Dr. Peter Fecci is a neurosurgeon and Director of the Center for Brain & Spine Metastasis at Duke University. He performs surgeries to treat brain tumors including the emerging technique called LITT or laser interstitial thermal therapy. He is also a cancer researcher and serves as the Director of the Brain Tumor Immunotherapy Program also at Duke.
Peter Fecci, MD PhD, is currently an Associate Professor of Neurosurgery, Pathology, Immunology, and Biomedical Engineering at Duke University, where he also serves as the Director for the Duke Center for Brain and Spine Metastasis, as well as for the Duke Brain Tumor Immunotherapy Program.
A neurosurgeon-scientist, Dr. Fecci focuses clinically on intrinsic brain tumors, both primary and metastatic. In the research realm, he heads an NIH-funded laboratory that focuses on integrating strategies for reversing cancer-induced T cell dysfunction with current immune-based platforms. For his research contributions, he was a recent recipient of the Cancer Research Institute Lloyd J. Old STAR Award and was likewise inducted into the American Society for Clinical Investigation.
Dr. Fecci also serves as multi-PI for the Duke R25 training grant. His recent work on brain tumor-induced T cell sequestration and exhaustion has produced numerous high profile publications. He is now actively engaged in exploring novel drug targets and therapeutics that his group has uncovered for side-stepping brain tumor-imposed immune dysfunction and for newly licensing immune-based approaches in this patient population.
Dr. Peter Fecci #1
Hi, my name is Christine Hodgdon. I’m a metastatic breast cancer patient and advocate. And I’m here today with Dr. Peter Fecci, and I’m very excited to talk with him today about his work on brain metastasis. Dr. Fecci is a neurosurgeon and Director of the Center for Brain and Spine Metastasis at Duke University.
He performs surgeries to treat brain tumors, including the emerging technique called LITT or Laser Interstitial Thermal Therapy. He is also a cancer researcher and serves as the Director of the Brain Tumor Immunotherapy program also at Duke. Thank you so much, Dr. Fecci, for joining us today.
Thanks for having me. I appreciate it.
I want you to take a step back. We said that you’re a neurosurgeon. Can you tell us what a neurosurgeon is and what role they play in the treatment of cancer?
Sure. In general neurosurgeons are those that operate on either the brain or the spine, and that can include pathologies that range from things like a herniated disc, all the way up to brain tumors, spine tumors, aneurysms, et cetera.
And we tend to all specialize quite a bit. From my perspective, I’m specifically a brain tumor surgeon. I have colleagues that operate on metastases or other tumors within the spine, but I focus specifically on either primary brain tumors which are tumors that arise in the brain, things like glioblastoma meningiomas, et cetera, or brain metastases; cancers that have traveled to the brain from either common places like the lung, the breast or the liver. And of course, breast cancer, being the topic of conversation here, tends to be the second, most common cancer that travels to the brain.
Yes. And what kind of surgeries do you perform on breast cancer patients specifically with brain metastasis?
In certain instances, those tumors can actually be removed or we say the word resected from the brain. When we look at a patient, basically what we’re trying to decide is a tumor that they have in their brain, more amenable to just radiation upfront or is it a tumor that should actually be removed prior to radiation.
The reasons we might consider one versus the other have to do with things like location in the brain. Is it safe to operate? How large is the tumor? If it’s particularly small, maybe less than a centimeter and a half or a centimeter, it’s not frequent that we would go in there surgically. Often we would reserve something like that for radiation, because it might be very effective against such a small lesion.
If tumors are larger, maybe larger than two or three centimeters, they’re in an area of the brain that we can go to safely and they’re causing a lot of symptoms in particular, then it’s often beneficial to take them out. Number one, to relieve the symptoms that the patient might be experiencing and also to make subsequent radiation therapy work better because that radiation tends to work better when a lot of that mass has been removed. In general, however, if someone has a lot of tumors, taking out one, isn’t going to make a big difference. So oftentimes people that have either, not very many tumors in the brain or maybe have one larger lesion, the remainder and that large lesion is causing symptoms those are the instances when we’re more likely to consider surgery prior to radiation.
