Brain Cancer Treatment in Israel

Central nervous system (CNS) tumors are a heterogeneous group of neoplasms of the brain and spinal cord, including primary gliomas, meningiomas, ependymomas, schwannomas, CNS lymphomas, as well as secondary metastatic lesions from lung cancer, breast cancer, melanoma, and renal cell carcinoma. The Ichilov (Sourasky) Medical Center in Tel Aviv accepts patients with newly diagnosed tumors, recurrences, and refractory forms, including after surgeries and radiation therapy performed in other countries. The neurosurgery department at Sourasky works in conjunction with the neuro-oncology service, molecular pathology laboratory, stereotactic radiosurgery center, and pediatric neurosurgery. Complete diagnostics with molecular profiling of the tumor takes 5–8 working days, after which a multidisciplinary council formulates an individual plan — from resection under neuronavigation and awake craniotomy to Gamma Knife radiosurgery, proton therapy, the Stupp protocol with temozolomide, and the TTFields method (Optune). The article discusses which subtypes of CNS tumors are treated at Ichilov, how diagnostics and therapy are structured, which doctors lead the direction, and approximately how much the treatment program costs for an international patient.

Types of CNS Tumors and Clinical Picture

The WHO classification of 2021 divides CNS tumors into primary, arising from nerve tissue or its membranes, and secondary — metastatic lesions from other organs. Primary tumors account for about 6–8 cases per 100,000 population per year, while brain metastases occur approximately 10 times more frequently; modern systemic oncology therapy regimens extend patients' lives, leading to an increase in the number of detected secondary lesions.

Gliomas are the largest group of primary tumors, arising from glial cells. Diffuse gliomas in adults, according to the 2021 classification, are subdivided by IDH mutation status: IDH-mutant astrocytomas (Grade 2–4) and oligodendrogliomas (must be IDH-mutant with co-deletion 1p/19q), as well as IDH-wildtype glioblastomas (Grade 4), the most aggressive variant with a median survival of 14–18 months on standard therapy. In children, distinct molecularly defined types are identified — diffuse H3 K27-altered glioma of the midline, diffuse H3 G34-mutant hemispheric glioma.

Meningiomas arise from arachnoid cells of the meninges, accounting for about one-third of all primary CNS tumors, more often Grade 1 (benign, slow-growing), less frequently Grade 2 (atypical) and Grade 3 (anaplastic). Clinically, they manifest focal symptoms, epileptic seizures, and signs of intracranial hypertension — depending on localization. Many meningiomas are discovered incidentally during MRI for other reasons.

Ependymomas develop from cells lining the brain ventricles and the central canal of the spinal cord. In children, posterior fossa ependymomas require a special surgical approach and evaluation of molecular subgroups (PFA, PFB, ZFTA-fusion), which determine prognosis and the need for radiation therapy.

Metastatic lesions develop in 10–30% of cancer patients, most often in lung cancer (non-small cell and small cell), breast cancer, melanoma, colorectal cancer, and renal cell carcinoma. The clinical picture depends on the number, size, and localization of the lesions: headache, epileptic seizures, paresis, speech and cognitive disorders, symptoms of increased intracranial pressure. A separate challenge is carcinomatous meningitis, which requires intrathecal therapy.

Diagnostics at Ichilov (Sourasky)

The diagnostic algorithm at Ichilov is designed to obtain a complete tumor profile — topography, histological type, and molecular profile — necessary for prescribing targeted or immunotherapy and planning neurosurgical intervention within 5–8 working days. The primary stage always begins with an in-person examination by a neuro-oncologist and neurosurgeon, assessment of neurological status, and review of the provided images and slides.

Brain MRI with contrast enhancement at 3 Tesla is the basic imaging method. The standard protocol includes T1, T2, FLAIR, SWI, DWI/ADC, and post-contrast T1 series with gadolinium contrast. For surgical planning, functional MRI (fMRI) is additionally performed — mapping motor, speech, and visual areas in tumors located in eloquent regions, and tractography (DTI) — reconstruction of the corticospinal, arcuate, and optic tracts. This data is uploaded into the neuronavigation system and used during the operation.

MRS allows for non-invasive assessment of the tumor's metabolic profile: the ratio of choline, creatine, and N-acetylaspartate, presence of lactate and lipids. In IDH-mutant gliomas, it is possible to detect a peak of 2-hydroxyglutarate — a characteristic oncometabolite, which helps to suggest the genetic subtype before biopsy.

MR perfusion (DSC, ASL) reflects tumor blood volume and helps distinguish recurrence from radionecrosis after radiation therapy, while PET-CT or PET-MRI with 18F-FET, 11C-methionine, or 18F-FDG is used when recurrence is suspected, in ambiguous MRI data, and when searching for a primary lesion in a patient with an isolated metastasis.

