audience a little bit about yourself and your role here at UChicago Medicine.

So I'm a neurosurgeon here at the University of Chicago, meaning I take care of pathologies that need surgery and the brain spinal cord and careful nerves. And I have a specific interest in small base neurosurgery, or tumors that are found at the base of the skull, and finding and working on minimally invasive techniques to approach those.

Great. And Dr. Park, you're actually joining us from a remote location on campus. If you can introduce yourself to our audience and tell us what you do.

So I am a neuro-oncologist and I work along with Dr. Das and the rest of the team to provide the medical side. So an example would be chemotherapy, and this includes all brain tumors and spinal cord tumors, and also complication of cancer therapy.

Right, and we want to remind our viewers that we will take your questions live on the air. So just type them in the comments section. We'll get to as many as possible over the next half hour. Now Dr. Das, we're going to start with the first question with you, and ask you just what kind of brain tumors are there that are out there. What do you see?

So brain tumors can be benign or malignant. And they can arise not only from the brain itself or the surrounding tissues, but also they can come from elsewhere in the body like metastatic diseases. Benign brain tumors can arise from the cells within the brain or also the covering of the brain, and many times present the same way. And of course metastatic tumors, they're not actually brain tumors per se, tumors from elsewhere, but can grow within the brain itself.

And commonly when you see the metastatic tumors, what is the genesis of those or that range, substantially?

So usually people have a cancer elsewhere in the body. It can be their first presentation, is that it presents with some sort of brain tumor. But many times patients already have a known cancer diagnosis, and the tumor cells can transmit through the bloodstream and reach the brain.

Interesting. So Dr. Park what is the most common type of tumor or types of tumors that you see?

The most common brain tumors are what Dr. Das mentioned, metastatic tumors. And those are potentially getting more and more common as are therapy for systemic cancer to continue to improve, patients live longer. So we're seeing towards the end, you go to the brain, which makes it very difficult to treat. As far as primary tumors go the most common primary tumor unfortunately, is also the most malignant, and these are the gliomas, particularly grade IV, also known as glioblastoma.

And you said that it's becoming more common to see the malignant tumors?

For the metastatic tumors.

Oh, the metastatic tumors.

Because people are living longer. So for instance, an example would be breast cancer is now in many cases, a chronic disease. Because they are living longer and longer and as the cells become more aggressive, once it goes to the brain it becomes very difficult to treat.

So it sounds like actually what we're seeing is, with some of the advances and in some areas, you're seeing more because of the fact, that folks are living longer and that's interesting. So what are some of the first symptoms of a brain tumor?

So it can vary depending on where in the brain that the tumor resides. So the symptoms come from the area of function that it's affecting. So it can present in many different ways. So many times people will say it's stroke-like symptoms because they can have problems with speech, or motor, or trouble with their walking. Occasionally people can present with headaches or confusion. Also seizure is a very common presenting symptom.

And are these-- do these symptoms come and go, or is this something that you consistently see?

Well, that's a good question. For some people they do come and go. And that's because if someone's presenting with seizures, that can be a not constant symptom, but it can present one day go away and then present again. So it may not be a constant thing that people experience.

So Dr. Park, how are brain tumors diagnosed?

So if a patient presents with the symptoms that we described, headache or seizures, often they're seen by their doctor. Depending on the examination, they'll perform some sort of imaging, could be a CT scan also known as CAT scan or an MRI of the brain. If we see something abnormal, then we would typically meet, discuss, and Dr. Das and her team, whether to biopsy or we'll make attempt to remove it all, if possible. At times, it is not possible to remove the entire tumor, so it really depends. It's a case-by-case decision that we make.

Then once the tissue is removed, it is sent to our pathologist, who will take the tissue, make thin sections, stain it, look under the microscope. We often join him for this. And he will also take remediating material and sequence the DNA to identify the subtype of tumor to arrive at an exact diagnosis.

