Dr. Alfred Perry Bowles, Jr., M.D., FICS, FACS
Conemaugh Neurosurgical Associates
Q: What are the benefits of Gliasite for patients with brain tumors?
A: One of the problems with brain tumors is that some of these tumors are malignant, they continue to grow despite our best efforts for surgical cure. A lot of brain tumors, when we talk about malignant brain tumors, can’t be cured surgically. So we have to help our surgery with radiation and chemotherapy, different forms of radiation therapy, different forms of chemotherapy. That’s where the GliaSite comes in because, you know, we can provide more radiation, which typically we can’t with just external beam because it’s a one time, it’s a one time shot. Now --- one time shot. Now, with malignant brain tumors, typically, these two common names you’ll hear are glioblastoma multiforme and highly anaplastic astrocytoma, a malignant astrocytoma, and these are tumors we just can’t cure surgically. Even though we remove it, remove every bit of the tumor that we can see at surgery or by the MRI that we obtain preoperatively and postoperatively, there’s always going to be tumor cells that are left behind and we have to supplement that treatment with radiation and chemotherapy. Now, typically if you just do surgery for these types of tumors the patients will succumb to their disease within weeks. As we provide radiation and chemotherapy we’re able to improve their lifespan. We’re able to improve patient outcome. We’re able to give our patients more time, a lot more time and that’s important. Now --- and you can only achieve that with the radiation and the chemotherapy. Now, you know, I was a neuro-oncologist before I became a neurosurgeon and in neuro-oncology all I dealt with were tumors, patients who had brain tumors, malignant brain tumors, and I was really trying to figure out ways to make life better for them, particularly when they had a disease that couldn’t be cured and one of the things that I was really impressed about is cause as I started the training as a fellow I used to think well, you know, if I had a malignant brain tumor and I had a few weeks to live what’s the difference between a few weeks and a few months. To me, when I started, I didn’t think there was much of a difference but in having an opportunity to work with patients who I became very very close to and began to understand what they’re going through. Days, weeks to months to years are incredibly important to a person or a patient who has a tumor that typically they can’t survive. So what we try to do is even though we know that some of these tumors we can’t cure, we try to do whatever we can to give our patients as much time, as much good time, as they can have for themselves and with their family and that’s how we continue to promote and push all these different treatments in order to link them --- their patient outcome and to improve their patient survival but ultimately these types of efforts and studies that come from a laboratory will eventually probably be able to provide a cure so that we’ll be able to provide much more for our patients.
Q: What is BrainLAB technology?
A: BrainLAB technology is a form of image-guided surgery. Another keyword is neuronavigation where with computer like precision we can, we can get to anywhere in the brain with accuracy. So say, just as an example, if we have a tumor that’s on the surface of the brain, when we open up the bone, open up the dura we can see the tumor and we know with a microscope --- I can either see it by eye or with a microscope so I know exactly where to go. Sometimes the tumor may be deep in the brain so you can’t see it. Now, you know, since I have a lot of experience with the brain I may be able to visualize it in my mind but with image-guided surgery that guesswork gets taken out of the equation. So with computer like precision the tumor will be visualized on a preoperative images and they’ll be volumetric, multiplaner, specific navigation so that we can get to that tumor. So what happens is the brain will be here and they’ll be a tumor that’s deep inside the brain but we have a representative MRI that’s on our monitor. So with a special --- and as the patient communicates with the BrainLAB imaging system which has infrared beams and a camera with a special wand or registered pointer, which can be any instrument, as we touch the brain, as we touch the surface of the brain where we --- where the pointer touches the brain it will show up on the monitor so I know exactly where I am with reference to the MRI and then I can push a button and an extension, a green extension, which is a magical line which will extend from where the pointer is and it’ll basically show me a path right to the tumor and then as I move the pointer deeper I can take it closer to the tumor. So the beauty is I have this beautiful specific navigation just to this deeply targeted tumor without any, without any guesswork as to where I need to be. So let’s say I wanted to guess about where it may needed to be and I took an approach that wasn’t quite on target, well I may go through a very sensitive area of the brain that I shouldn’t go through. So with this image-guided, with the computer precision I can go exactly to the target that I need to go to and then it opens