HealthONE - January 19, 2021

Mark Ruffalo, Maria Menounos, John McCain, and Elizabeth Taylor- an unlikely grouping of public figures, but they all have one thing in common: each has experienced receiving the unwanted news that they must undergo brain surgery to remove a tumor. No matter background, economic status, or past experiences, most would bristle at this diagnosis. It can be incredibly distressing to plan the invasion of this fragile, sacred space. But if you find yourself receiving this news, be encouraged that there is hope. Recent surgical advances allow Swedish Medical Center neurosurgeons to perform these types of brain surgery using gentler, safer, less invasive and more effective techniques, helping patients get back to their lives faster. “What gets me up in the morning is the ability to provide the most advanced, innovative and comprehensive brain tumor care available anywhere on the planet to my patients, right here in Denver,” says Vadim “Eddie” Tsvankin, MD, a neurosurgeon at the Sarah Cannon Cancer Institute at Swedish Medical Center. “And it starts in my OR, where I can bring the most cutting-edge techniques to patients who otherwise may have limited options.”

Minimally invasive robotic laser surgery

“One of the most exciting new tools available to patients with brain tumors is called LITT: laser-induced interstitial thermal therapy,” explains Dr. Tsvankin. “Only a small number of centers worldwide have the technology and experience to perform this, and it’s game-changing for patients with inoperable or recurrent brain tumors.”

LITT is a minimally invasive, robot-assisted procedure performed through an incision less than one centimeter long. Using real-time neuronavigation, a laser is guided to a precise location within the tumor, then gently heats the tissue of the tumor and destroys it. “Something like LITT is really made possible by an enormous confluence of state-of-the art technologies,” says Dr. Tsvankin. “Our navigation software is essentially GPS miniaturized to the scale of an operating room and allows me to place the laser with sub-millimeter accuracy. It all takes place inside an MRI scanner, which is continuously mapping temperature around the laser in real time. And I’m steering the laser robotically from the next room, shaping the heat precisely across just the tumor while avoiding the normal brain right next to it.”

After treatment, which takes less than half an hour, the laser is withdrawn, and the incision is closed with a single stitch.

“We’re living in an era where you can have brain surgery through an incision shorter than the length of my pinky nail in the morning, and go home the same afternoon,” says Dr. Tsvankin. “It’s certainly a new paradigm for patients with brain tumors.”

5-ALA aiding brain tumor visualization

Last year, Dr. Tsvankin was the first neurosurgeon in Colorado to use a recently approved drug called 5-ALA (5-aminolevulinic acid) in the operating room at Swedish. Use of 5-ALA has been shown to assist in a more precise and complete tumor removal. The drug is provided as a drink to the patient prior to surgery. Once ingested, it reacts with the cells of the tumor, causing them to fluoresce under a specialized microscope during surgery. This enhanced visualization allows the surgeon to safely remove more of the tumor. “It’s well-established that prognosis after brain tumor surgery is tied to two things: the completeness of tumor resection and the avoidance of new neurologic deficits, “Dr. Tsvankin explains. “So, in brain tumors with infiltrative margins, 5-ALA is an essential tool for us to ensure maximal possible resection of cancerous tissue, while enabling us to spare healthy brain tissue.”

Awake craniotomy saving critical brain function

For some brain tumors near critical or highly specialized brain structures, the best surgical option is an awake craniotomy, where the surgeon can “map” the brain during surgery to identify and preserve brain function during tumor resection. “Anybody can remove a brain tumor,” says Dr. Tsvankin. “The question is, can you remove a brain tumor while preserving all the essential brain structures? Some of the structures that may be infiltrated by the tumor, make the patient who they are, or that allow them to derive joy from life. Removing the tumor isn’t enough. The metric for success isn’t just a clean MRI after surgery – it’s the quality of life our patients enjoy after our job is done.”

Most awake craniotomies are performed for tumors in the frontal and temporal lobes—the parts of the brain that control speech and motor function. Surgery begins by sedating the patient while the surgeon accesses the brain. The patient is then brought back to full consciousness to interact with the surgeon during the procedure. The team asks the patient to perform simple tasks and answer questions as the neurosurgeon uses specialized electrodes to stimulate brain structures. By observing changes in the patient’s ability to perform the tasks, the surgeon can build a personal “map” of brain function in real time in the operating room. “An awake craniotomy is not a trivial surgery, and you need a highly-trained and experienced team like the one I have at Swedish to perform it safely,” says Dr. Tsvankin. “But the most important member of that team is the patient – each surgery for me is a stream of tiny, critical decisions, and the patient is literally awake, providing the input that guides each of those decisions.”

The end result is the capability of removing the maximal amount of tumor safely from the most delicate areas of the brain. “This is a technique that demands courage and focus – not only from me, but from the patient,” says Dr. Tsvankin. “But it’s the safest and also most aggressive option for patients with tumors in these highly sensitive areas of the brain.”

Swedish Medical Center ranks among the nation’s top neuroscience programs and was designated as a Neuroscience Center of Excellence (COE). A leader in the field of neurology and neurosciences and the treatment of stroke, the program at Swedish combines state-of-the-art technology with an outstanding team of staff and physicians who have extensive experience and expertise in treating nearly all forms of neurological disease. Learn more about the Neuroscience Center of Excellence at Swedish Medical Center.

Vadim ‘Eddie’ Tsvankin, MD is a, fellowship-trained neurosurgeon at Swedish Medical Center. He earned his bachelor’s degree at CU Boulder and medical degree from the CU School of Medicine in Denver, where he was elected to the Alpha Omega Alpha Honor Society. Dr. Tsvankin then completed his neurosurgical residency at Duke University Hospital in North Carolina, as well as a fellowship in surgical neuro-oncology at Duke's world- renowned Preston Robert Tisch Brain Tumor Center. Dr. Tsvankin is experienced in the full spectrum of brain and spine surgery, but his passion is caring for patients with brain tumors. His expertise focuses on complex and eloquent tumor resection, awake craniotomy and brain mapping, keyhole and minimally invasive resection techniques, laser interstitial thermal therapy, and radiosurgery. He has published extensively on immunotherapy for gliomas and intratumoral drug delivery and has served as an ad-hoc reviewer for the Journal of Neurosurgery and Journal of Neuro-Oncology.