Got it. And we are actually going to interview some experts in the field of radiation oncology as well. So we’ll definitely be answering questions that folks may have about that type of treatment. So what I’m hearing is that it really is going to depend, which we hear this a lot as a metastatic breast cancer patient.
I hear all the time we don’t really know exactly because every person is so unique. So what I’m hearing is that surgery is really going to depend on the size of the tumor, the location of the tumor and whether it’s causing symptoms.
Dr. Peter Fecci #2
And what kind of surgeries? I know that there are craniotomies, is there some other type of surgery that you can perform in the brain? And is one more common than the other?
Yes, craniotomy, as you were referring to, is essentially where we make an incision in the scalp.
We make an opening in the bone where we take that portion of bone out. That gives us access through the dura, which is the protective covering over the brain into the brain itself. There are kinds of various specifics to how we do that. That probably goes beyond what people want to hear about. But once that tumor’s out and, and we tend to try to get it out in one piece, if we can, then we put that bone back on.
We use little titanium brackets frequently, and then we close up the scalp over the bone and that’s what a craniotomy means. That’s kind of the most invasive type of surgery we do to get a tumor out. But there are minimally invasive procedures. You mentioned in the introduction of me, a procedure called LITT, which stands for Laser Induced Interstitial Thermal Therapy.
That’s just fancy talk for basically using a laser to cook the lesion. And it’s a very small incision, usually a centimeter or less. And then we drill a very tiny three to four millimeter hole in the skull. We lower a biopsy needle down a trajectory that we use navigation systems kind of like what’s in your car to kind of fix a trajectory.
Then we can take that biopsy needle out. Once we have a piece and replace it with a laser catheter down the same trajectory, and then use that laser to cook the lesion.It’s done in a kind of a clever fashion. We can essentially convert a regular MRI machine in the operating room into a giant thermometer.
And we can use the MRI data real time to give us temperature data. And so we’ll know when we’ve successfully cooked the lesion with the laser. And it’s a boon. It’s very common. We’ve been using it at Duke for about the last five years. That’s kind of been the period of time when it started to really gain popularity.
It’s great for a variety of instances where the role of craniotomy may be less clear, or it might be a little bit more dangerous. So usually where we use the laser now, or in patients who have already had either surgery and/or radiation for metastasis in the past, and it’s perhaps come back or perhaps there’s a radiation side effect called radiation necrosis, which is an inflammatory response that can happen many months later.
And the role of surgery for recurrent tumors or for radiation necrosis, the role of a craniotomy is a little less clear and perhaps a little troublesome or there’s risks because of wound healing issues that follow radiation, et cetera, et cetera. And in those instances, doing a much smaller surgery with the laser is sometimes advantageous.
And so most of the time when we’re using the laser in metastatic patients, it’s when a tumor has come back where, when we’re concerned that there might be something called radiation necrosis, which perhaps hasn’t responded to medical therapies like steroids,
Okay, I didn’t realize that you can use LITT on radiation necrosis.
So you can do both. It can be used on a brain metastasis or to treat radiation necrosis, which as you mentioned is kind of a side effect that can happen from radiation to the brain. And it sounds like what I really love about this procedure is that you can actually get a biopsy. So you don’t have to go through the full craniotomy to get a biopsy.
And so often brain metastases patients aren’t able to get a biopsy because surgery, I don’t think is that common. And so this allows you a chance to see what kind of cancer you’re dealing with. You know, we know that the receptors can change. And so, and I know one of your colleagues, Dr. Sammons did some work on the HR positive breast cancer, actually gaining that HER2 mutation in the brain.
So I just think it’s very interesting that you actually are able to see what kind of cancer you’re dealing with. And maybe that could change treatment options. It depends, especially if you have a HER2 positive brain met. I’m glad you explained that.
I wanted to ask one more question: Is LITT FDA approved?
It is FDA approved. It’s not FDA approved specifically for brain metastasis for, breast cancer, brain metastasis. It is approved for use in the brain to treat soft tissue lesions. Which of course includes things like brain metastasis, primary brain tumors, et cetera. It’s not an experimental therapy despite that statement that is made at times, and there’s a good amount of literature out there to support its use.
