Thank you for watching this program tonight with the best physicians of the region.

My name is Dr. Luis Munoz in the president of the El Paso County Medical Society.

It is our hope that you will find this program informative and interesting.

We at El Paso County Medical Society invest in community education with our programs.

I hope you'll find this program very informative with great medical advices in great medical information.

Thank you again for watching this program tonight and have a great night.

Advancements in brain cancer identification and treatment.

That's the topic of today's program.

And we have a lot of very hopeful information to go through.

We're going to talk about this evening diagnosis, brain surgery, brain chemotherapy, brain radiation and the gamma knife and how all of this is really helping all the folks in our region who are diagnosed with brain cancer.

This program is underwritten by tenant, the hospitals of Providence.

And we also want to think the El Paso County Medical Society for bringing this program to you.

Thanks for joining us.

I'm Kathrin Berg and this is the El Paso Physcian Thanks for joining us.

Again, this is advancements in brain cancer identification and treatment.

The show has a lot of information in it, a lot of hopeful information.

And with us today, we have a team of three, but there's really a team of five or six.

When you go back to the office and or all your medical situation.

I'd like to introduce everybody.

Originally, we have not had Akram Mahmoud here before, but I'm super happy that you're here.

You are a neurosurgeon, but you're also the director of neurosurgery at Sierra.

So thank you so much for being here.

We also have Buddy Winston, who's John Winston.

And I didn't realize a buddy was John, but I've known Buddy for more than 30 years.

Yeah, a long time.

Long time.

And he's going to talk a lot about the team that we have here.

And this is medical physicist for Gamma, which is kind of cool.

The gamma knife, which was first introduced back in 1994.

I've got some stories about that.

And then we have Joe Rodriguez, who is a gamma knife nurse coordinator.

And nothing can happen without you, right?

You're like the first line without my process.

Without your process.

And there is there's something you have to organize, everyone.

Yeah, I bet.

I bet.

And we do want to give shout out to Dr. John and Dr. Gupta, who are also the radiation oncologist that work on this team.

They're not here tonight, but we're going to talk about how that all gets put together.

So, Dr. Mahmoud, if we can start with you, if you can describe to our audience what it is that you do.

Yes.

You're a neurosurgeon.

You are the director of neurosurgery at Sierra.

But in what we're talking about tonight, brain cancer, what is that you do all day, every day.

So as a neurosurgeon, what I do is not resume patients with different elements, such as the general disease of the cervical spine, thoracic spine, lumbar spine, or see patients for traumatic brain injuries, patients who have strokes, whether they are ischemia or hemorrhagic part of the practice.

As we also see patients who have brain tumors, they can be primary, they could be metastatic.

We'll also see patients in the office, also in the hospital setting as well.

Very nice, buddy.

Sorry, Mr. Winston Slash John, I have to say to the audience, the reason that we're in the studio is because of you.

And I know that has nothing to do with the show, but has everything to do with the show because we didn't know we're we're going to go record.

We're glad.

So thank you for a Star City studio and thank you for this.

And then on the east side, you happen to be that medical guy too.

Yeah.

So on that note, let's take it forward on what you do medically.

And I bet all the people that see you perform in the music world are like, Oh, I know I did something, but what is he do?

They don't do other kind of parallel universes.

Exactly.

They are well, the physicist is handles all the technical aspects of the program, namely calibration, setting up the quality assurance, the licensing, regulatory issues and particular characterization of all the parameters we use to develop treatment plans based on Dr. Mahmoud and Dr. Gupta or Dr. Hong's.

They all get together and once it kind of goes through the system, then we develop these treatment plans.

And so the physicist is responsible for all all that technical work up to that point.

Okay.

So it's no small feat.

Oh, goodness gracious.

And then we have Joe who is here.

And again, nothing happens without your process.

That's right.

On that note, do we agree with that?

And though do basically what I do, I like to keep a concrete process all the way from the patient experience to also physician experience in the way that I'm able to get patients into the facility once they get referred to our program.

And I have to get acquainted well with the neurosurgeons in this case with Dr. Mahmoud.

And also I need to notified John Barry over here to make sure that he's going to be there and doing the treatment as well.

And then we perform, we do the imaging we performed the treatment.

And obviously we we set up appointments for patients so they can continue with their care, with their oncologist or PCP or or whoever they need to see after gamma knife.

So I'm involved in the whole process from beginning to end, and it's a very fulfilling role to be part of their well being of each patient very nicely explained.

And I'd like to kind of start in the very beginning stages here to set the stage.

So brain cancer, it's somebody even asked me today, Oh, what's the topic on the program tonight?

It's like brain cancer.

And I know.

Yeah, but what's the topic like?

No brain cancer, really, You know?

And so immediately you have this this heaviness to it, right?

Because it's not it's not easy.

We we talk about you said there is over 100 different types of brain cancers and we don't need to go into those.

But what I'd like to talk about now is how someone is diagnosed with brain cancer.

Like what are the symptoms?

What do people look for?

And just we can just start from there and go forward.

Yeah.

So some when people come in for, you know, symptoms, they have headaches, nausea, vomiting.

They usually have changed their personality.

They can have weakness on one side versus the other unsteady gait.

They can have a change of personality sometimes of patients are normally easy going, laid back.

They can become the complete opposite.

If you start seeing changes in their behavior or seizures, those kind of things, those are a warning as something has happened neurologically to cause those symptoms.

So usually the patients will normally either call their PCP or they normally go to the E.R.

for evaluation.

Once they're in the E.R., they're going to be seen.

If I go by the your physician, they do a quick history and a physical examination, then do a CAT scan.

CAT scan.

Usually the first line in the study process, they'll give you a picture of what's going on in the brain.

Is there a stroke happening?

Is there mass there?

Is it how large is it?

Where is it at?

It's a causing pressure.

Is it causing any kind of midline shift then that usually will prompt a consultant neurosurgeon who is on call.

I'll get on the phone, talk to your physician.

What's a patient like?

Yeah, we do.

We say we have to do an MRI scan at that point once.

If the patient is neurologically stable at that point not have any deficits, we usually put them on prophylactic steroids.

Kind of help take this one to come down.

We'll put him on a medication called KEPPRA, which helps prevent seizures, and we'll do the MRI scan, get more testing.

At that point that will just tell us they've got a mass.

There is that one lesion, two lesions, you know, where is it at, what part of the brain is, you know, what's going on in those kind of things.