Stereotactic biopsy under neuronavigation is performed in cases where open resection is impossible or impractical — in tumors of deep structures, the brainstem, multiple lesions, or suspected primary CNS lymphoma. The obtained material is sent for morphological examination and complete molecular profiling.

Molecular diagnostics at Sourasky include determination of IDH1/IDH2 mutation (immunohistochemically on R132H and sequencing for rare variants), MGMT promoter methylation (predictor of response to temozolomide in glioblastoma), 1p/19q co-deletion (mandatory criterion for oligodendroglioma), EGFR amplification and EGFRvIII status, TERT promoter mutation, H3 K27M and H3 G34 in children and young adults, BRAF V600E in pilocytic astrocytoma and ganglioglioma, NTRK fusion in infants. The NGS panel covers 50–500 genes depending on the clinical scenario. The complete result is ready within 7–10 working days.

Treatment Methods

Ichilov employs the full arsenal of modern neuro-oncology: surgical resection under neuronavigation and intraoperative visualization, stereotactic radiosurgery, conformal radiation therapy, proton therapy as indicated, standard and targeted drug regimens, the TTFields method, as well as clinical trials. The strategy is determined by a multidisciplinary council.

Surgical resection under neuronavigation. The use of 3D MRI and CT images integrated into the neuronavigation system (Brainlab, Medtronic StealthStation) allows for pre-planning of craniotomy, access trajectory, and resection boundaries with millimeter accuracy. Functional data from fMRI and DTI are transferred to the surgical plan to avoid damage to eloquent areas.

Intraoperative MRI (iMRI). Allows for assessing the completeness of resection during the operation, identifying remaining tumor fragments, and continuing removal in the same operating room without transporting the patient. This is especially useful in low-grade gliomas and pituitary tumors, where the radicality of the intervention directly affects prognosis.

5-ALA fluorescence. The patient takes 5-aminolevulinic acid a few hours before surgery, which selectively accumulates in high-grade glioma tumor cells and glows pink under a fluorescent microscope with a 400 nm filter. This method increases the rate of complete resection of the contrast-enhancing part of glioblastoma from approximately 36% to 65% according to the ALA-Glioma study, which correlates with increased progression-free survival.

Awake craniotomy. Used for tumors in the motor cortex, speech centers (Broca's and Wernicke's areas), and the insula. The patient is under controlled sedation with local scalp anesthesia; during resection, they are awakened, and a neuropsychologist with a speech therapist tests speech, counting, object naming, and movements in real time. Electrical stimulation of the cortex and subcortical tracts allows for mapping functionally significant areas and stopping resection just millimeters before damage.

Transsphenoidal endoscopic removal of pituitary tumors and skull base tumors is performed through the nasal passages, without incisions on the head. For craniopharyngiomas and skull base meningiomas, extended endoscopic approaches are used.

Stereotactic radiosurgery. Gamma Knife Icon allows for delivering an ablative dose to small (usually up to 3 cm) lesions with millimeter precision in 1–5 sessions with minimal dose to surrounding tissue. Indications include solitary and oligometastatic lesions, vestibular schwannomas, small meningiomas, arteriovenous malformations, and residual tumors after subtotal resection. IMRT and VMAT on a linear accelerator are used for fractionated radiation therapy in high-grade gliomas, glioblastomas, and for irradiating the tumor bed after surgery.

Proton therapy is discussed for children, young adults with basal meningiomas, chordomas, and skull base chondrosarcomas, as well as for re-irradiation, where it is important to minimize the dose to healthy tissue due to the Bragg peak effect. In the absence of a proton facility at Sourasky, routing is used to partner centers in Israel and Europe.

Drug therapy — Stupp protocol. The standard first-line treatment for glioblastoma includes concurrent chemoradiotherapy with daily temozolomide at a dose of 75 mg/m² alongside 60 Gy over 30 fractions, followed by 6 cycles of adjuvant monotherapy with temozolomide. MGMT promoter methylation doubles the median survival on this regimen. In elderly patients with MGMT-methylated tumors, hypofractionated radiation therapy (40 Gy over 15 fractions) is used in combination with temozolomide.

Targeted therapy based on molecular profile. In IDH-mutant low-grade gliomas, vorasidenib — an oral inhibitor of mutant IDH1/2 — has shown significant improvement in progression-free survival in the INDIGO study. In BRAF V600E-positive gliomas, a combination of dabrafenib + trametinib is used. In NTRK fusion-positive tumors — larotrectinib or entrectinib. In MGMT-unmethylated glioblastomas and recurrences, trials with bevacizumab and regorafenib are actively considered.

