U-M Neuro-Oncology Program

Neuro-oncology Program at the University of Michigan

Care of brain tumor patients is an inherently collaborative endeavor. The Neuro-oncology Program at the University of Michigan brings together a highly experienced and knowledgeable team of experts in neurology, neurosurgery, radiology, oncology, radiation oncology, otolaryngology and ophthalmology to provide compassionate care and treatment of patients with brain and spinal cord tumors as well as neurological complications from cancer.

Brain tumors are relatively uncommon. Some of the more rare tumor types are seen only once or twice in a career. The combined subspecialty training and interests of the more than 30 members of our team results in collective expertise for even the most rare of brain tumors. Our team uses advanced neurosurgical and radiation approaches, chemotherapy, anti-angiogenic therapy, experimental therapies, and state-of-the-art imaging and research to improve outcomes for our patients.

The patient’s best interests, function and quality of life drive every decision we make. We emphasize compassionate care, personalized attention, and involvement of the patients, their families and referring physicians in decision-making to help preserve the quality of life of the patients we treat.

As our program continues to grow through the addition of several new faculty with subspecialty experience in all types of brain and spine tumors, we are able to expand treatment options for adult and pediatric patients, particularly in radiation oncology and endoscopic procedures.

Neuro-oncology Program

2 | Neuro-oncology Program at the University of Michigan

“I love the practice of Neuro-oncology because of its triple challenge —

discovering more about the biological nature of the tumors we treat,

delivering the most advanced care for patients with these tumors, and

emphasizing neurological function and quality of life for our patients.”

Larry Junck, MD | Professor, Department of Neurology

M-LINE 800-962-3555 | 3UofMHealth.org/neurosciences

Multidisciplinary Clinical CareCollaboration among specialists is essential to delivering the best possible care and quality outcomes to patients and their families. The Neuro-oncology Program supports several multidisciplinary clinics to provide convenient access to specialists throughout treatment and follow-up. Although patients may be seen in different clinics depending on their situation, the team members that make up these clinics communicate on a regular basis to coordinate care.

One venue for communication is the weekly Brain Tumor Board, which is made up of neuro-oncology specialists from neurology, neurosurgery, radiation oncology, radiology and medical oncology. Cases may be presented for review of diagnosis or for discussion of treatment recommendations. Patients are typically presented after a new diagnosis, but they may also be presented when they are at a critical point where multidisciplinary input would be helpful. The Brain Tumor Board also facilitates second opinions and consultations as well as enrollment in clinical trials.

Depending on the patient’s case, follow-up care could be in one of the following clinics:

• Neuro-oncology Clinic. Located in the University of Michigan Comprehensive Cancer Center, the clinic is staffed by two neuro-oncologists, who oversee the care of patients with brain tumors and manage symptoms. They also prescribe chemotherapy, anti-angiogenic therapy, biotherapy, small molecule inhibitors, as well as offer clinical trials.

• Neurosurgery Clinic. Our neurosurgeons meet with patients who may benefit from surgical intervention, emphasizing minimally invasive surgery when possible.

• Radiation Oncology Clinic. Our radiation oncologists who specialize in brain tumors utilize highly conformal radiation therapy planning and delivery methods personalized for each patient, including intensity modulated radiation therapy and stereotactic radiation surgery, to optimize the effectiveness of radiation therapy.

• Pediatric Brain Tumor Clinic. Children with brain tumors are seen by pediatric neurosurgeons and pediatric neuro-oncologists.

• Pituitary Clinic. In our Pituitary Clinic, one of the busiest in the country, patients are managed by a neurosurgeon and an endocrinologist with advanced expertise in using multiple approaches to treat pituitary tumors.

• Skull Base Clinic. Patients may be referred to neurosurgeons and otolaryngologists with special training and expertise in removing tumors behind the nose, deep to the ear, and underneath the brain.

• Neuro-ophthalmology Clinic. Neuro-ophthalmologists manage patients with tumors involving the optic nerve and other parts of the visual pathway. They also collaborate with other specialists in monitoring vision in selected patients with brain tumors.