Once we're at that stage that I'm not going to come see the patient, do my consult initially, evaluate them, then make a recommendation would be the next steps.

Okay.

And when we're and we're going to get to it later because there's a difference of being primarily diagnosed with brain cancer and then something that starts somewhere else in the body and then migrates to the brain or just metastasizes to the brain is going to bring that up.

I know it's a whole different thing going forward.

But John, when you're talking about the technical aspect of this, are you also involved in the diagnosis process?

Are you involved with the treatment process, the treatment process and the treatment planning, all that works done before it gets even before there even a candidate for again, Okay.

I mean, not always you're again you're calibration guy because I'm thinking sound studio Oh yeah.

Musician Well that's part of it.

Yeah.

We determine all those parameters, but all that work, that document you've just mentioned was, is you know, he may not recommend a gamma knife.

There are many cases that aren't recommended so at that point when they get to Gamma knife, this one, that's where I know I'm involved.

Okay.

So I want to bring Joan to this, but I'm not sure if this is appropriate for you.

So I'm throwing this out there to when is the decision made or how is a decision made of what treatments are involved with certain brain cancer?

Yeah, I'll take that.

So okay, so once I get involved in patient's care and they've got a brain tumor, I usually go to see him and talk to him.

What's most important is identify, you know, are there any risk factors like smoking, alcohol use?

Is there any family history for cancer in the family?

Was he diagnosed that?

And we do it with the of metastatic workup.

We got to figure out, did it come from somewhere else?

Right.

So it turns out he his primary versus metastatic primary is it came in the brain and we know certain and we name brain tumors in the brain or CNS based on the cell types.

So we have different cells, for example, glial cells, astrocytes.

It's meningeal cells, collagen and glioma cells.

And these are the different types of tumor cells that we can see or cells that only occur in the body.

And these cells just take a different turning, start growing in a different direction.

They get the tumor, but the monocyte workup is doing a CAT scan on the chest, abdomen and pelvis, taking a picture below the neck.

Is there anything that we're going to see in the chest happening in the pelvis that could give us a clue that what we're seeing in the brain has a direct correlation that is either metastatic or primary or metastatic means.

It started somewhere else in up in the brain.

Primary is actually in the brain.

That's where it started out.

It's very rare for a primary CNS tumor to go outside the brain.

Interesting.

It's that was going to be my next question.

So if if it's not a primary brain tumor, chances are in other words, primary brain tumors are not going to move to other parts of the body seen as brain tumors.

So youre not going to see a meningioma into the chest or abdomen or pelvis.

Okay.

But you can see cancers that occur outside of the CNS, lung cancer, breast cancer, renal cell, prostate, colon, those type of cancers.

Right.

They can metastasize to the to the brain.

So I know we talked a little bit about it before the show, and I like giving examples and case studies.

And this one's my mom who's been gone for 30 years.

I feel like I'm allowed to talk about her, but I think that's where people have that relation, right?

My mother was diagnosed with small cell lung cancer, and within a year, within nine months, it had gone to the brain and then in small cell, large cell.

And I don't know if that is a big deal in brain cancers.

I know it is with lung cancers.

And if it is, let's describe the difference between the two.

And the reason I bring this up.

Just watching regular media, you will hear all kinds of medications for small cell lung cancer or for non-small cell or for non large cell.

You know, when people are like, if you're not in that game, you don't know what that means.

So maybe describe a little bit about what that means.

Yeah.

I mean, before we go to I think it's really important is that, you know, when you're working with the oncology team, so after we get this, you know, the most important is getting tissue diagnosis.

So how do you get tissue diagnosis?

So if we're talking about metastatic disease and you got lung cancer, the most important thing is how do you know what you're doing?

Because a CAT scan or MRI is going to show what you got to ask.

There.

It doesn't diagnose what it is, right?

So you have to get tissue.

So when it got someone's got metastatic brain, low metastatic disease of the brain, if you have an amenable lesion, say, in the lung and you can get that out causing any problems, you get a tissue diagnosis, you can get that done.

So tissue comes back from the lung biopsy.

You're done stereotypically with C.T.

guided, it comes back and based on the load in the brain, if you've got multiple lesions, which is most likely a consistent metastatic disease, depending on the location size and what the load is, or determine what our steps are going to be.

Right.

So non small versus small.

So they have different prognoses, different outcomes will determine whether I'm going to go in there and say resect or just the whole brain radiation and chemotherapy.

So that's what determines that.

Okay, so let's let's take a case study so that we can kind of go down not the rabbit hole, but explain where it is that we're going to have these different let's say now you've you see a cancer that a gamma knife would be appropriate for its treatment.

Describe what that would be.

And again, I know there's a hundred of them out there, but just just think of a case study that you that you've worked with lately.

No names, no ID, and talk about when you would involve Joe and Joe's team with prepping for a gamma knife type of a treatment.

So, yeah.

So I'll just take it down a step before I answer that question, if I may.

So what I normally do is once I get all my imaging done, my studies done, I have a family conference.

I explained to them, you know, you came with your diagnosis.

We found this lesion in your brain.

And I used the word lesion at the time because you have to say something.

Tell someone who got brain cancer.

It's very overwhelming.

They're in shock.

And they just after the first 5 minutes, they forget what you're hearing.

Right.

So the most important thing is to use the word lesion.

And then I say we need to get tissue diagnosis out.

When you determine how do you get tissue down, this is are two ways either brain biopsy or you do a resection.

What determines that tumors can occur anywhere in the brain, frontal lobe, temporal lobe, parietal, occipital cerebellum, brainstem anywhere.

If the brain lesion is small and it's an active part of the brain where it's deep, it's going to be hard to reset that causing a deficit.

I mean, our for tissue diagnosis, if a lesion is accessible, not our part of the brain, but it's causing a deficit and I haven't declined the offer resection.

There is the the two differ is that one you're both going to get tissue diagnosis.

Then we bring in the team, Dr. Horned Gupta and the medical oncologist.

He would say, listen, I've got this tumor.

It's a GBM, which is the most aggressive brain tumor, and GBM is GBM agreeable.

glioblastoma multiforme Okay, GBM.

So you guys know, we don't know yet.

So if you get that diagnosis, you know, and again, a little bit of history, if you do nothing with that diagnosis, let's say a diagnosis of patients got GBM if you do nothing whatsoever, less than three months of survival, three months, three months.