Treatment of metastatic lesions. For solitary and oligometastatic lesions, stereotactic radiosurgery is preferred; for multiple lesions (usually more than 10), whole brain radiation therapy (WBRT) is used, if possible with hippocampal-sparing planning and memantine to reduce cognitive loss. Systemic therapy is tailored according to the histology of the primary tumor: EGFR and ALK inhibitors for NSCLC, CDK4/6 and HER2 inhibitors for breast cancer, PD-1/PD-L1 checkpoint inhibitors (pembrolizumab, nivolumab) and BRAF/MEK for melanoma. Many modern targeted drugs penetrate the blood-brain barrier and show responses in intracranial lesions.

TTFields (Optune). This method of variable electric fields at medium frequency (200 kHz), delivered through 4 arrays of electrodes on the shaved scalp, disrupts mitosis in tumor cells. It is FDA-approved as a component of therapy for newly diagnosed glioblastoma after the chemoradiation phase in combination with temozolomide. The EF-14 study showed an increase in median overall survival from 16 to 20.9 months and a 5-year survival rate from 5% to 13% with the use of TTFields for at least 18 hours a day. The device is individually adjusted according to MRI maps.

Clinical trials. Ichilov participates in international protocols for glioblastoma, diffuse midline gliomas in children, high-risk meningiomas, and metastases, including trials with dendritic cell vaccines, CAR-T against EGFRvIII, antibody conjugates, new IDH inhibitors, and targeted drugs for rare molecular alterations. The possibility of including a patient is assessed individually.

Treatment Program — Stages

Stage 1 — Remote Consultation. A Russian-speaking coordinator requests medical records, MRI discs, slides, and blocks from previous biopsies. The neuro-oncologist and neurosurgeon prepare a preliminary conclusion with an estimated route usually within 48 hours and assess the feasibility of arrival.

Stage 2 — Arrival and Diagnostics. An examination is conducted within the first 3–5 working days, and if necessary, a repeat 3T MRI with an extended protocol (fMRI, DTI, spectroscopy, perfusion), PET as indicated, and stereotactic biopsy. The material is sent for review in the pathology laboratory and for molecular profiling.

Stage 3 — Council. A neurosurgeon, neuro-oncologist, radiation therapist, pathologist, molecular diagnostician, and if necessary, a pediatric neurosurgeon and pediatric oncologist discuss the strategy and prepare a written plan with alternatives. The plan is reviewed with the patient and their family with a medical translator.

Stage 4 — Active Therapy. Resection or biopsy, radiation phase, drug therapy — depending on the diagnosis. Hospitalization for neurosurgical patients usually lasts 5–10 days, longer in complicated cases. The chemoradiation phase for glioblastoma takes 6 weeks, and adjuvant temozolomide with TTFields lasts from 6 months.

Stage 5 — Monitoring. Control MRI is performed 4–6 weeks after surgery and then every 2–3 months for the first 2 years. Upon returning home, telemonitoring with image transmission and teleconsultation is possible, and in case of suspected recurrence, an unscheduled visit for radiosurgery or change of regimen may be required.

Prices and Costs

The final estimate depends on the histological type, volume of molecular diagnostics, surgical tactics, and duration of radiation and drug phases. Estimated ranges for international patients in 2026:

• In-person consultation with a neurosurgeon or neuro-oncologist with review of provided images and slides — 550–800 USD.
• 3T MRI with extended protocol (T1, T2, FLAIR, DWI, contrast, fMRI, DTI, spectroscopy, perfusion) — 1,200–2,500 USD.
• PET-CT or PET-MRI with amino acid tracers — 2,200–3,500 USD.
• Stereotactic biopsy under neuronavigation with histology and NGS panel — 12,000–20,000 USD.
• Open tumor resection under neuronavigation with intraoperative neuromonitoring — 30,000–55,000 USD depending on localization and complexity.
• Awake craniotomy with cortical mapping — 40,000–65,000 USD.
• Transsphenoidal endoscopic removal of pituitary adenoma — 28,000–45,000 USD.
• Stereotactic radiosurgery (Gamma Knife) — 18,000–28,000 USD for one session on one or several lesions.
• IMRT/VMAT course (30 fractions) for glioma — 22,000–35,000 USD.
• Proton therapy — from 55,000 to 120,000 USD per course, at partner centers.
• Temozolomide for the course (chemoradiation phase + 6 adjuvant cycles) — 8,000–15,000 USD depending on body surface area.
• Rental and maintenance of the Optune system (TTFields) — about 15,000–20,000 USD per month; usually arranged through the manufacturer.

The exact estimate is formed after the diagnostic phase. Payment is staged, and all invoices are issued in USD.

Leading Doctors in the Field

Professor Tzvi Ram — head of the neurosurgery department at Sourasky, one of the most renowned Israeli specialists in brain tumor surgery. He is proficient in all modern techniques, including awake craniotomy with intraoperative neuromonitoring, resection under 5-ALA fluorescence control, and endoscopic approaches to the skull base. He actively participates in international clinical trials for glioblastoma therapy, including those involving TTFields.

