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An Ommaya reservoir is a plastic, dome-shaped device inserted underneath the skin on your scalp. The dome is connected to a catheter placed in the ventricle of your brain where the cerebrospinal fluid (CSF) circulates.

Doctors often use Ommaya reservoirs in patients with leptomeningeal disease (LMD), specifically solid tumor LMDs, such as breast cancer, lung cancer and melanoma.

To learn about Ommaya reservoirs and how they¡¯re used in cancer treatment, we tapped the experts: neuro-oncologist , and neurosurgeon

What is the purpose of an Ommaya reservoir?

Doctors can use an Ommaya reservoir to inject medicine into the fluid around your brain and spinal cord or aspirate the fluid for testing.

LMD occurs when cancer cells from primary tumors enter the CSF or leptomeninges, the inner lining of the brain and spinal cord. Cancer patients who develop LMD may receive intrathecal chemotherapy as part of their treatment.

¡°An Ommaya can be placed to allow the delivery of chemotherapy directly to the cerebrospinal space. Doing so allows us to bypass the blood-brain barrier,¡± says O¡¯Brien. ¡°It can be a more effective, direct way of delivering chemo to some patients with LMD.¡±

How is an Ommaya reservoir placed?

An Ommaya reservoir is placed by a neurosurgeon while you¡¯re under general anesthesia.

¡°After the patient is asleep, we can use a stereotactic navigation system to select the location to guide the catheter into the patient¡¯s ventricle,¡± says Weinberg.

The surgeon makes a large, C-shaped incision in the scalp and drills a small hole in the skull.

¡°We intentionally make the incision big because we cut all the nerves that bring pain to the flap overlying the dome,¡± explains Weinberg.

This means the patient will feel no pain any time chemotherapy is injected into the dome.

¡°We make a small nick in the brain tissue and then use the navigation system to guide the catheter through the hole we drilled and into the ventricle,¡± explains Weinberg. ¡°Once it¡¯s in the ventricle, we test to make sure we¡¯re getting CSF flowing freely from the catheter.¡±

The Ommaya reservoir is secured with sutures to ensure it stays in place. The procedure typically takes 20 to 40 minutes.

Doctors will take a CT scan after the procedure to make sure the tip of the catheter is in the correct location and there¡¯s no bleeding. Patients stay in the hospital overnight. If there are no issues, you can go home the following morning.???

How do you care for an Ommaya reservoir after placement?

The most important thing is to make sure the wound heals properly.

¡°We don¡¯t want the wound to get infected, so you must allow it to heal. That can take anywhere from 10 to 14 days,¡± says Weinberg. ¡°Even then, the wound is still delicate, so make sure not to scratch or pick at it. You can exercise, but swimming is not recommended. It¡¯s best to avoid contact sports for about a month following surgery.¡±

Check with your doctor to see when you can resume normal activities.

Are there any risks associated with an Ommaya reservoir?

Risks can include:

Wrong location

If the Ommaya reservoir is placed or ends up in the wrong location, you must see a neurosurgeon to get it repositioned.

Bleeding

If there¡¯s a small amount of blood visible on a scan, your doctors may monitor for additional bleeding and do another CT scan. If bleeding is significant, you¡¯ll need surgery to have the blood clot removed. This is extremely rare.

Infection

If the wound gets infected, you will need surgery to have the Ommaya reservoir removed.

How is an Ommaya reservoir used in leptomeningeal disease treatment?

MD Anderson¡¯s Brain and Spine Center offers an Ommaya clinic for patients on Mondays and Thursdays. LMD patients with Ommaya reservoirs usually begin receiving chemotherapy twice a week.

When a patient visits the clinic, a neuro-oncology advanced practice provider (APP) cleans and sterilizes the area on the head. Then the provider inserts a needle into the reservoir and removes a small amount of fluid. This is known as an Ommaya reservoir tap.?

¡°The fluid is sent to the lab for testing, and some of the fluid is earmarked for research if the patient has consented to a research study,¡± says O¡¯Brien. ¡°After the fluid is withdrawn, the provider injects chemo into the Ommaya reservoir.¡±

CSF cytology identifies cancerous cells in the fluid and helps doctors assess how well patients are responding to treatment. Research testing helps doctors learn more about the underlying biology of LMD, in part by assessing the molecular profile of the tumor.