But if we are able to do maximum resection radiation and chemotherapy.

Now when you say resection, go back and explain what you mean by that.

So again, you're the surgeon.

Yes, ma'am.

So you're going into the brain.

And what are you we sectioning?

What are you what are you doing there?

So what were you can describe?

Identify that there's a mass lesion causing pressures.

We're shifting contents in the brain from one side to the other.

There's a team with her slides.

The inflammatory action going on, it's causing a deficit.

So at that point, we think the recession is about what's a chronic craniotomy.

So you have to make an incision.

You have to open the skin, you have to remove the bone, which is the cranial vault.

You have to open up the area called the dura, which is the covering of the brain.

You then we use navigation to kind of help guide us, identify what are the borders of the tumor so we can stay within that border to kind of minimize complications.

So the training is designed to remove that tumor.

Okay.

Now we try to get 100% resection.

Sometimes we're able to get a subtotal, which means we get part of it out because the location, it's vascular early where it's located.

If it's attached to battle structures, once we get that tumor out, then we're going to decrease.

Hopefully the pressure within the brain.

Right.

Decreasing the pressure and cranial pressure related, the mass effect from the brain and also improve actual symptoms.

And that's what the cranium will be doing once we get that done.

We didn't put it back together.

We close everybody back up, you know, put the covering of the brain back on, put the bone back on and close them all off.

Wait three days, get the final pathology at that point.

Then we'll say Dr. Honda to Gupta.

I got a diagnosis of the GBM, okay?

And then they're going to come in and say, okay, we want to do whole brain radiation.

We won't do chemotherapy.

There are other treatments out there that if we're able to secure an accurate diagnosis at the time of the craniotomy, we can put in what they call chemotherapy drug called gliadel.

And you do that in while you're in surgery in the brain.

It cells are physically assessed as we're doing the craniotomy and it's all opened up and the cavities, you know, drain everything else.

And then the pathologist comes back and says, this is a definite GBM, right stage for right words.

Cancer.

You can get it.

You know exactly what to do.

At that point.

We're saying give me the they wafers and they're like a dime sized wafer of chemotherapy.

We laman the tumor bed cavity.

We kind of hold them in place with some synthetic film, if you will, enclose the patient back up there are getting chemotherapy at the site directly, right while they're waiting the two week period to start radiation and chemotherapy.

And so what is happening again, physiologic.

I'm just trying to think this through as you're they're getting chemotherapy at the site in the brain, which I think is brilliant and great when you're looking at some side effects from there.

Just aftermaths after that surgery.

And again, I know there's so many different types.

And to you you said earlier, location, location, location is key here.

Depending on where the tumor is and what part of the brain is dealing with other parts of the body, are there a most is there in most location or most common location that this happens in the brain?

Like more often than not, it will be in the blank area of the brain.

So for the most part, you know, these brain tumors, you know, 12% to 10% of the brain tumors are malignant.

They recur anywhere but normal.

Okay, So repeat that.

I like that.

27% of the tumor is malignant because that's less that's that's a smaller percentage than I expected.

Yes.

So there's a lot of hope there.

So 27% are malignant.

That means the other percentage is benign.

You can do the math.

I'm not going to.

But that's such a beautiful thing.

There is a lot of hope in in brain tumors, is what I'm saying, And go for it because the ones that are bad are bad.

I get it.

Yeah.

So their brain tumors range from benign to cancer.

All right.

And when we talk about, we say with the GBM, a glioblastoma multiforme, a it's a global cell, a three stages, 1 to 4, stage one and glioma grade one is the most benign tumor and usually just watch them observe them.

You're nothing for them and they're slow growing.

These don't cause a problem.

Grade two, Grade three, or little more aggressive that each one of those tumors has a different prognosis.

A tumor can go from a two to a three, a three or four.

It can go from one to a four and sometimes can have different tumors.

So although we say 25, 27% are malignant, it is a good thing.

But what we lost is because some of these tumors are, you know, they have different prognosis and outcomes based on their cell type, everything else.

So it's you know, and again, there is no cure for GBM, right?

Right.

That's a tumor that's very aggressive.

And even in the best case in which you described earlier, Max resection put in the wafers, chemotherapy, radiation therapy, other models, we're talking about averages of between 12 to 18 months.

Okay.

So that's average.

Again, I'm just speaking as a human here and as a layperson, when there is no cure.

And that's understood.

We're just buying time at this point.

Is it all also palliative?

Is it is it also for pain purposes?

We do, right?

We always want to give the patient the choice.

Right.

Because you know, everything, you know, we're all we want to live.

Right.

Right.

And the whole thing is that we always want to do what we can.

If I'm going to, I'm going to change someone's life for the better.

That I want to offer them.

The best I can do if they're young, they're healthy or the middle aged they're healthy, or they got minimal co-morbidities and they can survive surgery.

It's better to be aggressive.

We come a long way into you and tumors in the last several years.

And again, people just want to be aggressive again.

The number I just told you a minute ago, 12 to 18 month, that's an average.

I've had patients that I've taken care of personally after five years.

Nice.

Right.

Right.

And again, it is it is based on the physiology.

Yeah, the medical history, genetics.

If it's a there's a family history, a lot of components going in there.

Not everybody will get the same results.

But, you know, the average is 12 to 18 months If you do nothing whatsoever, do nothing.

I described earlier, we're looking at less than three months.

This tumor sort of aggressive, will double every 10 to 14 days.

Oh, my gosh.

So that's how aggressive is tumors while and so in I and I and I want to let everything go to you.

But here's a question, too, that we talked about earlier.

How does the brain cancer develop if you can shoot it to anyone else on this table, that's great.

If not, because we were talking about preventative measures earlier and I looked at you.

I remember when I walked in and he said, well, preventative measures for brain cancer, I'm like, you can prevent brain cancer.

Well, no, but it's all about general, right?

So, you know, how do you get brain cancer?

Right.

And I think if you look back in time is that, you know, there are certain factors that causes brain cancer, genetics.

If you have certain genetic mutations and certain genetic disorders that can lead to more brain tumors, hereditary can also lead to brain tumors, family history and uncle, they can also either brain tumors, the exposure to chemicals, whether it's solvents, pesticides, plastic.

I mean, look, we're destroying our ozone layer.

We're destroying our oceans, dumping plastic, and that's just a food that we are separating.