Dr. Felix Bukshtein — leading neuro-oncologist at Ichilov, specialist in drug treatment of CNS tumors in adults, co-author of treatment protocols for gliomas and primary CNS lymphomas. He manages patients on the Stupp protocol, selects adjuvant regimens, oversees targeted therapy based on molecular markers, and inclusion in clinical trials. He works with Russian-speaking and English-speaking patients.

Professor Shlomo Konstantini — head of the pediatric neurosurgery department at Ichilov, one of the leading specialists in the world for CNS tumors in children, including posterior fossa ependymomas, diffuse midline gliomas, medulloblastomas, and craniopharyngiomas. He is the author of numerous publications on endoscopic neurosurgery and surgery for complex posterior fossa masses in young children.

FAQ

How urgently should one arrive for a newly diagnosed brain tumor?

In the case of a symptomatic tumor with significant mass effect, edema, and signs of intracranial hypertension, urgent hospitalization in the country of residence is indicated for stabilization with dexamethasone and anticonvulsants. After that, 1–2 weeks are reasonable for organizing the arrival: during this time, Sourasky can review the images remotely and prepare a plan. For an incidentally found asymptomatic tumor, planning may take longer without compromising prognosis.

Is it possible to get a second opinion without traveling to Tel Aviv?

Yes. MRI discs, slides, and biopsy blocks, if a previous operation or biopsy was performed, as well as medical records can be sent by courier. Within 7–10 working days, you will receive a written expert opinion from a neurosurgeon and neuro-oncologist and an estimated cost for a potential visit.

How important is molecular profiling of the tumor?

It is critically important. Since 2021, the WHO classification is based on molecular markers: IDH status, 1p/19q co-deletion, MGMT methylation, H3 K27M, and other mutations directly determine prognosis and therapy selection. Without this data, it is impossible to correctly prescribe temozolomide, vorasidenib, dabrafenib, or plan TTFields. At Sourasky, the complete profile is prepared within 7–10 working days.

What is awake craniotomy and is this operation dangerous?

Awake craniotomy is tumor resection on a conscious patient. The brain has no pain receptors; pain arises only from the incision of the skin and periosteum, which are locally anesthetized. Awakening is necessary to test speech and movements in real time during removal. This is a standard and well-tolerated technique in experienced centers, reducing the risk of neurological deficits after surgery for tumors in motor and speech areas.

What does TTFields provide and in what cases is it applicable?

TTFields (Optune) is a portable device that generates variable electric fields through electrodes on the scalp. It is approved for newly diagnosed glioblastoma after the chemoradiation phase as an adjunct to temozolomide and for recurrent glioblastoma. According to the EF-14 study, using TTFields for at least 18 hours a day increases median survival by approximately 5 months.

What to do with multiple brain metastases — should the whole brain be irradiated?

No. The modern tactic is to perform stereotactic radiosurgery on each lesion whenever possible, which better preserves cognitive functions than WBRT. In cases of multiple small lesions or carcinomatous meningitis, whole brain radiation with hippocampal-sparing planning and memantine is still applied. Concurrently, systemic therapy is tailored to the primary tumor — many targeted drugs and immunotherapy today show intracranial responses.

How does Ichilov treat children with CNS tumors?

The pediatric neuro-oncology program at Ichilov is led by Professor Shlomo Konstantini in collaboration with pediatric oncologists and radiation therapists. Techniques include neuronavigation, intraoperative MRI, endoscopy for ependymomas and medulloblastomas of the posterior fossa, proton therapy as indicated, and risk-adapted chemotherapy protocols from international groups SIOP, HIT, and COG. Parents remain with the child at all stages.

Is participation in a clinical trial possible?

Yes, if your case meets the criteria of an active protocol. Ichilov participates in international trials for glioblastoma, IDH-mutant gliomas, high-risk meningiomas, and tumors with rare molecular targets. Some protocols cover the cost of the investigational drug.

How to Obtain a Treatment Program

To start, submit a request through the form on this page or contact a coordinator via messenger. Attach the latest MRI on a disc or in the cloud, medical records, and if a biopsy or operation was performed, the histology report and, if possible, slides and blocks. Within 24–48 hours, the neuro-oncologist and neurosurgeon at Ichilov will provide a preliminary conclusion and plan. You will then receive an estimate for diagnostics and the first treatment block, an invitation to apply for a visa, a hotel reservation near the Sourasky building, and transfer. Treatment of CNS tumors at Ichilov (Sourasky, Tel Aviv) provides access to molecular diagnostics, modern neurosurgery, stereotactic radiosurgery, and international clinical protocols all within one hospital complex.