Some patients may experience headaches, neck pain or nausea after the procedure. Doctors work with patients to manage these symptoms by adjusting the amount of fluid taken or prescribing steroids to reduce inflammation that may occur from injecting chemo.

¡°Patients typically follow up with their neuro-oncologist every four weeks while on treatment, and we reassess with imaging of the brain and spine every eight weeks to make sure the treatment is effective,¡± says O¡¯Brien. ¡°At eight weeks, if the treatment is working and all parameters look good, we consider decreasing the frequency of the Ommaya reservoir taps. It may go from twice a week to once a week or from once a week to every other week.¡±????

Is an Ommaya reservoir the same as a shunt?

No. A shunt is commonly used in patients who have a blockage in their CSF pathway, causing fluid to accumulate in the brain.

¡°We will surgically place a shunt in the brain to help drain excess cerebrospinal fluid from the brain and transport it to another part of the body, where it gets reabsorbed back into the bloodstream,¡± says Weinberg. ¡°The Ommaya reservoir ¨C while we can attach a shunt to it, if necessary ¨C is specifically placed to be used only when needed. There¡¯s no continuous draining of fluid.¡±

How do you determine who is a good candidate for an Ommaya reservoir?

An LMD patient may have an Ommaya reservoir placed if doctors determine intrathecal chemotherapy is the best way to treat the disease. But it isn¡¯t right for everyone.

¡°For instance, intrathecal chemotherapy only penetrates a few millimeters, so this therapy is not expected to help patients who have bulky or nodular LMD,¡± says O¡¯Brien.

She carefully reviews the imaging to determine if the type of LMD the patient has can be appropriately treated by intrathecal chemo.

¡°If a patient functions well, doesn¡¯t have any significant neurologic symptoms and has options to treat any active cancer outside of their leptomeninges, then they may be a good candidate for intrathecal chemotherapy via an Ommaya reservoir,¡± she says.

The goal of intrathecal chemo is to keep LMD under control, not manage symptoms. It¡¯s important to have honest, realistic conversations with your doctors about your goals. Some patients want doctors to do whatever¡¯s possible to help them make it to a special milestone in their lives. Other patients place more importance on quality of life and do not want to travel back and forth to a clinic twice a week to receive chemo.

¡°LMD can be tough to treat, so we must consider our options carefully,¡± says O¡¯Brien. ¡°A nice thing about intrathecal chemotherapy is it only treats the leptomeningeal compartment, so patients can often continue receiving systemic therapy without concerns of their treatments interfering with one another.¡±

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What are the different types of skin cancer? How are they usually diagnosed? What do they look like? And how are they treated??

Below are the answers to these and other common skin cancer questions you might have.

Basal cell carcinoma is the most common cancer

Basal cell carcinoma isn¡¯t only the most common type of skin cancer. It¡¯s also the most common cancer, period.?

Fortunately, it also tends to be one of the least aggressive, and normally only requires surgical removal to treat it. These cancers tend to grow pretty slowly, too, so when we see one that¡¯s so large it can¡¯t be easily cut off, it¡¯s usually because someone left it there for a really long time. We do see some unusual cases here at MD Anderson, but it¡¯s still rare for patients to need additional treatment.

Basal cell carcinomas are primarily caused by excess UV light exposure. But they¡¯re also more likely to develop in skin that¡¯s been treated with radiation therapy. They¡¯re usually pink in color and translucent ¡ª almost pearly ¡ª in appearance. They¡¯re typically diagnosed when patients have a skin screening, but sometimes patients will notice something unusual on their own and come in to have it checked out.

Squamous cell carcinoma: the second most common skin cancer type

Squamous cell carcinoma is the second most common type of skin cancer diagnosed each year. In terms of aggression, it falls somewhere between basal cell carcinoma and melanoma. Like basal cell carcinoma, it can be red or pink in color. The difference is that squamous cell carcinoma is normally scaly and ¡°hyperkeratotic¡± ¡ª or rough to the touch, due to a build-up of hard, dead skin.