U-M Comprehensive Cancer Center is one of 41 centers in the U.S. to earn the National Cancer Institute’s “Comprehensive” designation — and the only one in Michigan to also be in the National Comprehensive Cancer Network.


Surgical TreatmentEvidence shows that patient outcomes improve significantly if brain tumors are removed. Whether a patient is referred directly to the Neuro-oncology Program through the Emergency Department or by a referring physician, our neurosurgical team offers extensive expertise in best options for brain tumor resection. Our neurosurgeons are happy to consult on patients with a brain tumor at any point in their treatment.

Advanced TechnologyOur goal in all brain tumors is to do as complete a resection as safely as possible. Our team has the experience and training that is important to result in maximum safe resection. Our years of experience coupled with the technology can get the best results for the patient.

The program features the latest technology in radiation oncology, including Intensity Modulated Radiotherapy (IMRT), Stereotactic Radiosurgery (SRS), and Stereotactic Radiotherapy (SRT) for brain tumors and Stereotactic Body

Radiotherapy (SBRT) for spine metastases. Advanced linear accelerators give us the ability to treat all types of tumors in an extremely precise manner, and also successfully target small lesions or deep, inaccessible lesions.

Our radiation oncologists are especially adept at employing the best radiation techniques in conjunction with non-invasive imaging practices that help us hone in on active tumor and determine what would cause deficits while improving outcomes and reducing side effects for the patient.

When changes on imaging occur, it can be challenging to determine if the change represents true tumor progression, pseudoprogression of the tumor caused by treatment, or after-effects of radiation therapy. Our team has extensive experience in dealing with these challenges with current technology, and we are also conducting research with other imaging modalities to find out how to better overcome these challenges.

“Every one of us treats patients very much as we would treat our own family members.

It’s extremely important to us to make certain that we’ve not only communicated what

we think about to the parents, but also to the child and that they participate in the

process by which we make decisions and treat them. We are very committed to our

patients—not just about getting them through the initial operation, but also seeing to

the quality of their lives long term no matter what time in their lives we care for them.”

Karin Muraszko, MD | Chair, Department of Neurosurgery


Radiosurgery ProgramStereotactic radiosurgery is an option in certain smaller tumors. Patients with metastatic brain cancer may also benefit from radiosurgery treatment. Radiosurgery may be used if more than one tumor needs treatment, which saves the patient from undergoing multiple surgical procedures. Our team of neurosurgeons and radiation oncologists collaborate with other specialists, including radiation physicists, radiation therapists and dosimetrists, to deliver accurate and effective radiosurgery treatments.

Intraoperative MRIWith an intraoperative MRI (iMRI) scanner for both adult and pediatric patients, we have expanded our ability greatly to improve the outcomes for surgical resections. Our extensive knowledge and experience with this cutting-edge technology allows us to better assess and adjust the effectiveness of treatment at every stage.

This technology also allows surgeons to minimize the risk of damaging other parts of the brain during the removal of the tumor based on brain mapping that determines where to operate safely. Studies have shown that taking as much of the tumor out as safely as possible leads to the best outcome for the patient in terms of recovery and function. We specialize in this process of mapping the brain to determine where we can safely operate. If needed, videoconference capability allows our neurosurgeons to consult with other medical experts throughout UMHS during the procedure.


The Neuro-oncology Program at the University of Michigan is at the forefront of brain tumor research, from investigating new treatment options for the deadliest tumors and improving imaging techniques for more precise resections, to translational research that informs new protocols for tumors that had not been successfully treated or previously treated before.

Through our research, our team has contributed to key advances in minimally invasive surgery, neuroimaging of brain tumors with MRI and PET, accurate targeting of radiation, and drug therapy. We offer all phases of clinical trials for adult and pediatric patients with glioblastomas, central nervous system tumors and brain cancer.

One promising study is an immunotherapy trial for adult patients newly diagnosed with glioblastoma multiforme. During first surgical resection, two therapeutic genes that have been encoded in adenoviruses are injected at the tumor site and followed up with chemotherapy to eliminate the tumor. This trial is currently enrolling patients with suspected glioblastoma or other high-grade gliomas prior to planned resection.

