Julie Kurtz, 56, was enjoying her winter vacation in Florida when she suddenly had a seizure. She remembers sitting at the breakfast bar in her condominium when she felt her arm become paralyzed. She knew something was very wrong and when she tried to speak to her husband, she couldn’t get the words out. Then, she fainted. Paramedics rushed her to the local emergency department where scans revealed a brain tumor.
“It was an unexpected and horrifying diagnosis. I thought I was dying,” Julie said.
A couple of days later, once she was stable, Julie returned home to New Berlin, Wis., and made an appointment with Wade Mueller, MD, an MCW faculty member and neurosurgeon with the Froedtert & the Medical College of Wisconsin Brain and Spine Tumor Program. Dr. Mueller came highly recommended to Julie by a friend.
“From the moment I called, I felt so well taken care of,” Julie said. “The new-patient coordinator for the Brain and Spine Tumor Program handled transferring my records and made my appointments. She was able to get me in for an appointment in less than a week, which was such a relief. Dr. Mueller was honest about what was to come, but his demeanor put me at ease. It made me feel like I was going to beat this.”
Julie was diagnosed with an oligodendroglioma. Oligodendrogliomas are rare tumors, but they are less aggressive than other types of brains tumors (like glioblastomas) because they grow slower and are more responsive to treatment. To pinpoint the exact location of Julie’s tumor and develop a plan for surgery, Dr. Mueller ordered a functional MRI (fMRI), a scan used to evaluate blood flow changes in the brain while a person performs a specific task or movement.
The fMRI showed Julie’s tumor was on the right side of her brain, affecting her supplemental motor cortex, the part of the brain responsible for coordinating movements on the left side of the body. Dr. Mueller consulted with his Froedtert & MCW colleagues at their weekly conference called a tumor board. The neuroscience tumor board is made up of a group of Froedtert & MCW specialists who each have specific expertise (neurosurgery, neuro-oncology, neuro-radiation, neuropsychology, neurological rehabilitation and neuropathology.) They meet to discuss each person’s case and recommend an optimal treatment plan. Because of the difficult location of the mass, Dr. Mueller consulted with Max Krucoff, MD, FAANS, MCW faculty member and neurosurgeon, who was trained in a surgical technique called asleep motor mapping. This technique allows the surgeon to track and protect the brain fibers critical for recovering movement after an operation. Dr. Mueller and Dr. Krucoff felt this technique would give them the best chance to remove as much tumor as possible while preserving brain function, which would be important for Julie’s long-term prognosis.
“The challenge with treating gliomas is that tumor cells invade normal brain tissue,” Dr. Krucoff said. “There is often a gradient of healthy cells combined with tumor cells at the edges of the tumor mass. There are no clear boundaries, so there is an oncological-functional balance to consider when deciding how much should be surgically removed. In Julie’s case, the asleep motor mapping technique gave us the ability to be as aggressive as possible, while also being safe. With this technique, we were able to get her a gross total resection. This means we removed at least 95% of Julie’s tumor, while also preserving the parts of the brain necessary to make sure she would make a good recovery. With other techniques, such as awake brain surgery, we would have had to stop short of 95% resection.”
Asleep Motor Mapping for Oligodendroglioma Surgery
The brain does not have pain sensors, which is why brain surgeries can be performed while the patient is awake when necessary, allowing the surgeon to test neurological function during the operation. Using electrical stimulation, the surgeon creates temporary lesions and tests the functions of different areas of brain prior to and during the procedure. Testing involves asking people to speak or move their arms or legs during stimulation, but with Julie’s tumor, it was more complex. Because the tumor involved her supplemental motor cortex, there was a risk of temporary loss of function in her right foot and right leg during the procedure. The loss of function wouldn’t give the surgical team enough information to safely remove all of the tumor, so residual cells would have to remain.
“With asleep motor mapping, we continuously monitor the critical motor pathways that transmit signals from the brain to the body,” Dr. Krucoff said. “To do this, we place electrodes on the scalp and in the muscles of the patient’s arms and legs to create an electrical grid. We send signals through the motor cortex and its descending white matter tracts, and as long as those signals are reaching the muscles, we know we can proceed with the resection. We combine this with precision stimulation mapping of the deeper parts of the brain to tell us exactly how far away we are from these critical areas.”
A Team Approach for Oligodendroglioma Treatment
Julie was diagnosed in February 2022, and she had brain surgery in March. She woke up from surgery with temporary paralysis on one side, but she knew to expect this as her doctors had prepared her for it, and she started to regain her movement the next day. After she fully recovered, she met with Christopher Schultz, MD, FACR, FASTRO, MCW faculty member and radiation oncologist, to discuss whether or not to pursue radiation therapy and chemotherapy as additional treatments to prevent the tumor from recurring for as long as possible. Given Julie’s age, as well as the size and location of the tumor, doctors decided to proceed. Dr. Schultz used advanced imaging to determine which parts of Julie’s brain would need radiation therapy. His team also created a customized thermoplastic mesh mask that would be used to immobilize her head during treatments.
“Our MRI technology allows us to identify and outline the margins of the resection cavity that may still contain microscopic residual tumor cells following surgery,” Dr. Schultz said. “Using these outlines, an individualized three-dimensional radiation plan is precisely delivered to the margins of the resection cavity, while avoiding the adjacent uninvolved brain tissue.”
In addition to six radiation treatments, the team determined that Julie needed 15 months of chemotherapy. Jennifer Connelly, MD, MCW faculty member and neuro-oncologist, met with Julie to discuss her options. For a grade II oligodendroglioma, Julie could choose between an oral chemotherapy regimen or a three-drug regimen that included an intravenous infusion. Julie chose the oral chemotherapy, and Dr. Connelly saw her each month to monitor her progress.
“The majority of brain tumor patients have incurable disease, but with surgery, radiation therapy and chemotherapy, we can reduce the risk of recurrence and slow it down,” Dr. Connelly said. “This type of diagnosis can be overwhelming, so we work with each patient to offer treatments that are well tolerated, that work for them and give them a reasonable quality of life. We also take into account the immeasurable psychological consequences of the diagnosis, so we can prescribe a medication to help with emotions and place a referral to a counselor who can provide support.”
Dr. Connelly prescribed Julie a serotonin uptake inhibitor to help her cope with depression during treatment. Julie also worked with Jessica Molinaro, MD, an MCW faculty member and psychiatrist in the Jeffrey C. Siegel Quality of Life Center at the Clinical Cancer Center. To better process what she was going through, Julie decided to blog about her diagnosis and recovery. She said she looks back on the experience as transformational, and said it brought her closer to her faith.
“I am not grateful that I had brain cancer, but I am grateful for how I have come out on the other side,” Julie said. “This is the type of diagnosis that can crush people, but I fought. I stayed optimistic and positive, and I had the support of a wonderful team of doctors and nurses.”
Julie is back to enjoying life with her husband, children and grandchildren and is excited to welcome another grandchild in the fall of 2023.
To learn more about brain tumors and treatment, visit: https://www.froedtert.com/brain-spine-tumor.