And like you said, a major advantage is that we can get a tissue diagnosis at exactly the same time. What it has done in our practice is it’s allowed us to offer people that type of diagnosis earlier. So in the past an MRI often cannot tell the difference between radiation necrosis, maybe many months after someone’s had radiation to a brain metastasis.
It cannot tell the difference between that or whether or not the tumor has come back. The MRI is just not sensitive enough to give us a difference. And sometimes it’s a mixture of both. And so rather than try to guess, or use medicines that may or may not work to see how people respond. This allows us to now just say, well, let’s just go in there and figure it out.
We’ll get a biopsy. We know that we have the laser at our disposal. It can treat either biopsy results, just fine. And people tend to leave either same day or the next morning with a bandaid on their head. Pretty much unable to tell that they’ve had a surgery. So it’s really, really a fantastic procedure.
So I’m thinking like a patient right now.
I’m curious, do you know if there are going to be issues with the breast cancer patient trying to get insurance to cover a procedure like this? Because it’s not specifically FDA approved for brain meds and breast cancer. I’m just curious.
So I won’t tell you that there are zero issues, but I will tell you that the majority of our patients are able to actually obtain approval without issue.
And then I’ll tell you a few things. So Medicare and Medicaid have no problem whatsoever with it. Actually, some of the private insurance coverage companies that have been stating that they feel that this is experimental. But those dominoes are starting to fall as well. I’ll tell you that I actually wrote, in conjunction with one insurance provider in North Carolina, that very first specific policy to cover LITT in patients with recurrent brain metastasis, radiation, necrosis, and other brain tumors.
And now other insurance companies are following suit because there’s a precedent. We actually at the neurosurgical societies, the tumor section, for instance, we’ve just started to put forth, position statements that allow us to kind of advocate for this with insurance companies. There is a code being issued to this procedure that will also help.
And the NCCN has now included LITT and it’s guidelines as well for the first time this year. So, even if there have been issues in the past, I think fewer and fewer of those issues will persist.
That’s really great to know because there’s many metastatic patients already on Medicare. So that is very good information for them.
And my next question as a patient, is it widely available? Will I be able to find this at my local cancer institution or do I have to travel to actually get this procedure?
In general, most academic centers will have the LITT procedure. And then there are some of us that are the leaders across the country right now. As far as places that perform the most of these, I would recommend going somewhere where the people are quite familiar with the procedure.
It’s like anything surgical, the more people do the better they are. Typically, smaller centers, smaller hospitals, community hospitals,I don’t think you’ll find this procedure available. So although you may have to travel, there are enough academic centers around the United States that have it that hopefully you shouldn’t have to travel too far.
Dr. Peter Fecci #3
Switching gears a little bit. I’m just curious in general, could you just talk about a patient who might be considering surgery and they’re nervous about the side effects. You just gave us two examples. We’ve got craniotomy, we’ve got laser surgeries. One’s a little more invasive than the other.
Can you tell us what the recovery time is like for each and maybe what kind of side effects patients might be dealing with?
Sure. I think that you know, obviously what I’m about to say is not true for everybody. There’s variation across the board. If I perform a craniotomy on someone, which is the larger, more invasive option, of course, typically I would say most people leave the hospital two days after surgery.
There are some folks that are just really motivated to get out of the hospital. Certainly COVID has served that motivation purpose in the last year and a half, who often will leave the hospital even the day after the surgery. . But some folks of course need to be there longer than that, a few nights. And then overwhelmingly, most people are able to be discharged home, but depending on where the tumor was and what some of the swelling in and around that area may cause symptom-wise for a period of time after the surgery, some people may need brief stays in rehab facilities to get some of their strength back, et cetera.
For the laser procedure everything’s a little faster, not surprisingly. So that’s where the patient might spend one night in the ICU after craniotomy. They are unlikely to see the inside of an ICU after the laser procedure. Typically, I said, we send people home the following morning, but also with COVID we’ve increasingly been able to successfully send people home the same day as the procedure.