And the other thing is radiation exposure.

So patients that work in the radiation field, technicians, surgeons are exposed to that.

Also, if you're immuno compromised, that puts you at a higher risk, right, for developing.

I'm saying that not everybody who has these genetic mutations or have component or immuno compromised is going to be leading to tumors.

But what else can we do if you live a good, active, healthy lifestyle, plenty of rest, plenty of sleep, you know, avoiding alcohol, avoiding smoking, cigarets tobacco, you know, and avoiding a an animal based diet.

More of a plant based diet.

Those are all factors that will help you decrease the risk of developing this right here, because we know there's certain correlations between lung cancer and smoking.

Cigarets we know that.

Well, if we know cigaret smoking and lung cancer correlated together, that can lead to metastasis.

So these are things we try to what can we do to educate the population?

What can we do as a society to change what we're doing to our world?

Because the world we live in, you only get one world right?

We can't keep going out and we only have one body.

That's right.

So whatever is remember that simple as that.

Your body is your temple.

So what you put in is what you're going to get out, right?

So that's the most important.

Making better choices.

If you know you've got a family history of cancer and your your your history that they smoked and drank alcohol, don't do that.

Right.

You got to make the right choice.

Right.

But also, if you're working in your field of occupations, a radiation oncologist or a surgeon like myself, you know, being in the all we're putting in spinal fixations, I'm exposed to radiation.

So what do I do to prevent that from getting any worse?

Right.

The proper equipment.

And speaking of equipment, I want to I want to get Joe in on here.

So I want to specifically talk about Gamma, and I have a fascination with it.

And I explained earlier, my mother died in 1994.

That's when Gamma and I kind of came on the market.

Right.

It was just something with that was only it was a couple of years later.

I would love to ask you when it is that you come into this picture when radiation oncologist now comes to you and says, okay, this is something that gamma knife appropriate, where do you jump in?

How does body slash medicine slash Mr. John slash musician guy jump in.

How how does that part of the teamwork going back to the case scenario with a doctor my mother was mentioning that say he sees a patient emergency department and and this is metastasis the brain to say the patient has some lesions that say five lesions.

And the the attending physician during the hospitalization will obviously consult the neurosurgeon, the radiation oncologist.

And an oncologist will get the the whole team involved.

It's a multidisciplinary team.

Basically, once the radiation oncologist and the neurosurgeon determines that is a patient's a good candidate for gamma knife, then obviously patients going to receive the appropriate care during the hospitalization to include the anti-seizure medications, the steroids to help with inflammation.

If surgery was not advise, occupation will go home.

And then what's going to happen?

They're going to visit the radiation oncologist at the clinic, the regional college.

Dr. Hahn, Dr. Gupta will discuss the whole process to them.

Obviously, at that time, the neurosurgeon, we already describe the coming out process at the moment.

I'll get the I'll get the referral.

My responsibility is to contact the patient and the family because I like to make it as a whole and make make sure I put everyone.

And that's either no parcel.

Thank you.

Thank.

But I love that we do that here.

Really.

After I contact the patient, I'll let them know in this day you're going to have your gamma knife treatment and also some of your questions.

They're not that.

Tell the patient I will call you back to give you all the details about the procedure, where to come in, how to come in, eat, not eat out.

I go.

I review their medications, possibly have to stop some medications here and there, and then there's some room for me to schedule the case with the neurosurgeon, with the radiation oncologists, and with Buddy Wright, the medical physicist, because he plays a big role and you're forever going to be the calibrator.

Okay.

Now, the calibrations, once the patient comes in on that, let's say some Monday morning, they usually come in at 530 in the morning, dear Lord, and here goes.

And I have to be very sincere.

We place a head frame.

And so if you don't mind, because this is for those people watching, show how this is place on the head, if you don't mind, I guess we could have you put it right like this.

Now it is place.

It is held with four small pins.

Okay, two in the forehead and two in the back of the head.

The ones that plays this is the neurosurgeon in this case will be Dr. Mahmoud and myself.

Obviously, it looks traumatizing.

We like they like to inject a lot of pain in the puncture sites like when you go to the dentist, you know, they numb the area.

We are pleased to have friend make sure as well as well attach it does penetrate the skin but the course attached to the skull, it does not penetrate the skull at all.

Only the tape coating basically.

Yes.

I want to make sure that they see these holes and.

Yes, yes.

And I make sure that I tell this to my to our patients because I want to make sure they don't get scared.

Is that is they're being they've been going through a rough time in their lives.

I want to make sure that I want to scare them after with them place in the head frame.

Then we take the patient for imaging, for an MRI of the brain to find the lesion or lesions to find the tumor to.

And then after the imaging is done, which takes what, 35 to 45 minutes with the MRI, then Buddy John will get those images and he's the one that starts working with the finding the location the symmetry how much radiation we can give to the site and John would like to describe that in a minute after John is done formulating the plan.

Obviously, at this moment, the radiation oncology will step in, will also help John, to coordinate the target area with the radiation.

It's the team, the team three of us.

So yes, John.

Yeah, all three are involved at that point.

Sometimes if a patient's had surgery, then it's difficult maybe to outline or describe where the margins are to treatment are going to be, then that's where we need the neurosurgeons to come in and say, No, no, don't, don't.

This is this is nothing that you need to worry about.

Sometimes it's not necessary and they'll the surgeon and the radiation oncologist will confer, and then I'll work directly with the radiation oncologist.

But all three of us have to approve, right?

The treatment plan.

So when you're working with the radiation oncologist, are you in.

Pardon my ignorance on this.

Are you trying to figure out how much radiation, what the.

When you say calibration is that no name is it different with the patients?

There's two different steps.

We're talking about treatment planning now.

There's a lot of work that goes in to before to treatment planning.

So we're mapping everything out.

Well, all those parameters that we look at on the computer have to come from somewhere, and that comes from the physics involvement before, you know, not nobody else is involved in that.

Okay.

So we determine all I mean, characterize those parameters for treatment and then the physicist does the dose rate calibrations, all of that's checked and approved and it's hidden.

I mean, nobody sees that.

But when we're doing the planning with the imaging and the targets that the physicians have outlined, then then we know we're given an accurate delivery because just because it's on a computer doesn't mean it's accurate.

Right.

Right.

So that's a that's a lot of the background work which which is a lot less interesting than some of the see you all at all.

But if it's not perfect.

