Two major challenges of treating glioblastoma multiforme have been the type and location of these aggressive brain tumors.¹ Surgical tumor resection is difficult due to the widespread nature of gliomas. Chemotherapeutic treatments are often unable to cross the blood-brain barrier or cannot be confined to cancerous cells only, thus causing toxicity in normal tissue.¹ One viable option is targeted therapy, which can result in both improved chemotherapeutic and surgical results.
Research initiated by Achuthamangalam Madhankumar, Ph.D., assistant professor of neurosurgery at Penn State Hershey, has shown it is possible to use targeted nanovesicles to carry anti-cancer drugs or contrast agents selectively to tumor cells. The latter approach enhances tumor visibility, enabling the surgeon to more accurately assess the extent of the tumor. In addition, because of the unique expression of the interleukin-13 (IL-13) receptor on certain types of brain tumors, this targeted delivery system may be useful in the diagnosis of tumors.
The research used a murine model to test parameters including the efficacy of targeted versus untargeted liposomal doxorubicin, a chemotherapeutic agent.¹ Mice with intracranial tumors measuring five millimeters received fifteen milligrams of doxorubicin for each kilogram of body weight once a week.¹ Over six weeks, the size of the tumor decreased to less than one millimeter in the group receiving targeted liposomes, but did not decrease in the two of eight surviving mice receiving untargeted liposomes with doxorubicin.¹ There was a significant decrease in the tumor volume on contrast MRI images in the targeted liposome group, as seen in the figure.¹ Continue reading
In 2013, a paper published in Neurology advocated a clinical opinion that statin use was protective against Parkinson’s disease (PD).¹ However, Xuemei Huang, M.D., Ph.D., professor and vice chair for research, Penn State Hershey Neurology, led a team in a prospective analysis of the connection between statins and PD in the Atherosclerosis Risk in Communities (ARIC) study, which strongly suggests the opposite finding.²
While the analysis was based on just 106 cases of the more than 15,000 patients enrolled in ARIC, Huang says, “The length of the study, measurement of cholesterol, and recording of patients’ statin history all combine to make top-notch data collection.” One especially interesting feature of the ARIC patient cohort is that the study began before statins were widely used, but continued for twenty years, marking a unique opportunity to analyze pre- and post-statin disease correlates. In addition, not only did Huang’s study find that statins may not confer a protective effect against the development of PD, but they may actually increase the risk of developing PD with long-term use.²
The changes of statin usage (A) and plasma total cholesterol levels in Atherosclerosis Risk in Community Study (ARIC) stratified by statin usage (B) and Parkinson’s disease (C) status.2
The peripheral nerve program at Penn State Hershey Neuroscience Institute uses nerve transfer procedures to treat complex cases. Division Chief of Peripheral Nerve Surgery, Kimberly S. Harbaugh, M.D., explains one option, “Oberlin transfer is a procedure in which the clinician harvests part of one of the nerves from the hand and transfers it to the nerve in the patient’s bicep muscle. In this way, we have been able to restore significant levels of elbow flexion.” This has multiple potential applications, even in patients with spinal cord injuries. A portion of the nerves that are still intact above the level of the injury can be transferred to areas below the injury. In this way, spinal cord injury patients may be able to reclaim some finger and hand function, leading to improved self-care options.¹
Assistant Professor of Neurosurgery, Elias B. Rizk, M.D., M.Sc., details a recent case: “I had a male patient in his mid- 20s with a direct injury to his brachial plexus. He had been in a car accident, and in a state of semi-consciousness, he tried to release himself by using a pocket knife. He stuck it into his chest wall, severing one of the nerves to the arm. As a result, he lost his functional elbow movement. After six months, we elected to do an Oberlin nerve transfer to his bicep muscle. He had a very good recovery, with restoration of elbow flexion, and is now back to work.” Continue reading
Penn State Hershey Neuroscience Institute, has a global perspective when it comes to providing quality, multi-disciplinary care. This is best represented by the Institute’s expansive global exchange program among neuroscience clinicians and researchers, spanning four continents. Every neurosurgical resident is given the opportunity to hone his or her skills abroad, and almost half choose to do so. The primary exchange program is with the Bureau of Public Health in Tianjin, China, a formal relationship that began in 2006. Through a grant funded by Integra Foundation, eight Penn State Hershey Medical Center faculty members have studied there, while thirty-four exchange students have learned alongside Penn State College of Medicine faculty.
