Dr. Christopher Duma

Last night Dr. Duma was a guest speaker at our brain tumor support group. He was a great speaker and had many interesting things to say....

Dr. Christopher Duma
Medical director of gamma knife program at Hoag
He does ~150 craniotomies a year and ~200 gamma knife procedures a year
There are a number of ways of improving outcome than what used to be available in the past
Biggest improvement is operating microscope, but since then, little has occurred until neurosurgical navigation (mri with real time intra operative guidance about 10 years ago)
Using navigation with microscope is the standard of care for any brain surgery that exists today. Navigation allows smaller cranial openings and smaller pathway to get through brain to tumor.
When you open a head, you usually can't see the tumor because they are usually deep. Used to use ultrasound to help find the mass, but sometimes that wasn't good enough. With computer navigation it makes it much easier, gives millimeter accuracy.
Improving outcomes
Gamma knife is good for metastatic tumors (tumor cells travel in the blood to the brain). Cyber knife also can be used for these types of tumors. Gamma knife has a more accurate focus and less radiation to the brain, but can only treat tumors within the brain. If out of reach of the gamma knife (spine, skull, etc.) cyber knife is used.
Implanting gliadel wafers (soaked with chemotherapy) into the cavity, if it is in the lobe of the brain (not deep) is also an option.
People are now starting to try gamma knife for GBM (newer technique). GBM tumors are able to migrate through the brain. Difference between I and II and IV is ability to migrate through the brain. Tests done on tumors to check migratory ability of astrocytomas, they found that the more aggressive ones become irregularly shaped and start looking and moving like an amoeba, they start spreading and getting polarized and start getting the ability to contract and move on their own (kind of like an inchworm)! When in-utero, brain forms as a ball of neurons in the middle of the skull, at a certain point of development, they migrate to proper positions to form brain. With GBMs, cells are reverting back to primordial way and regain the ability to migrate again. We want to fix it so they can't migrate. An experiment was done taking a GBM and put it in a jar...they radiated it with low dose radiation, then did high dose radiation (like gamma knife) found that cells moved more if they got low dose radiation vs 4x less if they received a high dose of radiation. Adding a high dose may help stop the migration, if they can't migrate, the cells will hopefully die off. At Hoag, we've been radiating leading pathways of GBMs to cut tumor off at the pass (callaed gamma knife leading edge); however, we still sometimes faile because tumor cells can migrate farther than we can imagine, you need scans that can show where the growth is (MRI spectroscopy that can show chemicals in areas in brain that can show where tumor growth may be).
Best chemotherapy adds 3-4 months survival (5% alive at 2 years). Our outcome (including gamma knife leading edge) has 20% survival at 2 years. My philosophy is to incorporate everything and throw it at the tumor. 1st start with good resection, radiation, boost, temodar during and after, gliadel on recurrence, more chemotherapy. (There are other approaches out there as well...i.e. Dr. Friedman (Duke) uses mostly temodar with other chemo agents)
Temodar is #1 drug for treating GBM. Original papers show it works well for grade 3, doctors started using it off label for GBM. Big study showed marked improvement for Temodar and GBMs (Stupp regimen). Studies show that it really has the ability of crossing blood barrier and being effective. New trial going on (Europe and USA) with 800+ people in study to look at effects of Temodar. If tumor recurs, then they are no longer valid for this trial and fall into the Hoag trial for gamma knife on recurrent tumors. All brain tumor patients should be getting scans every 2 months at minimum, at first sign of progression, you need to start doing something. We have had a patient on temodar for 4 years. There are risks of various cancers (leukemia) with all chemotherapies, but odds of succumbing to new cancers are low compared to the brain cancer itself.
Immunotherapy has improved outcome greater than temodar and gliadel wafer studies. Immunotherapy is currently in trial and only for upfront GBM. The idea is that our bodies will hopefully develop immunity to daily exposure. White blood cells have been educated and often know how to fight disease that they've already seen (i.e. chickenpox). We hope to make you immune to your own brain tumor by programming your white blood cells to fight brain tumor cells and destroy. Our trial takes some white blood cells out of your body and we "supercharge" them (make them angry toward the tumor) for about a week with a substance (interlupen 2?). Through another craniotomy, we pour mixture (or paint it) into the tumor cavity so that they can get in and fight the foreign matter (tumor cells) then go out into lymph cells and educate other white blood cells to fight any cell that looks like a tumor (bad guys). Hoag has a patient out 9 years with gamma knife to leading edge and immunotherapy.
Has a patient (8 years) resected, radiation/chemo, 6 months later tumor came back, did gamma knife and immunotherapy, still alive today. How is Hoag's trail different than UCLAs? Not much different at all. Dendritic cells are white blood cells that present antigens to T-cells grown from tumor, injected into your arm vs being "painted" in. Both treatments "supercharge" the white blood cells, same concept, different approach. Hoag doesn't harvest from actual brain tumor, but puts them back in tumor cavity directly. UCLA harvests from tumor itself then injects it back in the body.

PET/MRI for brain tumors like these is worthless, it will never show leading edge of tumor and won't show you where tumor is going. MRI spec and MRI (with flair sequence) are the best for showing where the tumor is going. MRI spec can differentiate necrotic tissue vs aggressive cells (maliginant tumor).

Virtualtrials.com by Musella (who is a brain tumor survivor that set up this site) is an excellent resource to keep up to date on what new trials are going on out there for brain tumors.

Mark is a candidate for immunotherapy and gamma knife leading edge. Mark's tumor is in a lucky spot in the brain. His symptoms are often described as: Gerstmann syndrome (calculation trouble, disorientation)

Don't normally see necrosis so soon after radiation.

Duma doesn't do spines, backs or necks. He only does brain tumors and Parkinson's disease treatment(stereotatic-type of treatment). He does surgery, he picks neuro oncologist, helps follow up on scans, etc. Here's his website: www.cduma.com