And so it’s usually at most one night in the hospital. Of course, again, same issue. If someone’s having some weakness due to some swelling, et cetera, they may need to stay longer and they may need a brief stay at rehab, but that’s pretty unlikely.
I think most people feel that after a craniotomy, which is again, that larger procedure that by two weeks most people feel that they’re about 90%. And then I always tell people that the last 10% of your energy levels take another four to six weeks to come back. So most people are out of work for, I’d say on average, about four weeks after craniotomy. Those periods of time are shorter for the folks that undergo the laser procedure.
It just, it just kind of amazes me that we can go into somebody’s brain and people can leave the next day or two weeks later. It’s pretty amazing. And when you said weakness, does that mean people have trouble like, maybe walking, lifting up their arms, doing things for themselves? Is that when you, when you mentioned weakness, is that what you see?
Generally, you know, in the brain, one side of the brain tends to control the other side of the body. . So a lot of the lesions that we intervene upon are located near areas in the brain that control strength and the opposite side of the body.
And so there may be a period of time, for instance,in the days after surgery, where there’s some swelling around that. And the way I explain it to patients is, look, if I operated on your ankle, you expect to have a swollen ankle the next day. The brain is no different. And if we operate on your brain, it’s going to swell a little bit.
And that swelling in the brain looks a little different than a swollen ankle. So I say, if you had a swollen ankle, you may limp, well, this is the brain limping, it’s producing a little bit of weakness, maybe some hesitant speech. And it all really matters where that lesion is in the brain that we’re operating on.
So for instance, for lesions that are right near those, what we call eloquent areas or areas that are really important for what they control. The swelling into those areas may produce symptoms that take a little bit, a little time,days, maybe even weeks to resolve. And that’s kind of what we’re talking about.
Okay. Thank you. What are the risks? There must be a few risks involved in brain surgery. You just mentioned swelling. Are there other risks involved, maybe more long-term side effects that patients might experience?
I think when I, when I provide risks to a patient, I kind of divide them up into a few different categories.
So I say first things first, all surgeries have some risk and no matter where we’re performing surgery, there’s a few things that are common to all of those surgeries. Number one, surgery tends to hurt. So we’ve put folks on pain medication before, during and after. You mentioned how we can go into the brain and people do well, the brain doesn’t have pain receptors, the brain doesn’t hurt.
Now, the scalp hurts and the dura hurts, but that’s really about it. So most people tolerate the surgery better than say, like a big belly or chest surgery where we really are sore and can’t move around afterwards. People are up walking around the next day, maybe with a dull headache, but that’s about it.
So pain doesn’t tend to be too bad for brain surgery. There are some exceptions of course, but we’ll just leave that as a broad statement. Bleeding, all surgery produces some bleeding, but in general, the bleeding from brain surgery is pretty minimal. And the chance that you would require something like a blood transfusion is almost next to zero, barring getting into an artery or something that really causes some blood loss, but that’s unusual.
And then all surgery has a risk of infection. We usually say about a 1% chance of infection following a surgery. So we put people on antibiotics just around the procedure, but not for very long. All surgery and the brain produces some additional risks. It can cause strokes or seizures, because we are in your blood vessels that feed parts of the brain.
We as surgeons try to avoid those blood vessels. And so we try to reduce the risk of stroke on our own. And as far as seizures are concerned, I tend to put patients on anti-seizure medication for a period of a couple of weeks after surgery. Those practices vary across surgeons, and just to kind of stave off evil spirits if you will, but it’s the far minority of patients that have issues with that.
And then the biggest risk that we kind of talked a little bit about is that swelling that can cause things like weakness or speech deficit confusion or dizziness all depending on where that tumor is in the brain. But there’s of course a risk that if we’re near those structures that are so important, we can cause more permanent deficits, more permanent neurological deficits.
That’s what we’re of course, really trying to avoid being exceedingly careful in our surgery. And I would say overwhelming, and the majority of our patients do not have long-term effects with the surgery if the surgery is done well.
Okay, great. I think it’s just important for patients to remember that, when we talk about the uniqueness of each individual patient, that really you are taking into consideration all of those factors as to whether or not a patient may experience long-term side effects, depending on the location of the tumor.