Other current research includes:

• Two other immunotherapy vaccine trials for glioblastoma, among the most promising treatments available based on preliminary results.

• Mapping of brain tumors to maximize resection without compromising neurological function, particularly in patients whose tumors were deemed inoperable.

• Studies in glioblastoma — cancer stem cells — the small fraction of tumor cells that continue growing and dividing. Treatment directed against stem cells may be the secret to a new level of success in treatment of these tumors.

• Studying microRNA sequences to better understand malignant transformation, where a tumor goes from a low-grade tumor to a high-grade tumor, and how it affects function in brain tumors.

• Using intensified radiation with chemotherapy and state-of-the-art MRI and methionine PET imaging to target the resistant parts of brain tumors. Preliminary results show a higher rate of control of glioblastoma compared to standard therapy.

As we continue to grow, our clinical trial portfolio expands along with available treatment options for patients. For a complete list of clinical trials, call M-LINE at 800-962-3555 or visit www.umclinicalstudies.org.

On the left, the view of the brain that neurosurgeons currently see

during an operation using bright-field microscopy.

On the right, an SRS microscopy view of the same area of brain —

in this case, a mouse brain that has had human brain tumor tissue

transplanted into it. SRS might someday allow surgeons to see this

same view of patients’ brains.

Science Translational Medicine 2013, vol. 5 (201), p.201rall9

“My research is focused on allowing us to use imaging to optimize surgical results. With Simulated Raman Spectroscopy (SRS) microscopy, we can see ‘invisible’ tumors on a microscopic scale, which allows us to achieve an even finer level of accuracy

during surgery.”

Daniel A. Orringer, MD | Assistant Professor, Department of Neurosurgery

Research


Pediatric Patient Care

Top-Ranked Pediatric Hospitals for Neurology & Neurosurgery, U.S. News & World Report “Best Children’s Hospitals, 2014”

The majority of the pediatric patients we treat for central nervous system tumors become long-term survivors. Specializing in these types of complex tumors in children, our multidisciplinary team works together to evaluate each patient and develop a custom, individualized care plan for pediatric patients and their families.

Our goal is to provide the highest possible quality of life after treatment. Every patient is supported by our dedicated group of providers, which include neurosurgeons, neurologists, radiation oncologists, radiologists, endocrinologists, oncologists, ophthalmologists, otolaryngologists, rehabilitation specialists, social workers, and child life specialists.

We offer comprehensive, compassionate care and access to the latest, most effective treatments available. Our patients receive the most advanced diagnostics and therapies including:

• Quick and accurate diagnosis from our dedicated neuropathology team.

• Precision surgery with availability of intraoperative MRI and guidance system to maximize tumor resection while preserving neurological function.

• Advanced pediatric radiation oncology therapies, including precisely targeted radiosurgery and fractionated radiation therapy, to minimize a child’s exposure to radiation.

• Access to Positron Emission Tomography (PET) scan and PET fusion imaging, which provide precise anatomical and functional images to help guide our treatment decisions.

• Chemotherapy delivery that minimizes hospital admissions when appropriate, including outpatient/oral administration of chemotherapy and access to Phase 1 clinical trials.

• Supportive care and rehabilitation programs that help children regain lost motor skills and strength.

• Continuous follow-up care to manage disease, detect tumor recurrence and mitigate late effects of treatment.

One of the hallmarks of our Neuro-oncology Program is the seamless integration of care in both the pediatric and the adult populations. For more than 20 years, we have provided uninterrupted care for pediatric patients and their families throughout childhood and as they transition into adult care. That continuum of care not only leads to security for the families we serve, but also allows us to truly assess our outcomes over time.


Neurosurgery

Larry Junck, MDProfessor, Department of Neurology

Aaron Mammoser, MDAssistant Professor, Department of Neurology

Our dedicated team of adult, pediatric and multidisciplinary faculty is passionate about caring for patients with brain and spine tumors. We are committed to understanding all aspects of why these tumors occur, and striving to eliminate them by improving clinical care and uncovering the best possible treatment options through research.