This type of skin cancer is another one that¡¯s caused by sun damage. But certain types of leukemia can also increase patients¡¯ chances of developing squamous cell carcinoma. And certain targeted therapies, immunotherapies and chemotherapies ¡ª or even the immunosuppressant drugs used after a stem cell transplant ¡ª can make patients more likely to develop it.?

To be clear, people who¡¯ve undergone these treatments and don¡¯t already have sun-damaged skin aren¡¯t just going to start growing a bunch of squamous cell carcinoma. But what doctors have noticed is that patients who were already prone to develop squamous cell carcinoma tend to get more of it when they¡¯re on these drugs.

Squamous cell carcinoma is typically found during skin cancer screening exams or noticed by patients. It¡¯s usually treated the same way as basal cell carcinoma: by cutting the cancer out. But in cases where a patient is immunocompromised, or the cancer has spread or is showing aggressive tendencies ¡ª such as wrapping itself around nearby nerves or blood vessels ¡ª we also might treat it with immunotherapy or radiation therapy.

Right now, we¡¯re exploring whether immunotherapy can treat basal and squamous cell carcinomas through clinical trials. I consider this a huge breakthrough, because previously, we didn¡¯t have many systemic treatments to offer these patients. Chemotherapy was not very effective, and for a small subset of patients who had really aggressive tumors, we didn¡¯t have anything great to give them.

These clinical trials are still ongoing, of course, so it¡¯s too early to say for sure, but it appears that we might have something to give those patients in the future. The results have been very promising so far. And the prospect of having more therapy options to offer our patients is really exciting.

Melanoma is the type of skin cancer with the biggest genetic component

Melanoma is a type of skin cancer that develops when melanocytes ¡ª the cells that generate the pigment called melanin ¡ª grow out of control. Of the three types of skin cancer I¡¯ve mentioned, melanoma has the most potential to become aggressive. But when we catch it early, it¡¯s not.

Many cases of melanoma are diagnosed when a patient notices a black, dark or multi-colored mole or lesion on their skin and asks a doctor to look at it. But it¡¯s still shocking to me how many people come to MD Anderson for something else and find out that they also have melanoma.?

Melanoma doesn¡¯t always develop in areas that get a lot of sun exposure. Sometimes, it appears on the palms of the hands, in between the toes or even on the scalp, hidden by thick hair.?

That¡¯s one reason why many of my patients tell me they keep coming back to MD Anderson for their annual skin exams: because we look EVERYWHERE.

Melanoma causes and treatment

Melanoma can be caused by environmental risk factors, such as sun exposure. But out of all the skin cancers, melanomas also have the largest genetic component. Doctors have found that people with the BRCA2 mutation, for instance, are at increased risk of developing melanoma. So, patients who carry that gene are automatically flagged to get regular skin exams as a part of their follow-up care.

The treatment of melanoma depends on its stage. For stages 0 and Ia, we¡¯d normally just remove it surgically. Any stage higher than that might require us to remove sentinel lymph nodes, too, or cut out more tissue around the tumor to ensure we get clean margins.

We don¡¯t use chemotherapy much to treat melanoma now, though. Instead, it¡¯s all targeted therapy, radiation therapy and immunotherapy. In fact, ipilimumab ¡ª the very first immune checkpoint inhibitor ¡ª was approved by the Food and Drug Administration (FDA) initially for the treatment of melanoma.

Actinic keratosis is the precursor of squamous cell carcinoma

Actinic keratosis is worth mentioning because this skin condition is the most common thing we see in our clinics.?

Actinic keratosis is not cancer yet. But it¡¯s considered a precursor ¡ª or ¡°pre-cancer¡± ¡ª of squamous cell carcinoma. It usually appears as a rough spot on the skin that won¡¯t go away. We can treat it in the office, by freezing it off with liquid nitrogen.?

See a dermatologist if a skin change doesn¡¯t go away

With all of these skin conditions, it¡¯s really important to catch them early. That¡¯s when they¡¯re typically easier to treat. So, if something unusual on your skin doesn¡¯t resolve on its own within a month or so, go see a dermatologist.