No, but incredibly we follow definite protocols.

And whereas up to date, as any cancer center in the United States or in the world, we follow these protocols adjusted for all of the physics work done.

But that's transparent.

And by the time we get to treatment planning, that's got to be done, improved and tested and out of sight.

Now we can concentrate on actually developing a treatment plan that agrees with them.

Okay.

So throw an example out there for me for the audience to grab on to a water treatment plan is So you're talking about, again, relocating the tumor, finding exactly where it is, and then, you know, the pinpoints of radiation and I remember a different show Dr. Gupta was on.

And I was amazed when she was talking about of how specific you can get a radiation.

Ray.

Right.

Well, to a certain partnership in 92, different with cobalt 60.

So I hate to use the word focused because you don't focus gamma rays.

You point them.

Right?

Right.

Okay.

So we have flexibility in how we can shape these distributions.

Okay.

Okay.

See, this frame is put on the patient's head.

And what it does is it establishes a stereotactic coordinate system.

Mm hmm.

One of the questions was about what is stereotactic?

This is established is a coordinate system based on where he put it on their head.

And typically you try to get the tumor if there's only one centered in this coordinate system.

So once we have this coordinated, we have a system, a routine that we go through that defines what we call, like cell spacing.

Okay, This figure, a cube of data, and it's up, it's submillimeter.

So we can we can target the area.

We can draw on these images that are inside this frame.

We define it into stereotactic space, and then we can construct these treatment plans to within tenths of a millimeter.

That's amazing to me.

Well, it's very important when you're in certain areas of the brain.

Well, that's a lot of flexibility.

Exactly correct.

And I just remember, again, I'm I'm thinking 30 years ago and I remember at that time the images of the gamma knife that I used to see.

And I don't even know how many points of contact there were, but it just seemed like there 100 some odd there was 201 on the early that they reduced it to 192.

Now.

Okay.

Just because she specified.

Well, no, the shape of the of the unit and it's all all automated now.

Okay.

So it's a lot of engineering behind that, but you can get as good or better distributions.

So Joe, I would like for you to show us this mask as well.

You said this is something that this is the new standard.

Yes.

So we have two ways of immobilizing the head, obviously.

So the way the medical physicist and their radiation and colleagues and the neurosurgeon can do a definite a good precise target mapping of the lesion of the tumor.

And obviously, we have to make sure that the patient does not move their head for the obvious reason.

We don't want to give their radiation someplace else.

Correct.

So that's why we use the head frame.

But now with our new icon, Gamma knife, we're able to do a mask.

Now, this match is well tied to the face.

And obviously, again, we try to mobilize and this is specific to the patient's face for a specific order to their specific face.

Exactly.

Right.

Now.

Now, the the reason that some patients prefer the mask is compared to the frame, Again, we have to put those we we have to put those patterns.

And patients cannot tolerate sometimes that type of pressure or that type of pain.

So we can do a mask.

Now, also, if the patient let's say the patient has more than ten lesions and and they need to be inside the machine for a period of 2 hours, if we do the mask, we are able to treat 25 lesions today and possibly two days from now we can treat the other five lesions and we can use the mask.

That way we don't have to place a hip frame.

So we, given that flexibility, is more comfortable.

I know it is compressing the face, but we give them a mouth sedation.

I was going to ask if there's any sedation involved.

Yes.

Again, a mild medication for that.

And they're able to today able to go go to sleep.

Are we doing the treatment after we're done with the whole treatment?

Obviously, the neurosurgeon will follow with the patient.

Obviously, the radiation and colleagues will see the patient also as an outpatient and also the oncologist will see the patient as an outpatient.

So we complete the whole process from the beginning, from the E.R., all the way to discharge home and all the way to following up with the physicians.

And obviously, they they continue performing their MRI's into one month, three months to assure that the radiation we gave is working.

Okay.

And so go ahead.

Who was just doing just that?

One of the things you don't see this Doctor Mahmood has not put a frame on, so we have to figure out a way to get this head into stereotactic space.

That's what this day.

So how do you do that?

Well, you do that with measurements on the computer or.

Well, know, there's a this is the picture of the newest unit.

This is called a cone beam c.T.

Maybe hold it straighter up so you can get the non you can see the little arm on there that is basically a ct scanner that will allow us to scan the patient that's in the mask and define the leg cell space.

We talked about that for the treatment plan.

We have to get it into that space.

Oh, yeah, that makes sense because the machine is calibrated to stereotactic space and so we have to define that.

So just we can't just bring an image in and use it.

It has to be defined.

Now we have an option of using the frame and the mat and the mask.

Now I'm sure Dr. Mahmood would have some consider he would be in let let him talk to that.

But something that's trigeminal neuralgia is stuff.

I don't think you're going to use a mask.

I think you're going to use.

Yeah.

And then I'm sure he has other criteria for when and when patients.

Perfect segue way to you then on that.

I mean, I prefer the frame versus the mask.

Okay.

Yeah.

I mean, because, you know, that's a pretty steady frame.

Everything else, I prefer that one less motion, better target.

That's just opinion.

Okay.

And so we did talk just a smidge about sedation.

So I'm thinking about the patient now and just the psychology that goes around the treatment and how that is interpreted.

Again, as a layman, you talk to families, you're the one that talks to the patients.

I know everybody does.

But in general, since you're the coordinator of this entire process, so to speak, what are some of the questions that are asked of you?

What are some of the discomfort levels that people ask of you and how do you help people get to a calm point?

Right.

Of course, that's I think that's really a major part of your team's job and it is getting people to like, okay, let this is how this is going to go down in explaining it to where I know it's uncomfortable, but and I'm going to let you take it from there.

Yes.

When they come to the hospital on the day of treatment, after we have concerns, we give a mild sedative, a pill to help and relax.

Then after that, if I know that before I do, ask all the right questions.

So the way they're claustrophobic, they cannot be in enclosed places either suffer from anxiety.

Most of these patients, they do because they've been through a roof.

Yeah.

So it's a hard road.

So with the mood said, you talk about brain tumors, trauma right there and and we like to again, we like to use the word lesions, you know.

And so anyhow so we do a mild sedative through in the process of waiting for the MRI, waiting for the plan to be done.

If I see the patients inside it levels increasing, I can easily as than your sergeant.

Sir, can I.

Can I give the the patient more medication.

So we glad to give it to the point that they sleep throughout this morning until they're ready to have their treatment.