up a whole new arena of things that we can do; image-guided neuronavigation, these supplementary technologies that I use for every brain surgery, brain tumors, trauma, aneurysm surgery, epilepsy surgery. We do tailored resections of the temporal lobe based upon the neuronavigational technology that’s provided with image-guided surgery. BrainLAB is one of the companies that we use --- BrainLAB is one of the companies that provides their specific image-guided technology for us to use in the operating room. There are other companies that provide image guidance, image-guided surgery and, you know, essentially what we do is we --- for every case we bring the patient to the MRI suite. We put specific fiducials on the surface of the patient’s scalp. An MRI per BrainLAB protocol has to be special --- is taken. All that information is downloaded to my BrainLAB or image guidance workstation in the office through the Ethernet and then I can develop a treatment plan for that specific pathway; where the tumor is, where it is in relationship to vessels, what specific trajectory that I need to take. All that information is then transferred to a USB port. I then hand deliver that and connect it to our BrainLAB equipment. All that information, the preoperative MRI is transferred and then I will then make sure that the BrainLAB, with the MRI, is able to adequately communicate with the patient that I have in the operating room and make sure my tips are all registered appropriately and then I’m able to proceed with surgery with computer precision.
Q: What benefits does BrainLAB provide to the patient?
A: The benefit to the patient is going to be better surgery for the patient; smaller incisions, fewer mishaps, quicker recovery, the incision will heal more quickly, less bleeding and they’re in the operating room --- they’re in the hospital a lot --- not as long. So it’s very beneficial.
Q: What other kinds of procedures can you use image guidance for?
A: Well, what we, what we do is we have this image-guided system and we are integrating it with our neuroendoscopy technology which we will integrate eventually with intraoperative MRI. Now, with the image-guided system, per chance as its integrated with neuroendoscopy, we’re able to provide the best neurosurgery with minimal exposure, minimal trauma to the brain. So for example, with the image-guided surgery with computer precision we can get to a point anywhere in the brain, on the surface, deep in the brain, at the base, anywhere that we need to. We can supplement this with further technology with neuroendoscopy. Neuroendoscopy is using a camera that’s attached to this long instrument that you can hold with your hand and then you put the camera, this long camera, into an air space at the --- within the brain or at the base of the brain or within a water space within the brain, for the most part, such as the ventricles and then by making this little small opening through the brain into the water space with special optics from the camera you can visualize the inside which come up --- which are displayed on the monitor much like a video game and you can use optics for air vision or you can use optics for water. So in essence with this neuroendoscopy you can take this camera on the inside of the brain, look inside the brain and so whatever surgery that you may need to do and so what we do is we incorporate image-guided technology with our neuroendoscopy technology to provide the best in the way of minimally invasive surgery and that minimally invasive surgery will provide faster recovery and better outcomes. An example of that is say we have a patient with a hydrocephalus, which is caused from a tumor deep in the brain in the ventricle in the water space, so with image guidance we can register the endoscope so that we can take the endoscope and make sure that it goes through a very small area of the brain, a little small pea hole opening that’ll be passed through the brain into the water space and we know exactly that we’re taking the endoscope exactly to the water space because the computer position is provided for us with the BrainLAB and once we get in the water space the camera will then show us on the inside of the brain and so that we’ll be able to then see the tumor and put little instruments along the side and remove it. So that’s image guidance that is integrated with neuroendoscopy. I use image guidance for brain tumors so that I know exactly where the tumor is before surgery and I can develop a pathway to that tumor that causes the least amount of damage to the brain. I use the image guidance for skull-based lesions. Skull base lesions are these lesions in the base of the skull that are very difficult to get to and, again, by using this technology we use smaller incisions, less exposure and it’s much better tolerated by the patient. I use image guidance for AVMs. I use it for the treatment of patients with epilepsy for epilepsy surgery. I use it for aneurysm surgery. I use them for spine. I use them for trauma. I use them for congenital disorders. Basically, the image guidance is a tool that we can use for every --- just about every brain surgery that we have. It just makes it better. It makes it easier and gives us more computer precision in the surgery that we need to do.