BY DARCY LEWIS

The brain, more than any other organ, captures the essence of what it means to be human. It’s the seat of personality, humor, memory, and higher reasoning. This complex organ controls emotion, movement, and the senses of touch and vision, among many other conscious and unconscious processes that keep us alive.

It’s easy to take a healthy brain for granted. In the U.S., an estimated 1 million people are currently living with a brain tumor, and each year another 95,000 people will hear the words that no patient—or parent—ever wants to hear: “You have a brain tumor.” Or: “Your child has a brain tumor.”

Although brain tumors can be devastating, they are rare. The National Brain Tumor Society reports that more than 72% of brain tumors are benign. According to the American Cancer Society, the overall chance that a person will develop a malignant brain tumor in their lifetime is less than 1%.

If you or a loved one does receive a brain-tumor diagnosis, it’s important to seek care at a comprehensive cancer center, says Albert Kim, MD, PhD, WashU Medicine neurosurgeon and director of The Brain Tumor Center at Siteman Cancer Center. Siteman is based at Barnes-Jewish Hospital and WashU Medicine. “Because brain tumors are so rare, you need a multidisciplinary team to come together to provide personalized, precision medicine for your unique circumstances,” he says. “You want a highly specialized medical team, with each expert providing their own perspective and expertise to guide your care.”

Physicians at Siteman have long provided exceptional care to patients with malignant and benign brain tumors. Since 2020, those efforts have been supercharged by The Brain Tumor Center’s multidisciplinary focus on this single area of disease. More recently, the Center’s move to the newly opened Gary C. Werths Building at Siteman Cancer Center has consolidated its operations into a single location for adult care. That consolidation has fostered even closer collaboration among physicians and the researchers who study different aspects of brain tumors.

Siteman’s Brain Tumor Center’s team of experts includes medical oncologists, neurologists, neurosurgeons, neuroradiation oncologists, pathologists, radiologists, otolaryngologists, endocrinologists, and basic scientists, as well as psychologists, social workers, and nurse navigators. Working collaboratively, these specialists perform more than 1,000 brain tumor related procedures a year, one of the highest volumes in the U.S., and have amassed exceptional expertise. The Center’s leadership includes Dr. Kim, its director, as well as Tanner Johanns, MD, PhD, medical director; Alex Stegh, PhD, scientific director; and radiation oncologist Jiayi Huang, MD, MSCI, and neuro-oncologist Milan Chheda, MD, associate directors.

Types of brain tumors

There are more than 100 types of brain tumors. The Brain Tumor Center offers specialists with the expertise to diagnose and treat them all. The majority of primary brain tumors fall into one of the three following categories.

• - Meningiomas: These tumors, which are nearly always benign, grow in the meninges, the linings that cover the brain and spinal cord. Meningiomas can press inward against these delicate structures if not treated. About 40% of primary brain tumors are meningiomas. They occur in women about twice as often as in men.
• - Pituitary tumors: These tumors grow in the pituitary, the body’s master gland, which is located in the center of the skull, nestled against the brain. Like meningiomas, pituitary tumors are almost always benign, but they can result in health problems if they cause the pituitary to make too much of any kind of hormone, or if they grow so large they press against the optic nerves. They comprise about 17% of all brain tumors.
• - Glioblastomas: These aggressive, fast-growing tumors are the most common type of primary malignant brain tumor in adults and are typically diagnosed at an advanced stage. They can cause many distressing symptoms, including seizures, severe headaches, hearing and vision problems, and personality changes. Glioblastomas represent about 14% of all primary brain tumors.

Additionally, experts from The Brain Tumor Center often treat people with brain metastases, in which cancer from another part of the body spreads to the brain. These metastases are, overall, the most common form of secondary brain tumor. Primary lung cancers, breast cancers, and melanomas are the most likely tumors to spread to the brain.

Brain Tumor Center clinicians understand that receiving a brain tumor diagnosis brings both physical and emotional challenges. For starters, even though half of the people they treat have benign tumors, there still can be medical cause for concern. “Unlike other body parts, where a benign tumor can be much less concerning than a malignant one, the skull’s rigidity means that tumor growth can damage the brain and nearby structures as internal pressure builds,” Dr. Kim says. “And a brain-tumor diagnosis is always a shock to people, so we focus on listening to them talk about what they’re going through so we can respond to their physical and emotional needs.”