The exchange program functions as part of a developing program to encourage collaboration between clinicians and researchers at Penn State Hershey Medical Center and Tianjin’s largest hospitals. These reciprocal relationships enable providers to share best practices and advanced technology to improve patient outcomes. From a clinical standpoint, foreign physicians can gain experience with virtually every neurosurgical procedure that is currently performed at Penn State Hershey Medical Center. In the research arena, groundbreaking studies are being conducted through the Center for Neural Engineering and Penn State Hershey Neurosurgery laboratory. Research is ongoing in neurodegenerative disease, brain iron deficiency, brain tumors, epilepsy, and brain-machine interfaces. Physicians from the US and China also collaborate on clinical trials, mutually benefiting with shared data from their genetically disparate populations. Continue reading
Robert Harbaugh, M.D., professor and chair of Penn State Department of Neurosurgery and director of Penn State Hershey Neuroscience Institute, encourages all members of his department to take an active role in the field. “One thing we encourage in our residency training, aside from the usual missions of education, patient care, and research, is involvement in organized neurosurgery.” As they train new residents, Penn State Hershey Neurosurgery faculty members also encourage younger physicians to pass on their knowledge and adopt a citizenship role in the field.
Harbaugh himself holds multiple leadership positions, including president of the Society of Neurological Surgeons. He previously served as immediate past president of the American Association of Neurological Surgeons and director and member of the Advisory Council of the American Board of Neurological Surgery. Harbaugh has traveled extensively to lecture on various topics, including his clinical specialty of cerebrovascular neurosurgery and his research work on computer modeling of intracranial aneurysms.
Robert E. Harbaugh, M.D., FAANS, FACS, FAHA
Director, Penn State Hershey Neuroscience Institute
Distinguished Professor and Chair, Department of Penn State Hershey Neurosurgery
Professor, Department of Engineering Science and Mechanics
RESIDENCY: Neurological Surgery, Dartmouth Hitchcock Medical Center
MEDICAL SCHOOL: Penn State College of Medicine
Brad E. Zacharia, M.D., M.S.
FELLOWSHIP: Surgical Neuro-Oncology, Memorial Sloan-Kettering Cancer Center, New York
RESIDENCY: Neurosurgical, New York Presbyterian Hospital- Columbia University, New York
INTERNSHIP: Surgical, New York Presbyterian Hospital- Columbia University, New York
MEDICAL SCHOOL: Columbia University, New York
CLINICAL INTERESTS: Brain tumors, endoscopic skull base surgery, Gamma Knife® radiosurgery
Brad E. Zacharia, M.D., M.S., brings new techniques to Penn State Hershey Neurosurgery, to improve the safety and effectiveness of brain tumor surgery, including functional brain mapping and endoscopic skull base surgery. Please call 717-531-3828 with questions or to schedule an appointment for your patients.