So when you identify that subtype of tumor, what are you looking for and how does that help you as you diagnose and, I guess, determine the course of treatment?

So we so we look at an example of glioblastoma, for instance. I mentioned it is unfortunately the most common. We know that there are subtypes of glioblastoma and it's not readily distinguished by looking under a microscope. So we need to actually sequence particular genes to further classify. And the reason that's important is because it will speak to prognosis, potential outcome we discuss with the patient, and also enrolling into conquered trials. Because a lot of the trials are really moving forward towards highly targeted personalized studies. So this information is absolute critical to provide care for our patients.

So we are receiving some questions from viewers, which we always love to see that because they have usually really good questions. And want to start with the first one, this is from Stella, and Stella says my husband was found to have a pituitary tumor causing no symptoms. Does it have to be removed? And I don't know which one of you would like to take that.

I can answer that. Thank you for your question, Stella. No, it does not. It depends very much on the symptoms and the size and how he presented. Many pituitary tumors are not growing. They grew at some point and now they're static in size, meaning they'll stay in there and not cause any problems. Occasionally these tumors can be growing, and that is when we usually treat. If they're large they can cause problems with your vision, and so it's very important to note if the vision is normal or not. And occasionally these tumors can secrete hormones, which can also require surgery. But not each of these tumors require surgical intervention. Many times we can watch this, and so just as Dr. Park mentioned about malignant tumors, it's very important that we take the personalized look at patient scan and also what's going on to make a decision.

So this one is from Dave, and Dr. Park, I'm going to throw this one to you. And the question is what about astrocytoma?

Thank you, David, for the question. So astrocytoma is a type of glioma. So these are intrinsic tumors that arise from the brain cells. And there are different types, and people often mistake it by calling it a stage. But we're not talking stage here. We're talking about grade. And grade just means how aggressive the tumor looks under a microscope. And grade goes from 1 through 4. And that drives how aggressive the tumor may be and also how we plan our therapy, depending on the grade.

What can you do? Can you talk just a little bit about the therapy depending on the grade? What do you do?

Yes, so for grade 1 tumor, which is really a distinct entity, you have the term benign. That term is misleading because when we call something a cancer, by definition, we call it cancer because it has the ability to spread, or invade, or metastasize. Brain tumors typically do not leave the brain. There are certain situations it does. Those are very, very rare.

However, we define aggressiveness by its ability to infiltrate across the brain. So typically grade 1 tumor we may call it benign. However, if a tumor is located in a critical area of the brain, now, the tissue itself may appear benign, but due to its location in a critical part, to the patient it's not acting benign. The patient may be left with losing vision or, for instance, not able to walk. So these are certainly not benign. So we have to be careful of the term that we use here.

Now for grade one tumors, if Dr. Das goes in and removes all of it, often we just watch. And we'll do serious scans every three months, every six months. And often the patient will do quite well.

When we get to grade 2, these are now what we'll call infiltrated tumors. They're not growing like a ball. They're projecting roots, like tentacles, so it's very difficult to remove all of it. These patients we have to monitor more closely. They may require radiation and chemotherapy. Once we go to grade 3, definitely get radiation and chemotherapy. And then grade 4, we often will combine radiation and chemotherapy upfront together to try to hit as hard as possible, followed by additional chemotherapy.

You know, that's is a really interesting point that Dr. Park is making, Dr. Das, because I think oftentimes we think of tumors in various parts of the body. And if they are benign, you leave it alone. But in the brain, it's certainly a different situation, and that's where you come in.

Yes, so not all benign tumors require removal. Certainly there are some that don't grow, that are found and not causing any symptoms, and we wouldn't want to intervene. We'd just want to watch that. But for other benign tumors, which are causing symptoms and are growing, there are many safe surgical techniques where we are able to remove tumors fully without leaving patients with much deficit at all.

That's great. So we have more viewer questions. We've got some really good viewer questions that have come in so far, and so I want to get to as many as we possibly can during the program. Elizabeth asks if there's a lesion on the back of the skull from prostate cancer, do you often see that shrink after chemo?