Innovation improves outcomes

“We offer every single imaging and treatment tool in every oncology-related department. Very few academic medical centers can say the same,” Dr. Kim says. “That’s important because it allows us to develop treatment plans based solely on what’s best for the patient, rather than based on the equipment we have available.”

Siteman was the first cancer center in Missouri to offer treatment of brain tumors using a Gamma Knife. Not actually a knife, this technology directs a powerful dose of radiation to hard to-reach tumors in the brain. Though no incisions are involved, Gamma Knife is considered a form of surgery because it can eliminate tumors with the accuracy of a surgical procedure. Patients reap the benefits of surgery without many of the risks, including infections, bleeding, and complications arising from anesthesia. With Gamma Knife procedures, a local anesthetic is often the only painkiller required.

In another breakthrough, Siteman was the first in the world to offer both MRI-guided radiotherapy and compact proton beam radiation. MRI, or magnetic resonance imaging, provides clear, detailed views of a tumor, allowing it to be precisely targeted with radiation while protecting nearby tissues and organs. Compact proton beam radiation also offers precision and is used to treat inoperable tumors that are particularly close to sensitive areas, such as the eyes, brain, and spinal cord, and to treat solid tumors that haven’t spread. Dr. Kim notes that this kind of precision—which minimizes the long-term effects of treatment—is especially critical in the care of children with brain tumors.

Bhuvic Patel, MD, neurosurgeon and surgical director of WashU Medicine’s Pituitary Center, also emphasizes the value of having a multidisciplinary tumor board available to provide guidance when a brain tumor is diagnosed or suspected. All National Cancer Institutedesignated cancer centers, including Siteman, have tumor-board case conferences attended by specialists from various disciplines who meet regularly to develop and refine patients’ treatment plans.

“Our tumor boards meet every week. All the specialists in attendance—often as many as 30 or more—bring their own, high level of expertise to the group,” Dr. Patel says. “As a result, these meetings make a real difference to patients by improving the care we provide.”

Once a patient’s case is presented to the tumor board and all attending specialists weigh in, a treatment plan is developed that is personalized to the patient and the tumor. In some cases, multiple forms of treatment are part of that plan. For example, standard-of-care chemotherapy drugs like temozolomide can be used as part of a multimodal plan that may also include surgery and radiation therapy.

The Brain Tumor Center offers other advanced treatments available only at a few cancer centers in the U.S., including an innovation called laser interstitial thermal therapy, or LITT, a procedure used to treat tumors that are otherwise inaccessible. During treatment, a neurosurgeon uses robotic technology to guide a tool that drills a small hole in the skull near the tumor. A laser probe is then inserted and used to emit heat that destroys tumor cells.

Additionally, Dr. Patel reports a “seismic shift” in treating skull-base tumors, those located behind the eyes and nose, and in or near the skull’s floor. “Advances in imaging and surgical techniques have made treatment markedly better than what was possible even five or 10 years ago,” he says. “Today, we have a new way to approach these tumors entirely through the nasal cavity, an option that can lessen postoperative complications.”

Searching for new treatments

Dr. Kim emphasizes that the opportunity to participate in clinical trials is especially important for people with brain tumors. “We tell patients that tomorrow’s standard of care—the care that everyone will receive— is the clinical trial of today,” he says. “That’s especially true if you have a disease like glioblastoma, for which the standard of care is not a cure.”

The Brain Tumor Center participates in Siteman’s robust clinical trials program—led by WashU Medicine physicians and researchers—and also has access to trials elsewhere. The goal is to match a patient to an appropriate trial, offering opportunities to improve medicine while also making the most advanced treatment options available to patients who qualify. Dr. Stegh singles out several innovations that are under development, particularly for the diagnosis and treatment of glioblastoma.

One of the main challenges in brain-tumor research is determining how to best deliver drugs across the blood-brain barrier, a layer of cells that prevents harmful substances in the bloodstream, including bacteria and viruses, from entering the brain. Unfortunately, the blood-brain barrier also filters out chemotherapies and immunotherapies, a class of drugs that activates the patient’s immune system to kill cancer cells.