So. Yes, there’s risk involved, but like you said, there’s risk in every surgery. So, thank you for sharing all of that information.
Dr. Peter Fecci #4
I wanted to know if you had any success stories. I’m curious if, how successful is surgery in the brain? I personally don’t know many patients that have had brain surgery, many of the brain mets patients I work with have radiation therapy. So I just wanted to know if you had any success stories and how successful these surgeries are in the brain.
So I think it’s important to recognize that the field has changed a bit, really, even in the last 10 years. When I was in training, which I won’t date myself here, but it wasn’t all that long ago. It was a “knee jerk” on neurosurgeons to kind of send folks with brain metastasis for radiation. And not too long ago, the only real form of radiation that people got was whole-brain radiation, which is now kind of a bad word in the brain metastasis realm.
Now there are more advanced radiation techniques that are focused beams of radiation called stereotactic radiosurgery that only hit the lesion itself and not the surrounding brain. That, of course, has advantages for not exposing the normal brain around a lesion to unwanted radiation. There are still instances where whole-brain radiation is appropriate, of course. But stereotactic radiosurgery is really the gold standard for treatment of patients with even numerous brain metastases now, and that represents a shift in the last few years.And that’s a good shift, frankly. So every patient will get radiation because that is the gold standard, but certain lesions now, as we realize that people are surviving longer and longer with brain metastases, that role of surgery in making radiation more effective by what we’d say, cyto reducing or reducing the size of that lesion by removing it, reducing the number of tumor cells that are still there.
It really can impact that radiation. And so surgery plays a role there. And like we talked about surgery really may be helpful to remove a larger lesion that radiation might not be as effective against, or that might be causing problems for the patient, ifit’s pushing on important structures and it’s causing weakness or speech deficits or anything like that.
And so as our surgical techniques improved too, we can operate in areas of the brain now that people once thought were dangerous to go into. Now I don’t recommend doing that everywhere. And I would recommend sticking to academic or experienced centers that have a lot of these advanced technologies and surgeons who specialize in this.
But some of the success stories I can remember are patients that are told at various hospitals that they have inoperable brain tumors. They have weeks to live, months to live, go home, make yourself comfortable, and put your affairs in order. I just spoke to one of those folks who we took two lesions out of their motor ship, which were deemed inoperable at a place.
She was given a couple of months to live. We operated on her. I think it’s about three years ago now and she’s doing just fine. So you know, there are plenty of success stories because the combination of surgery and radiation, when surgery is appropriate can offer, 80, 90, 95% local control rates for breast cancer metastases in the brain, depending on those histologies, those molecular markers, et cetera.
And so we have many patients surviving years, following even brain metastases with no evidence of recurrent disease anywhere in their body. That’s far different than what I was taught even a decade ago where we would offer people a three and six month prognosis. That’s just not, it’s just not the case.
It’s inappropriate to tell people that they don’t have options at this point.
I just want to highlight the value of getting a second opinion, and especially getting a second opinion at an NCI designated cancer center can really make a huge difference. And so we’ll make sure to highlight that on our website as well, because it is an invaluable thing.
You can’t, you, you just can’t replicate that. You really need to make sure that you’re hearing from other doctors. So I’m really glad. Thank you for sharing that.
Dr. Peter Fecci #5
So speaking of how far we’ve come, it’s nice to hear that since you started, when you were in training and to now that you’re seeing a lot of improvements. Are there any other emerging research, is there any other emerging research in the neurosurgery field that patients should know about? I know that you also run a lab and you’re a researcher. And so anything you can highlight that would be of interest to patients living with brain metastasis.
I won’t bore people with some of the surgical techniques stuff, but you know, we’re always trying to make our procedures less invasive.
So there’s, there’s ways to do things through smaller and smaller openings, so the surgeries are more tolerated. We have a lot of technologies that allow us to visualize things in three dimensions during the surgery. And in fact, there’s a technology now that instead of having to look through a microscope and crane my neck, everything’s out on large screen TVs in 3D.