Yes, many times if it's outside of the brain, like let's say if it's in the skull where these can often be found, these can decrease in size with systemic therapy, if overall the cancer is responding to that elsewhere in the body as well.

Dr. Park, Natalie is asking, should I see a neurologist if I'm being treated for another type of cancer?

That would depend on what type of cancer. And also whether or not her nervous structures, including brain and spinal cord, and even the peripheral nerve, that are involved, and may be involved due to the growth of the cancer going directly, pushing against it. Or it could even be as a result of chemotherapy or radiation. So, yes, having neurologic symptoms definitely should be seen by a neurologist.

Sounds good. Carmen asks if there's a family history, should you be screened?

So usually not, most of the brain tumors that we see are sporadic, meaning they're arising by chance due to genetic mutation. There are some very rare genetic hereditary disorders where people are predisposed to certain tumors. And this usually would be found like over many, many generations and people would already have the diagnosis. But usually if you just have one or two people in the family that have had a brain tumor, certainly if it's metastatic, you know that is probably sporadic and there's no reason to screen for that.

Great. So Dr. Park, how are tumors tested for cancer in general? I know you touched on this earlier in the program, but if you could kind of just walk us through that process, what do you do and what do you see and look for?

A lot of that work is done by our colleagues in pathology. So they will first screen by taking a section. I mentioned looking at the microscope. And there are certain features that we look for. We may look at part of the cell nucleus, see how aggressive it looks and if are there cells that are dividing. The normal adult brain would only have cells that are dividing. There are few exceptions, but we look for the presence of cells that are dividing the tumor tissue. And if so, what's the percentage of cells that are dividing? And that gives us the sense of how aggressive the tumor is.

In addition, there are a series of genes. There's a whole panel that we test for, looking at disruptions of the gene, and that could affect these signaling of the cells to state whether to divide or not to divide. So there are varieties that we look at to determine how cancerous it is or how aggressive this tumor may be.

So we have another question, and I'll throw this one to either one of you. This is from Eileen. And Eileen had a meningioma removed in May of 2019. She says she's doing well, but she wants to know if it's safe to get the COVID-19 vaccine. And I don't know who wants to take that one.

Yeah, Eileen, I would definitely encourage you to take the COVID vaccine.

Yeah, are there instances where you would tell somebody not to? I mean, I think we want to encourage, obviously, as many people as possible to get the vaccine. Would that be accurate?

Yes, and particularly patients that are going through chemotherapy, their immune system is actually weakened. So it is particularly important that they protect themselves with the flu vaccine, COVID vaccine, if they're older also the pneumococcal vaccine. Definitely. There's no reason for them not to get the vaccine.

Perfect. This is kind of a difficult question, but it is one that gets asked a lot. How long will you live if you do have a brain tumor? What would you-- what do you tell patients?

So I think that's very different for different types of tumors. Like if we talked about these benign tumors, even let's say if it's in a difficult area, that could affect their life expectancy. A benign tumor that we could take out completely may not have any effect on the life expectancy. And certainly on the other end of the spectrum, we have our malignant brain cancer, like the glioblastomas that Dr. Park was talking about. And although the average life expectancy is thought to be about 18 months or so for that, everybody is different. And we look at the genetics of the tumor to help predict their course. And certainly the patient's underlying medical conditions can also affect what they're able to tolerate, like if they're able to tolerate the chemotherapy, surgery, or radiation. So everyone is very different, so it's very hard to make a blanket statement.

Sure. So Dr. Das, I am kind of curious because we've heard about, and I've spoken with other physicians about this, and one of the things that always impresses me about the work that's being done here at UChicago Medicine is the team approach that happens. And I would imagine in your field, especially, it's important. Can you talk to us a little bit about that? And when you work with the patients, you really develop a plan and you communicate with the patients and their families as well from the very start, if I'm not mistaken.