Laser interstitial thermal therapy may change that, says Dr. Stegh. “At The Brain Tumor Center, we’re investigating ways that LITT may stimulate an immune response that could kill more tumor cells than ablation alone,” he explains. “This has enormous potential for combining two proven therapies—LITT and immunotherapy drugs—to finally cross the blood-brain barrier.”

Another challenge in treating glioblastomas is that they often are diagnosed at an advanced stage. The presence of a glioblastoma can go undetected in the brain for as long as a year, its symptoms attributed to other causes. Late detection can mean fewer treatment options. If it became possible to detect and diagnose glioblastomas earlier in the progression of the disease, treatment could begin earlier, and survival rates could improve.

Eric Leuthardt, MD, WashU Medicine neurosurgeon at Barnes-Jewish Hospital, and Hong Chen, PhD, WashU biomedical engineer, are investigating an approach that could improve glioblastoma detection. Essentially, they are asking: Can a technology called focused ultrasound open the blood-brain barrier to allow cells from the brain tumor to enter the bloodstream, thereby creating a chemical footprint? If so, detection and diagnosis could be done without surgery to biopsy the tumor.

On the radiation-oncology front, Dr. Huang sees promise in an experimental treatment known as temporally modulated pulse radiation therapy. In this technique, the standard, daily radiation dose is split into multiple microdoses with three-minute intervals between pulses. “Cancer cells may be more sensitive to lower radiation doses delivered in pulses, and this approach may lessen damage to healthy tissue, too,” Dr. Huang says, adding that he is the principal investigator of a new, randomized clinical trial evaluating this technique for people with glioblastoma.

Treating adults and children: a patient-centered approach

The first principle of caring for people with known or suspected brain tumors is that they must be seen promptly. “Everybody who finds out they may have a brain tumor is scared, whether or not it turns out to be benign,” says Dr. Kim. “The most important thing we can do is see that person as quickly as possible, so that we all know what we’re dealing with.”

Care and treatment at the Center includes access to a nurse navigator, who is available to help ease a person’s journey through treatment. “The only thing our patients should have to think about is their health, not the logistics of getting care,” says Dr. Patel. “When you work with one of our nurse navigators, you have someone who will be there with you throughout your time with us, helping with scheduling, answering questions, and offering support.”

Unfortunately, children are not immune from developing brain tumors. “Children tend to develop different tumors than adults, so it’s important to have pediatric specialists,” says Stephanie Perkins, MD, WashU Medicine radiation oncologist at Siteman Kids at St. Louis Children’s Hospital and director of Siteman Cancer Center’s S. Lee Kling Proton Therapy Center. Cancer care at Siteman Kids includes a team of child life specialists that works closely with young patients and their families. These specialists provide support and guidance, using play, art, music, and other activities to help children cope with stress, fear, and anxiety. Reduced fear and stress offer a number of benefits that can have real impact, including the potential to reduce the amount of anesthesia a child requires during treatment.

“We know from Day One that some of the children we care for are in a fight for their lives,” says Dr. Perkins, “and we know that some will become long-term survivors. It’s important to think ahead to how that child can continue to be cared for on into adulthood if that becomes necessary.”

Dr. Perkins is particularly proud of the twice-weekly neuro-oncology clinic at St. Louis Children’s Hospital. “We have streamlined the experience for our patients and their families,” she says. When a child and family members visit, they don’t have to move from room to room to see the various specialists on their care team. Instead, the specialists come to them. “This way, a child and his or her parents can see their oncologist, neurologist, endocrinologist, and social worker in one stop, which can reduce stress for the family—and it also helps with coordination of care and communication between the team members.”

Overall, Dr. Perkins is optimistic about the future of pediatric brain-tumor care. “Every five to 10 years we see improvements in treatment happen in leaps and bounds, which is inspiring,” she says. “We want families to know how important it is to seek out a care team that has the expertise and experience needed to leverage all the new medications and technology. That’s what each child deserves.”

Learn more about tumor boards.