UP TO 50 PERCENT OF BRAIN TUMORS RESISTANT TO STANDARD CHEMOTHERAPEUTIC AGENT TMZ
When a patient presents with a malignant glioblastoma, the current standard therapy is total resection surgery followed by radiation, either alone or in combination with temozolomide (TMZ) chemotherapy.1 Used to treat several types of cancer, orally-administered alkylating agent TMZ is known to inhibit cell reproduction by blocking the replication of DNA.2 Although it is less toxic than other alkylating agents, TMZ does not display efficacy in as many as 50 percent of brain tumors.3 Because of this, as well as the high rate of chemotherapy resistance in recurrent brain malignancies, there is an urgent need for new drugs for treatment-resistant tumors.4 Continue reading
ONE-OF-A-KIND FUNDING MODEL ALLOWS FOCUS ON TRANSLATIONAL RESEARCH
Data manager, Nicole Matthews shares information with Scott Simon, M.D., assistant professor of neurosurgery
Penn State Hershey Neuroscience Institute is home to the Office of Patient Oriented Research (OPOR), which facilitates neurological human trials research. Director, John Graybeal, explains that the OPOR acts as more than just an industry-sponsored clinical trials office, but also makes it possible for physicians to conduct translational research on existing data, with a focus on stroke, cerebrovascular disorders, and tumors of the central nervous system. The unique funding ratio of the OPOR—40 percent from industry, 40 percent from government, and 20 percent from within the department itself—is one key component of this ongoing work.
Robert Harbaugh, M.D., director of the Neuroscience Institute, elaborates: “The OPOR has facilitated substantial growth of multidisciplinary clinical trials in the treatment of cerebrovascular disease and brain tumors at Penn State Hershey Medical Center. The goals of the Neuroscience Institute, to foster interdisciplinary collaboration and support bench to bedside and bedside to bench translational research, are greatly enhanced by the work of OPOR.” Continue reading
DECREASED STROKE RISK CITED AS PRIMARY BENEFIT OF REGIONAL ANESTHESIA, ESPECIALLY IN OLDER PATIENTS
Carotid endarterectomy (CEA) has long been used in selected patients with carotid stenosis, especially in those with 70 to 99 percent stenosis of the internal carotid artery.1 The majority of those surgeries are performed under general anesthesia; however, an increasing number of neurosurgeons believe that performing the procedure under regional and local anesthesia results in superior outcomes. Assistant Professor of Neurosurgery, Scott Simon, M.D., strongly agrees. In fact, he and Robert Harbaugh, M.D., professor and chair of the Department of Neurosurgery, insist that all CEA patients receive regional anesthesia, in the absence of mitigating factors.
As Simon states, “Most of our patients have already had a stroke, and there’s evidence that putting a brain that’s already been injured under general anesthesia can cause cognitive limitations when the patient wakes up.” When asked about the landmark CREST (Carotid Revascularization Endarterectomy versus Stenting Trial), which appeared to indicate that stenting offers similar outcomes to surgery, Simon points out that the data clearly indicate a much lower risk of postoperative stroke with CEA (2.3 percent versus 4.1 percent with stenting),1 a significant indicator of patient quality of life post-procedure. Further, of more than 2,500 patients in the CREST trial, only 10 percent received regional anesthesia.1 Continue reading
NOVEL PROGRAM OFFERS PATIENTS LESS INVASIVE TREATMENT OPTION
Spinal column reconstruction for the management of adult spinal deformity (ASD) is technically challenging and has been associated with high complication rates,1 which may explain why few locations perform it. However, at Penn State Hershey Medical Center, specialists perform the correction using a posterior-only approach, as opposed to the more traditional anterior-posterior approach.2 Assistant Professor of Neurosurgery, John P. Kelleher, M.D. states, “This minimizes the need for next-day staging of the procedure. However, when staging is necessary, we use a minimally invasive extreme lateral approach which causes minimal blood loss and leads to rapid recovery.”
Patient unable to stand for a significant time, secondary to excruciating pain with sagittal imbalance. On the right are standing films of the same patient after multilevel surgery correction of the sagittal imbalance.
The major surgical procedure required to reshape the spine in cases of ASD typically requires an inpatient stay of between seven and ten days, followed by robust support in the weeks thereafter, making it unrealistic for many patients and their families. However, Kelleher has joined the Penn State Hershey Neurosurgery team to spearhead the spinal deformity surgery program in collaboration with colleague J. Christopher Zacko, M.D., who also uses this less invasive approach. Continue reading