Absolutely. The team approach is so important, especially for treating brain tumors. Because it's not just the surgeon, it's also what can our radiation oncologist do for the patient? What can Dr. Park, as the oncologist, do for the patient? And we use this team approach to make the decisions that eventually get implemented into treatment. And actually every week, we have a tumor conference where we all sit together, including at other surgeons, so we can get multiple opinions. Because the more minds there are looking at a problem, certainly we can come up with better solutions.

To me, that's just so impressive because it's putting aside territory and egos and things like that and working together, which we do here at UChicago Medicine, and do it quite well. And listening to other people's thoughts, and that's just going to be critical to what you do.

Oh absolutely. And it's not just people from other specialties, but also our own partners maybe in the same specialty. People can really open your eyes to look at problems in different ways because they have a different way of thinking. And that's so important.

And from the patient's standpoint, also I think this is important. I know that you work with the patient and their families as you develop their plan to attack this and treat this. And communication is key, and I've heard this from many patients, that the communication here is also very, very good. And they feel like they're informed every step of the way.

Oh, absolutely. Especially when you have a diagnosis of a brain tumor, you can understand how that could be such a scary thing. And so we take pride in the fact that our patients can reach us, whichever member of the team you're seeing. And we have our office staff and everyone available to give us the questions if they're coming through over the phone. Or we're able to call you back right away if it's something critical.

Great. And Dr. Park, if we can, we've always received a lot of questions about COVID and the impact of COVID on visitors and patients. One of the things that we want to make clear in all of these programs is that we are open for business, and it's better to go in and get treated for your serious illness. Being scared of COVID isn't going to help you at all. In fact, we're very careful around here. Could you talk a little bit about that?

Yes, and also if I could comment on the team approach a little bit before that. There are a lot of people that are patients that have been encountered that are absolutely critical players in managing our patients. This would include our radiologists. And our imaging facility here is excellent. It's one of the best.

In addition to the typical anatomic MRI, we're able to offer a functional imaging MRI spectroscopy. I work very, very closely with Dr. Jack Collins about this. And I mentioned-- I also mentioned pathology, Dr. Patel is an outstanding neuropathologist. Without him, it will be impossible to get my job done. And Dr. Das would have mentioned our colleagues in radio oncology, who are critical. And she also mentioned a tumor conference which is absolutely critical to-- and sometimes we'll debate treatment options, and try to arrive at a consensus that is best suited for that particular patient.

Right. And talk to us a little bit about the COVID protocols that are in place and how we keep our patients safe.

Yes. So we follow the hospital policy, whatever is recommended by CDC hospital policy. Personally I never closed my clinic. Because I think, while virtual business can be helpful for certain patients, when dealing with such a grave diagnosis, I really prefer to see the patient in person, take a deep history, and get a critically very detailed exam, so I could follow that. And if a future patient could only be evaluated virtually, at least I have a baseline examination I could use to detect changes, if any.

Great. And I'll throw this next question up and to both of you. I think this is an important one, also that shows some of the strength of UChicago Medicine, and that's clinical trials. Can you talk to us a little bit about clinical trials, how important they are, and maybe some of the exciting treatments that you see on the horizon? I don't know who wants to start on that one.

I think clinical trials are a very important part of treating patients with cancer, especially brain tumors, because many of the therapies have been the same for several years. So participating in trials is an important way that we can push the field forward and also to get patients possible additional therapy when perhaps there is none that is the routine standard of care.

And Dr. Park, from your standpoint working in an academic Medical Center, I think that's got to be important for these clinical trials.

Yes, without a question. Dr. Das briefly mentioned the poor outcome that we deal with for the glioblastomas. And unfortunately it hasn't changed a lot over the past several decades. While we are learning much more about the biology of the disease and the genetics we've actually done with the NIH, it's been sequenced the entire tumor genome sequence, but that are yet to translate into effective therapy.