Also, do everything you can to reduce your chances of getting skin cancer. That means staying away from tanning beds, applying sunscreen properly, wearing hats and other protective clothing outside, and staying out of the sun between 10 a.m. and 4 p.m., when its UV rays are strongest. With skin cancer, a few simple prevention steps can make a big difference in reducing your overall risk.

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Melanoma is a type of skin cancer that occurs in melanocytes, the cells that carry pigment.

But are there different types? How is it usually treated? And are there any new therapies available?

We checked in with melanoma specialist ., for answers to these questions and more. Here¡¯s what she had to say.

What are the different types of melanoma?

The vast majority of cases occur in the skin and are called cutaneous melanomas. These can be further subdivided into four major types. The most common one is superficial spreading, followed by nodular melanoma. Other cutaneous melanomas include lentigo maligna and acral lentiginous.

But melanomas can also develop in melanocytes located in other areas, including the eye (uveal and conjunctival melanomas) and mucosal surfaces throughout the body (mucosal melanoma), such as the gastrointestinal tract.

Desmoplastic melanoma is another distinct subtype that occurs in skin regions with chronic sun exposure. Other very rare subtypes include primary central nervous system melanoma, which occurs in the leptomeninges (the lining of the brain and spinal cord) and melanoma of soft parts (also known as clear cell sarcoma), which arises in the dermal layer of the skin and other soft tissues.

How is melanoma usually diagnosed?

Some melanomas are diagnosed during regular skin screenings. Others are found after patients notice a swollen lymph node in their neck, armpit, or groin. And in a few patients, melanoma is discovered entirely by chance, during a scan that was ordered for another medical reason.

But in a good number of cases, either the patient or somebody close to them notices a change in a pre-existing mole. That spurs them to see a dermatologist, who then orders a biopsy.

How is melanoma staged?

Staging for melanoma is usually based on the three-tiered ¡°T-N-M¡± model.

• T stands for ¡°tumor.¡± It considers both the thickness of the primary tumor, and whether a pathologist can see ulcerations under a microscope.
• N stands for ¡°lymph nodes.¡± A surgeon may remove these to determine if the cancer has spread.
• M stands for ¡°metastases.¡± These are secondary locations where the cancer has spread. In this tier, doctors will note either the presence (M1) or absence (M0) of metastases.

All of these taken together are what doctors use to determine how advanced a particular melanoma is.

How is melanoma typically treated?

That all depends on the stage. Surgery is the initial treatment in most cases, especially if the cancer has not spread. Some patients may require radiation therapy, too. But melanoma can also be treated with a variety of other systemic therapies, such as targeted therapy and immunotherapy.

At MD Anderson, treatment is tailored to the specific needs of each patient. So, we take into consideration the type of melanoma, its stage and any other medical issues a patient might have.

What are the latest advances in melanoma diagnosis and treatment?

Over the past decade, the Food and Drug Administration (FDA) has approved a number new drugs for the treatment of melanoma.

In the immunotherapy category alone, there are ipilumumab, pembrolizumab, and nivolumab, plus the combination of ipilumumab and nivolumab taken together. These are given through an IV.

There are also three FDA-approved oral targeted therapy drug combinations for melanoma patients with a BRAF mutation: vemurafenib and cobimetinib, dabrafenib and trametinib, and encorafenib and binimetinib.

Other approaches for treating advanced melanoma include injecting an oncolytic virus called talimogene laherparepvec (T-VEC) directly into the tumor.

Not all of these therapies will work for everybody, of course, but it¡¯s still really exciting to have them. Because now, patients have many great FDA-approved medications available, and numerous clinical trials they can join, should they exhaust all current treatment options.

We¡¯re seeing some really amazing results, too. Patients who would¡¯ve lived maybe 4 to 6 months after being diagnosed with a melanoma brain metastasis before, for example, have a chance of living for years. And some are seeing complete responses. So, while we still have a lot more work to do to help our patients, having melanoma today is very different from having melanoma a decade ago.

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