Dr. Ryan Merrell (NorthShore)
Thanks for your question Mary. Survival in metastatic tumors depends heavily on the type of tumor. For example, many patients with metastases (tumors spreading from the body) from breast cancer have better survival than patients with metastases from melanoma. Also, within a particular tumor type, some subtypes do better than others. For example, certain mutations associated with non small cell lung cancer are associated with beter outcomes. Also, the extent of disease in the body is very important. If a patient has a cancer that has not spread to multiple organs and only the brain, the survival is better. We see some patients with metastatic brain tumors with long term survival.

Dr. Ryan Merrell (NorthShore)
Thank you for your question Sangeetha. The simple anwer is that this is unknown. There are no known environmental risk factors for malignant brain tumors. The cell phone studies have not been revealing. It is rare that malignant brain tumors occur in families. Even having a first degree relative (sibling, child, parent) with a brain tumor does not put a patient at increased risk. There are rare tumor syndromes associated with brain tumors. We at NorthShore are involved with an international study whose purpose is to study both genetic and environmental risk factors for brain tumors. We hope to uncover some answers in the next few years.

Dr. Ryan Merrell (NorthShore)
Great question Kenya. Yes, there are significant differences in treatment. The biggest difference is the type of chemotherapy used. Primary brain tumors (gliomas) have specific chemotherapy drugs that are not used in metastatic tumors. Radiation is often used for both types of tumors, but the type of radiation is different. In general, IMRT (partial field radiation) is used for primaries and whole brain radiation of stereotactic radiosurgery are used for metastatic tumors. Surgery is often employed for both.

Dr. Ryan Merrell (NorthShore)
Thanks Beth. This is a provocative question. My sense is that the future of brain tumor surgery is moving towards less invasive procedures. For now, open craniotomies (big surgeries) are the gold standard. However, neurosurgical techniques are becoming more and more refined. For example, we are now using an endoscopic technique that allows the surgeon to make a smaller incision and disrupt less of the normal brain during surgery. The idea is that this will lead to shorter recovery times and better long term outcomes. We also have a minimally invasive thermal laser ablation technique that we are currently using to treat metastatic tumors that develop delayed swelling after radiation (radiation necrosis). This technique allows a patient to go home the day after the procedure. We are looking to expand this procedure to the direct treatment of tumors as well.

Dr. Ryan Merrell (NorthShore)
Thanks Mateo. Not always. This depends a lot on the age of the patient, the presence of other medical problems, and the location of the tumor. For example, an 80 year old patient would more likely need rehab than a 40 year old patient after surgery. A tumor that is near the motor cortex causing weakness on one side of the body would likely require rehab for the patient after surgery. We have many patients that go directly home after surgery. We have an outstanding inpatient rehab unit at Evanston that allows us to directly transfer patients to the unit a few days after surgery if necessary.

Dr. Ryan Merrell (NorthShore)
Thanks Andrea. Good question. Unfortunately, there is no best clinical trial. Nobody in the world can make that claim. That is why they are trials. We participate in several clinical trials, the majoritiy of which are for glioblastoma. Current clinical trials for glioblastoma involve targeted therapies and immunotherapies. We have both. We have phase I , phase II, and phase III trials. I am happy to discuss our specific trials with you and others at another time.

Dr. Ryan Merrell (NorthShore)
Thanks Karl. That depends a lot on the context. Stopping chemotherapy when the tumor is not growing or when it is growing. For example, in glioblastoma, there is no evidence that giving more than 12 cycles of the chemotherapy drug temozolomide leads to better outcomes when the tumor is not growing. When a glioma is growing and we have exhausted all treatment options and the patient can no longer tolerate treatment, we have to make the difficult decision to stop the chemotherapy. Of course, the patient's decision is the most important. The patient has the right to stop chemotherapy at any time.

Dr. Ryan Merrell (NorthShore)
Thanks Phil Like most physicians, I am on the fence here. I think there are some symptoms such as pain and nausea that clearly could benefit from medical marijuana. However, most of the time we are able to treat these symptoms with traditional treatments in our brain tumor population. I am open to the idea of using medical marijuana in select patients. We are waiting to hear from the state of Illinois and NorthShore regarding the logistics of how we will be able to prescribe it.

Dr. Ryan Merrell (NorthShore)
Thanks Keith. Great question. The location in the brain is key. For example, tumors in the brainstem, motor cortex, and deep brain structures (basal ganglia, thalamus) are not able to be removed safely without harming the patient. These areas can be biopsied. Other brain locations are tricky, but can be operated on by skilled neurosurgeons. I highly recommmend getting a second opinion if you are told that a tumor is inoperable, because it may be that the neurosurgeon that is telling you that is just not comfortable doing the surgery. At NorthShore, we are aggressive at operating on any tumor location, but also very cautious about not doing any surgery that would cause permanent neurologic harm to a patient.

Dr. Ryan Merrell (NorthShore)
Thanks Lana, This is a tough question. As I said in response to an earlier question, there is no way for anyone to know which trial is better than another. If a particular trial appeared to be producing home run results, we all would steer patients to that trial. That has not happened yet. I tell patients to choose trials based on the science behind them. Does a trial seem scientifically more interesting than another. Also, what does the trial require in terms of time committment. Does the trial require weekly visits and a lot of travel time? Some patients prefer open label trials over randomized trials. Some patients prefer trials that allow crossover at the end, meaning that they can get the study drug if they were in the placcebo group initially.

Dr. Ryan Merrell (NorthShore)
Ted, thank you for your question. Most neuro-oncologists train in neurology first and then specialize in neuro-oncology. They are often better trained to tackle the specific neurologic challenges of brain tumors. That dose not mean that a medical oncologist (oncologist) is not capable. In fact, many medical oncologists at top centers specialize in taking care of brain tumors. I would make your decision more on how many brain tumor patients the physician sees per year and if that is a substantial potion of their practice.

Dr. Ryan Merrell (NorthShore)
Thanks Kenny. The answer is probably not. There have been several cell phone studies, all of which have not shown definitively one way or another if cell phones are a risk factor. Many of my colleagues and I believe that the exposure a cell phone emits is theoretically too small to cause a brain tumor to develop. But, like many things in the brain tumor world, the jury is still out. It is most likely fine to talk on cell phones with regard to brain tumor risk.

Dr. Ryan Merrell (NorthShore)
Thank you for your question. This depends highly on the type of tumor, metastatic or primary and covers a wide spectrum. Most tumors will require either radiation and/or chemotherapy after surgery. There are some malignant tumors (for example low grade gliomas) that can be watched after surgery. All malignant tumor require close follow up with serial MRI scans at the minimum after surgery.