We wear 3D glasses in the surgery, and then we have technologies that allow us to manipulate things like a white matter tracks, which are the kind of wiring in the brain that connects important structures. So we can actually plot trajectories that really thread a needle through areas that are pretty treacherous in the brain, but we can now get there safely based on a lot of these techniques, particularly combining them with things like mapping that allow us real-time in surgery to detect that a specific area of a person’s brain is functional and that we shouldn’t touch it or disturb it. So I won’t go through all that. It gets a little technical and boring.
Very interesting. I didn’t realize that.
I can remember giving a talk to one of the clinical heads of our cancer center.
Well, he was in the audience. I gave a talk recently highlighting all these new technologies and showing videos of all these cool things. This is someone that’s been around for a long time and certainly refers patients to us for surgery. But even afterwards, he just said, wow, I just can’t believe the stuff that you guys can do these days.
He’s been around the block, of course. So I think there are a lot of new, exciting things that are coming out. I think that’s on the surgical side, but more importantly, frankly, as far as impacting patients and their survival and their quality of life are the types of therapies that are coming out.
And I think you and I were talking earlier about the notion that previously patients who, you know, developed a brain metastasis, let’s say while they were on a clinical trial, kind of got booted off the trial and for a variety of reasons, none of which really matter. But that shouldn’t be the case anymore.
And in fact, one of the things we’ve done in building a center at Duke is we’ve focused,and that was always our motto from forgotten to focus. Right? So we took patients who were getting booted off these studies and said, no, we’re going to focus on these patients because there’s a lot to be done here to help them.
And so now instead we have clinical trials that the criterion to be on the trial is that you have a brain metastasis.We have over a dozen of those open at our institution. And I think you’ll start to see that via trend. And a lot of those are treatments that are meant to get into the brain or are meant to treat cancer regardless of histology, et cetera, et cetera.
And so I think there’s just a lot out there now that is available to folks as long as they’re willing to, like you said, get a second opinion or kind of do their homework and are willing to travel or what have you.
And also to participate in a trial. I think if we can get more patients participating, that’s going to help as well.
But the truth is part of the work that I do is we need more trials. There’s so many that are excluding the patients. I’ve seen a lot of trials where they say’ “Oh, sure, brain mets can participate.” We really want trials that are specific to brain metastasis and frankly leptomeningeal disease.
So I’m really happy to hear that Duke has a dozen or so. We’re going to highlight those on the website as well. I think that was all I had today. Did you have anything else that you wanted to add?
I’ll certainly mention a few things that I think are exciting. We have, as we’ve built our center, really tried to focus on all areas.
We do focus on leptomeningeal disease. We’ve published on it. We have a researcher at Duke, who has uncovered some of the mechanisms of leptomeningeal spread. We actually have submitted recent research proposals on it too, to try to understand that late stage of metastasis, again, to say these are folks that people perhaps are giving up on.
We don’t want to do that. We want to discover the next path forward. And, and so a lot of those things are occurring at various institutions, not just Duke. The key point here is these patients, patients with brain metastases are now becoming a focus of medicine. It’s important to recognize that part of that is because as people survive longer with cancers, as our therapies get better, larger proportions of people will survive long enough to develop these kinds of late stage portions of cancer, where the cancer can travel to the brain or the spine.
And so now we really need to focus our effort on tackling that problem. We do a lot of research. I, myself, am engaged in some really exciting research projects where we have some novel therapies that are perhaps just a couple of years away from getting into the clinic. I work with a Nobel Laureate there, and we have discovered a novel target.
We have drugs that are coming out for that. And I think it’s an exciting time to be in medicine, and it’s an exciting time in so much as it can be exciting to be a patient with this problem where previously you may not have felt there were options, but now there really are. And there’s a group of people out there who are looking to make your symptoms better or your lives better and your treatments better.
I think I’d like to include myself in that group, but I know there’s a variety of other folks out there doing this.
Well, that is wonderful. That is music to my ears, and probably many other patients to know that there are therapies coming down the pike. I think we’re all very excited and I’m very grateful for you coming here today and chatting with us.
And I’m grateful for the work that you do. So thank you so much.