Our FacultyADULT FACULTYNeurology

Shawn Hervey-Jumper, MDAssistant Professor, Department of Neurosurgery

Daniel Orringer, MDAssistant Professor, Department of Neurosurgery

Jason Heth, MDAssociate Professor, Department of Neurosurgery


Pathology

Parag Patil, MD, PhDAssistant Professor, Department of Neurosurgery

Sandra Camelo-Piragua, MDAssistant Professor, Anatomic Pathology

B. Gregory Thompson, MDProfessor, Department of Neurosurgery

Oren Sagher, MDProfessor, Department of Neurosurgery

Andrew Lieberman, MD, PhDProfessor, Department of PathologyDirector, NeuropathologyDirector, Neuropathology Fellowship

Stephen Sullivan, MDAssociate Professor, Department of Neurosurgery

Paul McKeever, MD, PhDProfessor, Department of Pathology

Aditya Pandey, MDAssistant Professor, Department of Neurosurgery


NeuroradiologyPEDIATRIC FACULTYNeurosurgery

Neurology

Gaurang Shah, MDAssociate Professor, Department of Radiology

Hugh Garton, MDAssociate Professor, Department of Neurosurgery

Patricia Robertson MDProfessor, Pediatrics

Ashok Srinivasan, MBBSAssociate Professor and Director of Neuroradiology, Department of Radiology

Cormac Maher, MDAssociate Professor, Department of Neurosurgery

Karin Muraszko, MDChair and Julian T. Hoff, MD Professor, Department of Neurosurgery

ADULT FACULTY (continued)

Radiation Oncology

Daniel Hamstra, MD, PhDAssociate Professor, Department of Radiation Oncology

James Hayman, MDProfessor, Department of Radiation Oncology

Theodore Lawrence, MD, PhDIsadore Lampe Professor and Chair, Department of Radiation Oncology

M-LINE 800-962-3555 | 11

If you would like to consult with a member of the Neuro-oncology Program, or refer a patient, please contact M-LINE 24 hours a day, seven days a week.

M-LINE (800) 962-3555

NEURO-ONCOLOGY PROGRAM

UofMHealth.org/neurooncology

Executive Officers of the University of Michigan Health System: Michael M.E. Johns, Interim Executive Vice President for Medical Affairs; James O. Woolliscroft, Dean, U-M Medical School; Kathleen Potempa, Dean, U-M School of Nursing; T. Anthony Denton, Acting Chief Executive Officer and Chief Operating Officer, U-M Hospitals and Health Centers. The Regents of the University of Michigan: Mark J. Bernstein, Julia Donovan Darlow, Laurence B. Deitch, Shauna Ryder Diggs, Denise Ilitch, Andrea Fischer Newman, Andrew C. Richner, Katherine E. White, Mark S. Schlissel (ex officio). The University of Michigan, as an equal opportunity/affirmative action employer, complies with all applicable federal and state laws regarding nondiscrimination and affirmative action. The University of Michigan is committed to a policy of equal opportunity for all persons and does not discriminate on the basis of race, color, national origin, age, marital status, sex, sexual orientation, gender identity, gender expression, disability, religion, height, weight, or veteran status in employment, educational programs and activities, and admissions. Inquiries or complaints may be addressed to the Senior Director for Institutional Equity, and Title IX/Section 504/ADA Coordinator, Office of Institutional Equity, 2072 Administrative Services Building, Ann Arbor, Michigan 48109-1432, 734-763-0235, TTY 734-647-1388. For other University of Michigan information call 734-764-1817.

© 2014, Regents of the University of Michigan. RBD11490730

UofMHealth.org/neurosciences

Neuro-oncology ProgramComprehensive Cancer Center1500 E. Medical Center DriveLevel B1, Reception EAnn Arbor, MI 48109

M-LINE (800) 962-3555 | UofMHealth.org/neurosciences

“Brain tumor patients present challenges that many other cancer patients don’t. Neurologic complications are common, given the tumor location in the nervous system and the agents needed to treat them. We are experts in dealing with these complications, and avoiding them where possible. We all share an approach that focuses on the patient’s best interest, and our management recommendations are a blend of current practice and individualized care.”

Aaron Mammoser, MDAssistant Professor, Department of Neurology

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U-M Neuro-Oncology Program