And even in the treatment we give them some more.

Sometimes we have to give them intravenously to help and relax faster.

And once they do, they wake up.

And what happened?

We done We're done.

Okay.

I said, That's it.

That's a beautiful they're helping you express to me that way because I am the girl that's a bit anxious.

I am majorly claustrophobic.

So I'm just thinking to myself, as you're talking about this, I'm like, Oh my God.

But when you're talking about, again, sedation, but you have to I'm assuming you have to have some kind of awareness.

Yes.

And I'm glad you mentioned the word awareness because the point about government is for them to ask questions during the process.

For example, when the planning is ready, the neurosurgeon, the radiation oncologist, they go talk to the patient in the family.

We have a good plan because they want to allow the family to ask questions such as, Did the tumor grow there?

Did you see anything else?

Are you going to start you're going to the patient's going to continue with medications, Things like that is something that the physicians will know.

So we allowed that time.

And obviously what we want the patient to acknowledge, to be aware of what's again, we come back to the whole approach.

Then after that, if I see the patients as anxious, we are given medication for the treatment.

Okay.

But at that moment they at least understood what's happening.

Exactly.

And that makes all the sense.

So again, pardon my ignorance is probably more for the neurosurgeon and I don't know if it's brain cancers or tumors or what have you, but we've all seen that medical show where somebody is getting your giggling.

So you know where I'm going, right?

We've all seen that medical show where they're in the operating table and the person's awake, you know, and somebody's doing something to the brain and they're describing what they're feeling.

Can you feel your toes?

Is there a tingle?

What is that?

Is that part of this process, too, or am I just am I just looking at Hollywood here?

No, no, no.

Actually, it's a way craniotomy.

So if we're dealing with a tumor that's out on a part of the brain, let's say it's right around the motor strip area which controls motion movement of your arm or your legs, we can do with the kind of way craniotomy.

So with the patient in the preoperative area, we ask them certain questions.

There's a speech pathologist they're asking.

And you know, we're going to show you this card.

What is it?

And then repeat the same questions over again.

So basically, we get them back in the operating room, put them in the frame right there.

That's right.

In the right sedation, once we make an incision, you know, cut on the skin, there's no more pain.

Then we do the craniotomy.

Then as we open up the dura, as we're resected this mass because it's part of the brain or near vital structures, the pathologist or speech pathologist in the front is awake during the operation, and we're asking questions.

So as they're talking or dissecting, and that kind of freaks me out.

But it is so cool.

But at the same time.

But it's the best way to minimize post-op complications.

Okay, we're resetting this match so we can do other things, too.

We can if you don't want to go away craniotomy, we can do what they call mapping of the motor strip.

Right?

Right.

So there is a lot of technology out there that we use to outline the tracks on the MRI.

Then that MRI put into the navigation piece layered over the MRI image and resect where it's at and avoid those structures.

So if you don't want to do a way, craniotomy kind of bothers you.

That's another way of doing it.

But during the weight craniotomy, the patient is able to tell us what we're doing.

So very something is two more getting close to the speech area and the speech changes.

We stop.

So that's our limit.

And that's the beauty of doing Wake or any army.

Once we've done the tumor resection, everything's done, you know, Then we went to sleep and then we use giving close everything back up I just want to add something.

Yes, please.

Yes.

And I want to make I do wanna make sure the audience understand that the Gamma Knife radiosurgery.

We don't do any craniotomy.

A craniotomy.

We don't open anything.

That's totally mean.

That's basically the only I think the only ugly thing about Gamma.

And I put in the head frame those pants, the mass again, is only compressed to your skin, but it's not too, too bad.

Now, during the treatment of gamma knife, the patient won't.

Won't feel anything, see anything, smell anything, Nothing like nothing.

Scott, talk a little bit more about that.

That's super important.

Yes.

I want to make sure the audience understand that, that, yes, Dr. Morris is talking about craniotomy, which is is happening in the operating room.

Here with us is the machine that you all saw the picture.

It looks like a MRI machine.

Basically, the old stabilized the head with an adapter so the patient won't be able to move the head.

We can play music in there.

They can go to sleep still go to sleep.

They mostly go to sleep.

They'll go inside the machine.

They won't see nothing.

Feel nothing, smell nothing.

We can talk to them.

They can talk to us.

We can play music for their preference.

Then sometimes when the patient is a little bit uneasy, I even get the family to be outside the room and be talking to them.

Oh, very much so.

That way they can be relaxed and calm until we're done with the treatment.

Right.

But it's it's very pleasant.

It's very fulfilling, especially when it comes to the family, because obviously they're nervous.

And I was also with the patients and you have a very nice and calming demeanor about you, very good with it's very obvious.

It's great time they get there.

They're they're relaxed during that question.

Yes.

Well, he's the guy that let me into the door today and he's like, Who are you?

I love everything about this.

So when we're talking about radiation, usually there is and I'm just thinking breast cancers is like, okay, you have to go to radiation for every day for so many weeks.

What is it with brain cancers and with gamma knife treatment?

How does that work?

Is it every day for a certain amount of time?

You described earlier that you can pinpoint certain areas in the brain one day, and if it's just a little bit too much, then they come back the following day.

They do some more pinpointing there.

So that's interesting to me.

And a little bit different than other radiation oncology, though.

Yes.

So if we can with with gamma knife is it's only a one time deal.

It's a onetime deal.

Yes.

Unless unless unless if it's let's say right now, earlier, we're talking about, let's say lung cancer.

If six months from now, a patient that develops more lesions, then again, the process starts all over where they really then colleges will refer this patient to the radiation oncologist.

They'll contact the neurosurgeon and they'll refer the patient back to us.

And then we treat the gamma on those new lesions.

Okay.

Lesions.

Okay.

When it comes to two brain tumors, this doctor, I'm always talking earlier.

There's malignancy on those tumors, and they can start spreading in other areas if there's any.

And we can treat them fast, like, in fact, like literally within days.

In that case, Dr. Mahmoud, if he sees the patient develop in another tumor, then he'll refer that patient again to the radiation oncologist.

Okay.

And then both of them will contact me.

And it's how I start the process again with them, with the patients.

So, buddy, you were talking about tomorrow, you were going to say something.

So I was going to say, don't forget to tell.

This is outpatient.

Yes, it's an outpatient.

Okay.