And we are working with very limited armamentarium here, so trials are absolutely critical and these studies can really only be done at major academic centers in partnership with others. So we work very closely with my former colleagues at the NCI where I came from. Even here in Chicago, I work with neurooncology at different hospitals, North Shore for instance and Northwestern. We all have each other's a mobile number, and we discuss difficult cases, and we consult each other. And this is the only one way to optimize therapy for our patients.

That's great. Stella has a question. And she asks if there are specific risk factors for brain tumors or brain cancer. Who wants to take that one? Could we maybe start with you, Dr. Park?

There are some, probably the most obvious one is radiation. And there have been several animal studies and also experience stemming from other countries when children were radiated, but for different reasons and they went on to develop brain tumors. Other than that, we haven't found particularly professional risk or certain mutations that we are aware of yet. There was a lot of interest in looking at cell phone, whether or not that actually would increase its risk. The data is still murky. It's not 100% yet.

Interesting. Yeah, we hear about the cell phone potential. I think you see that on the internet every once in a while, but there's never been any definitive studies that have shown anything like that. So got a few more questions coming in. So if somebody is found to have a brain tumor, what are some of the best treatments that are possible? And Dr. Das, we'll throw that one to you.

Sure. So after the tumor is found on imaging study like the MRI or CAT scan, then we decide if surgery is an option. Because many times if you're able to remove all of it with little problems afterwards, that can be the best treatment. But it depends very much on what type of tumor. And then after that, as Dr. Park was mentioning, after surgery can be radiation or chemotherapy, either combined or alone, either one.

How dangerous is brain cancer surgery?

Well brain cancer surgery can be done very safely, especially in parts of the brain which don't have the critical functions, like your motor or your speech. And even in those areas we have many advances in the field of surgery, which makes these surgeries much more safe, such as awake craniotomy. Also, obviously, we have microsurgery which has been developed several decades ago, and also endoscopes where we can provide more minimally invasive methods. And all these methods can make surgery much more safe than it once was, maybe 50 years ago.

And I mentioned recovery times, and just recovery in general probably has improved dramatically.

Yes, a simple brain tumor operation in a part of the brain that doesn't cause any deficits, many patients can spend just one night, or two nights, in the hospital and then they're home after that.

Dr. Park, we have a viewer question wondering if you provide second opinions to patients.

Absolutely, yes. Without a question. I mentioned I'd prefer to see patients in person. However, if they live far away, for instance, I've done second opinion patients living in Nevada, for instance, Missouri, so yes.

And I would imagine, again, that's one of those situations. It's almost like we're talking about the tumor boards of the tumor meetings, that the more minds you get working on a problem, that, the better off you are. So a second opinion is important, particularly in an area like this. Another question from a viewer, and I think this will probably be the last one because we are just about out of time, and I'm going to have a hard time pronouncing this, but I'll do the best-- actually have two more questions. Would you be able to discuss intraosseous, am I my close? Looks like meningioma, I may have really messed that up.

Oh, intraosseous meningioma. Yes, we can discuss that. So yes, meningiomas, they can arise from the covering of the brain but many times it involves the bone or the skull. And when we remove these tumors, if they need removal, if it's the scan that's changing over time or if it's very large causing symptoms to cure the tumor fully, if it's involving the bone we have to remove the bone as well. And I think, I'm not sure if that's what the viewer is asking, but that's basically how we treat those.

Right. We are about out of time, but you guys were fantastic. It was really, really informative, and the questions from the viewers were excellent. That's great to always see that participation. We really do appreciate that. Thank you for taking time out of your busy days and, again, I know you are all busy, so we appreciate you doing that. Thank you to those who watched today.

If you do need more information about any of things we discussed today, you can check out our Facebook page or go online. And check out our Facebook page for a schedule of programs coming up in the future. To make an appointment online, you can go to uchicagomedicine.org or you can call 888 824 0200. Thanks again for being with us today, hope everybody has a great week.