Our neurosurgeons perform thousands of procedures, including traditional, open brain surgery and minimally invasive brain surgery, each year and are among the most experienced in the country with complex brain tumors. Below are just a few of the techniques our faculty may use depending on the size, type, and location of the brain tumor.
Awake craniotomy
This is an advanced surgical treatment to remove brain tumors that allows for intraoperative speech and language mapping during the procedure. To ensure the neurosurgeon is treating the correct area of the brain and not disturbing any healthy functional areas, they will ask questions during the operation and monitor the patient's responses and activity occurring in the brain.
Originally, this type of procedure was utilized by epilepsy neurosurgeons. They would remove the section that was causing a patient to experience seizures. Realizing that this technique could also be used for tumor resection, Penn started a collaborative program so neurosurgeons could remove primary brain tumors and certain metastatic brain tumors as well. The benefit of doing an awake craniotomy is that it allows our neurosurgeons to maximize the surgical resection while also minimizing the neurological risks.
With the patient needing to be responsive, anesthetics are handled in a completely different way with these treatments. There are no inhalation agents used like with most other surgeries. This procedure requires intervenes and nerve blocking techniques that the anesthesia team gives to specific areas on the scalp. Not fully putting the patient under allows the neurosurgeon to essentially "wake up" the patient from a sleep state after they've gotten the procedure started so they can interact with them.
Brain mapping
At Penn we use advanced imaging tools such as fiber-guided tractography and individualized brain maps to locate and safely remove brain tumors. Diffusion Tensor Imaging, or DTI, works by measuring the direction in which fluid moves within the brain, gathering data to help determine the location and function of different brain fiber clusters. Advanced diffusion tractography software then uses that data to produce 2D or 3D maps of the brain that reveal its internal wiring.
The brain is mapped both before and during the surgery. Mapping helps neurosurgeons pinpoint areas of the brain that control different behaviors. It requires a grid of sensors or electrodes positioned only on the surface of the brain to detect electrical signals. The cortical and deep areas of the brain are stimulated while a sophisticated neuromonitoring team collects real-time data, guiding the surgeon. This technology is especially helpful for removing brain tumors and sparing healthy brain tissue in the process.
Minimally invasive
Transorbital approach
Traditional surgery to resect skull-based tumors involves large incisions on the scalp and removal of a significant amount of bone. The newer transorbital approach (TOA) was developed as a minimally invasive alternative, made possible by advances in endoscopy. Typically, this means going into the skull base through an incision in the eyelid or eyebrow. For patients, this approach leads to a smaller scar that is less noticeable, and easier to hide than a traditional craniotomy.
Although it does not replace all craniotomy approaches, TOA is an excellent option for the right candidates. TOA can be used to treat a variety of skull base lesions, including benign tumors such as meningiomas, encephaloceles that cause cerebrospinal fluid leaks, and bony conditions such as fibro-osseous dysplasia. Less commonly, TOA is used to treat abscesses and other inflammatory or infectious lesions.
The main goal of TOA for skull base surgery is to remove the primary lesion. But important secondary outcomes include protecting a patient’s vision and minimizing facial disfigurement. Patients who require craniotomy approaches often experience some facial atrophy, which can often be minimized or avoided with TOA.
This approach takes a lot of planning and collaboration with experts in other departments. Typically, our faculty will work alongside members of oculoplastics and otorhinolaryngology to get the job done.
Endoscopic endonasal
Tumors that are located at the base of the skull are some of the more challenging ones to resect. Medical institutions often have to refer their patients to Penn Medicine if tumors are located here because they just simply aren't advanced enough to treat it. Our neurosurgeons are able to perform an Endoscopic Endonasal procedure that goes in through the patient's nose and sinuses to remove these specific skull base tumors.
Using a specially designed endoscope for shining a light and transmitting images, this minimally invasive surgery can remove tumors that are up to the size of an apple through the natural nasal passages that we already have in our skull. This means that there is no actual manipulating of the brain or important nerves since the approach for this procedure comes from the front. Our patients won't have to worry about incisions, they'll have a quicker recovery time, and there is a greatly reduced risk of neurological damage.
With the nasal passages being so small, pieces of the tumor are broken off bit by bit and suctioned out until it is completely gone. This procedure can be used to treat tumors both benign and malignant, and with recovery time being so quick the patient can also start radiation therapy or chemotherapy soon after if needed.
Stereotactic radiosurgery
At Penn Medicine, we have been performing laser surgery to destroy cancer cells for more than 20 years.
Today, Stereotactic Radiosurgery is a treatment that utilizes a large dose of radiation to destroy tumor tissue and although it's in the name, it doesn't actually involve any surgery.
This is a popular option for treating brain cancer because most nearby tissues aren't damaged by the procedure, there's no pain for the patient, very little noise, and no time that patients have to spend in confining spaces.
When our Neurosurgeons perform this treatment, they place the patient's head within a special frame, which is then attached to the patient's skull. They use this frame to precisely aim the high-dose radiation beams at the tumor. They can get the measurement down to the millimeter and can't have the patient's move their head or it can risk damaging other parts of the brain and body.
With advancements over the last few years, radiation can now also be used to treat arteriovenous malformations, trigeminal neuralgias, acoustic neuromas, and tremors. It can either be delivered by a Linear Accelerator, Gamma Knife, or Proton Beam Therapy.
TumorGlow®
What is TumorGlow® Technology?
TumorGlow®, a type of intraoperative molecular imaging, relies on an injectable dye that has been specially engineered to accumulate in cancerous tissues, much more so than normal tissues.
When we illuminate tumors, we brighten the odds for all cancer patients. That's why we're leading the way, investigating a new technique capable of making tumors glow under near-infrared cameras. TumorGlow® technology is engineered to enhance the visibility of undetected tumors-improving outcomes and reducing the odds of follow-up surgery.
How does TumorGlow® work?
Before surgery, patients are injected with a dye that causes cancer cells that might normally be invisible to CT scans to "glow" under near-infrared light. During surgery, the tumors strongly glow under near-infrared cameras, guiding surgeons to cancerous tissue in areas previously undetected. The results to date have been extraordinary.
What are the benefits of making the tumors glow?
There are two main benefits to the patient. The first benefit is that by seeing where the tumor is located, the surgeon can make sure to get it all out. This investigational method can make surgery safer for the patient if it allows the surgeons to cut out only what they need to take out, and nothing else. We believe that this approach will prove to be more precise.
Another benefit we have seen in these studies is the dye’s ability to “find” cancerous lymph nodes. This is especially important because identification of disease in the lymph nodes tells the oncologist that you may need to give the patient more chemotherapy, or that their cancer has progressed. This technology may also allow us to identify which lymph nodes we should take out and which lymph nodes we should leave in.