Single fractions, even with the mask, outpatient, they they're getting treated and then they go to recovery for about an hour or so.

About an hour.

That's about what you leave in about an hour.

Basically, the patient will come in at 530 in the morning.

Okay.

And they'll be home by 1 p.m..

Okay.

Watching TV.

It's impressive.

Yeah, that's impressive.

They can go shopping.

They go shopping and they do shopping.

So you were talking about this TV.

I start tomorrow.

So if they don't want to, you know, to is that, you know, life.

You know, when you were given life with this, the design what can we dealing with.

But if we're talking about other tumor types, if it's not amenable to giving it based on the size, the location, everything else.

Right.

And with Gbn, you know, the example of the home is sometimes we'll do whole brain radiation.

This whole brain radiation means you have to go.

It could be anywhere between a 5 to 6 week course Monday through Friday, all Saturday and Sunday, where you get treatments every day, you know, for six weeks.

Right.

And that's a different so there's a difference based on, you know, what the tumor type is, what we're trying to achieve.

They certain tumors respond very, very well to came in life.

Right.

It depends on if it's already been resected what is a tumor cavity like?

Is it small, Is it large.

You know some of won't be minimal to that.

So you have to do a whole B radiation.

So when you're talking about tumor count cavity, just make sure it's so the tumor is gone.

But you're looking the space of the tumor was in because you want to radiate that area more as a preventative treatment going forward.

And a different Joe was saying that if you have someone who's got metastatic cancer with brain mass and you've already treated that one lesion that's metastatic with gamma knife and you get a second lesion Right.

If it's not causing any intellectual decline or any mental, you know, midline shift, not having any deficits that can be given with and then the game of treatment.

However, if you've already undergone whole brain radiation and it comes back, you can't do it again.

I see.

That's a difference.

Okay.

So just could you then go and do life so but not whole brain to it.

It would depend on the size of the lesion location.

And I example, it was a case where a patient had a resection.

Okay, of a tumor.

And at the first resection we got 90% of it out, 10% sliver was there.

We watched it over the course of three or four months.

It went from very small start expanding, so went to force on a meters.

So we did we couldn't it wasn't a response to gamma.

They actually did fractionated, radiation therapy, which is different.

So we watched her and now it's come back.

It's growing.

Hmm.

So now that's a person we would take back to surgery, see if we could shrink it down.

We said the tumor and then may be minimal to have an IV.

So.

So give me a timeframe when all this is happening.

When you were saying it's growing, growing, growing in how fast of a time, I know everyone's different, but in this one, because I know you're talking about days, sometimes weeks, sometimes months.

What was the aggression speed on this took out it was basically over a course of six months.

Okay.

Yeah.

And then what we did and is all of the patients doing well clinically and we knew that hers was a benign tumor.

Oh, perfect.

Okay.

So we had some leeway, right?

So I could watch it, observe it.

She's doing well, clinically, not causing any problems.

There's no edema, no swelling on the MRI scans.

Student Okay, she's well-controlled, and then we start having deficits of it.

Mars Done.

Do you see a change?

Okay, so we're following the patient ruling class.

We don't as like, say, come back and see when you want to.

There's a follow up rate because every couple, every couple of weeks, you know, for a while, then if they repeat a scan, three months, six months, if they have a change, we'll do it sooner than later.

And so those are the things we look at.

Okay.

I'm going to stop everything for a minute because we have exactly 11 minutes and like 12 seconds before we end the show and goes super fast.

So what have we not yet discussed that we really want to discuss tonight?

Because, man, that you're right, we can discuss it.

Right?

But I know that you're you're wanting to say something.

I can Well, I want to just emphasize a couple of things.

This this is a this procedure is highly regulated and highly monitor.

You know, I mean, we we have to answer to the Texas Department of State Health Services.

The regulations require that that the three that the medical physicists, the radiation oncologist, the neurosurgeon, be involved in the treatment assessment and planning state regulations require the radiation oncologists and the physicians to be there the entire time.

Hmm.

Start to finish.

Oh, wow.

Okay.

So we have to be on site.

It's a it's a lot of radioactive material that's well controlled that the FBI monitors us.

We have to respond.

I do this as the radiation safety physicist that does this and then go with some of the security issues.

But that's all transparent to anybody else.

But it's a huge burden of regulatory issues that have to all be well.

That negotiations feel so much better.

Yeah, it's a very safe operation for patients and staff, and it's a very tightly knit team.

I mean, it's not willy nilly this stuff and there is a lot of communication goes back between yeah, I want to kind of I don't have to is that when you're treating cancer, whether it's metastatic or primary, it's a team approach this is it's not one person.

It is a team and the team code and nurses, the oncologist, medical oncologist, radiation oncologist, a neurosurgeon, the primary care physician, the physical therapist.

There's a lot of people involved there.

This is not a one person show.

It's a team.

And the team that we have does a very good job because there's a lot of things when you just when you got brain cancer, it's life changing, right?

The world's goodness.

Right.

What do you do?

What do you say?

I think we'll just came to a crashing halt.

So we give a lot of resources.

I'm trying to in difficult time to reassure them that we'll get through this.

I think the more education we give them upfront, the more available that we are and that the good doctor Hahn or from what they do, Joe and John, they're also phenomenal.

But again, I want to point out it's a team approach.

It's not one person and that's that's the difference is that you can't bring them on one person.

And I again shout out to Dr. Gupta, she she worked on my mom 30 years ago.

It's just it was amazing to me.

Then she floored me and then I just fell in love with her.

As it said, you guys throughout the years, absolutely amazing how in body we talk about this, too.

The radiation.

I used to talk to her about the person who's bringing all the new toys to town.

Right.

She would write grants and she would do the research and get the right medical equipment here that we needed.

She never let up on that.

So thank you for everyone on this table and to the entire team for bringing that to our region.

And I saw you.

Yes.

You know, get your notes out.

Yes.

You are a man after own heart because look at this.

You know, I just want to add something.

Yes, please.

In in our government, we not only do brain tumors, lesions and metastatic lesions, we also do some functional problems, such as trigeminal neuralgia pain, say that slowly over trigeminal neuralgia pain, which is facial pain, many patients complain of facial pain and they go see primary care physicians.

Then the primary care physician will send it to a neurologist.

The neurology will send these patients to the neurosurgeon.

And basically you can talk a little bit about that doctor remote interaction.

Mineralogy It's a it's a basically where the fifth cranial nerve is got pressure usually from a vessel or some kind of compression.

Okay.

So normally you go through a medical therapy with medication, try injection therapy.

Now, if the patient's got multiple comorbidities, not a good surgical candidate, we can offer a gamut of treatment for that, which is a good treatment option versus a surgical resection, which involves surgery, craniotomy, you know, drilling off the bone, a lot of hair and a lot of risk for post-op complications.

Right?

So this is a good alternative.

So you're looking at finding a nerve, specifically a nerve in there.

You're bleeding It is that what's happening here is where the accuracy comes first.

Okay.

Okay.

This is where the accuracy comes in.

Sorry, Seri was listening to our.

Okay, my apologies for that.

Goodness.

So accuracy.

And we didn't even talk about, I guess, a whole nother thing.

I know, but yes, but excuse me.

Sorry.

Well, that's one of the most accurate.

You know, we the gamma knife is is the gold standard for accuracy and treating brain tumors and lesions and nerve pain, all the other modalities and I've worked with them I know are good.

But they they're all try they all try to match this for accuracy.

And our limit of what we would call a an acceptable region is far beyond what other tenths of the Mm hmm.

Tens of millions of a. Mm.

You know, that's pretty tiny goodness.

And when when we do some tests, if there if anything varies less than 3/10 of a millimeter, it'll fail.

We won't be able to treat.

So I test this every day that we treat right.

But we're talking about being in a delicate place for the brain and adding this high dose of radiation.

You need that.

So this is one of the reasons you were there on site, just like.

Really?

Yes.

Eagle I think so.

We're well, yeah, it's a team right now, but we're definitely glued to the every image on the MRI, Right.

Yeah.

And so he's a senior is the same process.

They shall be referred obviously Dr. Mahmud, the neurosurgeon you will refer to radiation oncologist and will come to me.

The government have coordinator.

Now I'll arrange everything.

Now the after we're done with the trigeminal Raja cases, they go back to their neurologist or PCP and obviously the neurosurgeon follow follow ups with this with these cases, I believe you see them every six months or sometimes three months, depending to see how they're doing.

Right.

And then I think life is also helpful.

You and I know it's a brain tumor discussion, but we can also treat vascular malformations like NGO.

Ms. AVM Yeah, lesions that so with the acronyms throughout with the acronyms, again, just for the latest malformation, Okay, It's a vascular malformations.

It's a congenital component.

That is where we have a mixture of artesian veins.

They shouldn't they should be two separate, actually.

They come together and they can cause bleeding.

Some can be large, can be small, and sometimes they can be other parts of the brain.

So normally before Gemini, for relationship, we came out, we had to go back and we sent them surgical.

Okay, so now with the advent, we can use Gamma not to treat these lesions effectively without a major operation.

So for moving towards like A.I.

into minimally invasive procedures, which is gamma knife got aborting the surgical scar, those kind of things right.

But, you know, we had talked about brain tumors that kind of want to lay out some numbers.

And here this is going back and numbers change.

Right.

But you're going to figure there's 90,000 people that are diagnosed with brain cancer.

There's over a million people living with brain cancer in eight states, living with brain cancer, living, okay.

There.

You know, brain cancer and CNS tumors account for the fifth most common type of cancer.

Wow.

Okay.

That I was not aware there's over 100 types of brain tumors.

I could spend a whole lecture on the brain tumor and what they do with benign versus cancer.

And so when you talked about that earlier, I thought, you know, and you even said we can't go down that rabbit hole because it would take a couple of hours and in 27% of all tumors can be malignant, you know, we lose 17,200 souls every year to brain cancer.

You know, and you're talking about 90,000 living with brain cancer.

We lose about 17,000.

Is that what I'm understanding?

Okay.

Okay.

So it's real.

Yeah, it is.

We all have memories that our own family, like you said, friends of friends have had this.

I mean, I remember when I was in residency, in partnership and how the outcomes were different, but through research and grants and dedication by the team and writer Gupta, Dr. Hahn, Joe, John, all the, you know, medical personnel out there that's trying and working every day to try to make a change in a better person's lives.

Right.

Right.

And we never can forget that.

So, you know, you see the clock in front of you.

And I know that you talked earlier about advancements.

And I would love for you to give that like a one and a half minute shot out there.

And you said, what are the advancements coming up?

What's new on the horizon?

Well, besides the the mechanical and the combined CTE that we talked about that allows us to register the patient's MRI's to the machine, some of the work in the software has been amazing.

And I think it's already a I mean, I has been around for many years.

It's just kind of when it started writing term papers, it got popping.

But, but it's true, some of the things now that the programmers and the mathematicians, physicists back in elected and wherever they wherever they are, have developed routines that allow us to generate multiple plans very quickly.

So beforehand we used to do very mechanical, very and we could do a really good job.

It may take several hours.

Now we can do it in in minutes.

That's amazing.

So so they can show up and say, well, here's plan one, two, three, let's go through see which one is most.

And it's already specific to their anatomy, to their head.

It's like completely, completely dedicated to them with air.

You can't make a mistake in that area.

Well.

Well, I would say that's a wrong wording.

I used, you know what I mean?

It's very precise.

It is very precise.

And that's what we do there in the planning stages.

But the fact that the algorithms now are so optimized that it can look at what we've put in and then help us develop plan so you can come in and say, look, let's have a look at plan one, two or three.

And you say, well, three is a little bit too aggressive and so forth.

So instead of one or two of us working for several hours to get a plan that is a good plan.

But we can now give a it's like tumor tumor board on steroids with, you know, both the plan and if you miss part of the show or if you want to watch it again, there are several places you can do that.

You can go to PBS El Paso, Dawg.

You can also go to Ypsi, Macomb, that's the El Paso County Medical Society.

You can also put that in the search engine that will pop up.

And then YouTube.com is I think a lot of people kind of default and go.

The important thing there is to type in the words the El Paso physician and from there you can see this show.

You can go back and see shows that we've got.

My goodness, I want to say they're archived for for years and years.

But thank you so much for joining us again.

Tonight's program has been on advancements in brain cancer identification and treatment.

It was heavy but super informative.

We thank you for being with us.

Dr. Mahmoud.

Buddy Slash, John, Slash Winston Slash Joe Rodriguez.

Thank you so much for joining us.

Thank you.

I'm Kathrin Berg.

And this has been the El Paso Physician.