Fighting Brain Cancer: Taking Out More Than Tumors
PHOENIX, AZ ( Ivanhoe Newswire) - Operating on what was once considered inoperable. A procedure for people with deadly brain tumors also removes a part of the brain.
"I didn't see myself being an older man. I didn't plan on 40," Erik Humphrey told Ivanhoe.
Erik Humphrey never thought he'd get this card. He was diagnosed with a grade three brain cancer and developed a tumor the size of two golf balls.
"I was waiting to die. All I knew is it was bad," Erik said.
Living with thisfor more than three years is rare, but neurosurgeon doctor Kris Smith of Barrow Neurological Institute recommended Erik try something that could give him more time called subpial resection. It focuses on functional divisions in the brain called the gyri.
"When a tumor occurs, it usually occurs on this type of Glioma, within one gyrus, "Dr. Smith said.
The aggressive technique removes not just the tumor, but the entire gyrus involved.
"My belief is that you have to be as aggressive as possible getting to that natural border. If a gyrus is already infiltrated and sacrificed just take the whole thing, don't leave any of it behind," Dr. Smith said/
Doctor Smith said the subpial approach and months of daily radiation, coupled with a year of treatment with a powerful new chemo drug called Temodar, can give people like Erik a better chance at a longer life.
It's been nine years, three times as long as Erik's best survival odds predicted. Although the brain surgery cost him some of the movement in his left arm and leg, to him it's a small price to pay for more time. Doctor Smith is one of the only doctors in the U.S. using the subpial resection approach to fight malignant brain tumors. He's currently teaching the technique to surgeons from around the world.
BACKGROUND: Glioma is a broad term of brain and spinal cord tumors that comes from glial cells. Glial cells are the main brain cells that can develop into cancer. The symptoms, prognosis, and treatment of a malignant glioma can vary depending on the person's age, the exact type of tumor, and the location of the tumor within the brain. These tumors tend to grow or infiltrate into the normal brain tissue, which makes surgical removal very difficult and even impossible for some patients. This makes the prognosis for many patients very dim. 42% of all brain tumors, even benign tumors, are gliomas, 77% of malignant brain tumors are gliomas. (Source: www.medscape.com, www.webmd.com).
SYMPTOMS: Symptoms of a glioma are similar to other malignant brain tumors and vary depending on the area of the brain affected. The most common symptom is headache -- affecting about half of all people with a brain tumor. Other symptoms can include seizures, memory loss, and physical weakness, loss of muscle control, visual symptoms, language problems, cognitive decline, and personality changes. These symptoms may change, according to which part of the brain is affected. Symptoms may worsen or change as the tumor continues to grow and destroys brain cells, compresses parts of the brain, and causes swelling in the brain and pressure in the skull. A person may be unaware that they have tumor as the symptoms can be somewhat deceiving. (Source: www.webmd.com).
CAUSES: The only known risk factor for malignant gliomas is prior radiation to the brain. Family history accounts for less than 5% of causes for developing these tumors. Some genetic disorders increase the risk of development of these tumors in children but rarely in adults. There are no lifestyle risk factors linked to malignant gliomas. This includes alcohol, cigarette smoking, or cell phone use.(Source:www.webmd.com).
NEW TREATMENT: Traditional treatments for glioma patients include surgical removal of the tumor, or chemo and radiation therapy. Unfortunately, gliomas can grow back very quickly so although treatments may initially appear to be working, once treatments are stopped the tumors can resurface. Now, an approach that has been common in other countries is also being used by one doctor in the United States. An alternative approach call subpial resection commonly used to treat seizures is also used to treat gliomas. The results attained from removal of the glioma have shown great success in some patients.
"My belief is that surgeons should make every attempt to remove these kinds of brain tumors all the way to their natural borders if possible. I believe you should go right to those edges and peel the tumor and the brain off of the pia and remove it to its boundaries," Dr. Kris Alan Smith, a Neurosurgeon at the Barrow Neurological Institute, said. "Even with this technique however, I recognize that there is a deep margin within the brain that will still harbor some infiltrative tumor cells. But with the most aggressive surgical removal possible, the adjunctive therapies, like radiation and chemotherapy, have a much higher chance of working because they're working on a far smaller number of cells." (Source: www.indiasurgerytour.com, www.mayoclinic.org, interview with Ivanhoe Broadcast News).
Doctor Kris Allen Smith, a Neurosurgeon at the Barrow Neurological Institute, talks about fighting brain cancer with an aggressive surgery.
Tell me about Eric, when he came to you what was he presented with?
Dr. Smith: He was a young man who presented with weakness and seizures that kept bothering him with his left arm. He felt tingling and numbness and had motor problems with poor coordination in his left arm. He had an MRI scan performed, which revealed a tumor. It was right next to the motor strip of the right hemisphere, which controls the left side of the body.
How big was the tumor? Was it in a particularly bad place?
Dr. Smith: It was about four centimeters, so about the size of two golf balls next to each other. It had what's called heterogeneous enhancement. This means when we use the contrast agent gadolinium for an MRI scan, some of the tumor would light up with the contrast, which is actually a bad sign. The tumor was in the region right in front of, or even involving the primary motor area of the brain. There are more favorable places to have brain tumors. Some of these more favorable locations are in the tips of the temporal lobes or the tips of the frontal lobes, where we think we can sometimes remove them completely with a lobectomy. In this case it was right next to the motor area, and many surgeons would just say that we shouldn't try to remove it at all but that it should just be treated with a biopsy followed by radiation.
What would be the prognosis of this tumor?
Dr. Smith: He ultimately was found out to have a grade three glioma (anaplastic oligoastrocytoma). His expected survival would be for only about three years at the most, with the average survival being about eighteen to twenty-four months.
With a tumor like that what would be the traditional decision to make?
Dr. Smith: Many centers would just recommend a stereotactic biopsy or a needle biopsy to make a diagnosis, and then make a further decision. I think most centers would treat this with radiation and chemotherapy and probably not try to do an aggressive resection. We utilized a newer technique at that time which was integrating the functional MRI scan with the image guidance system for our surgery. An image guided system for surgery utilizes a preoperative MRI scan. You register it to the patient's head after they are asleep in surgery. We have a map, it's kind of like a GPS system for the brain and it tells us exactly where we are in the brain within one or two millimeters.
What does the image guiding system do?
Dr. Smith: It's something we're very fortunate to have here. Most neurosurgical centers have these now, but did not at the time of Erik's surgery in 2003. Today other centers may only have one or two of them. We are lucky to have one in every one of our eleven neurosurgical operating rooms. What it means is that after the patient's asleep, their head is pinned in a fixation device to hold them still for the surgery, but then we register the outlines of their face and head so that the image guided system can be utilized. The MRI scan is registered to the computer and when I look over at the computer screen I'm holding a wand and I point to the part of their head that tells me exactly where their tumor is underneath their skull where we can't see. We can plan the incision to be right over the tumor and make the incision as small as possible but still centered directly over the tumor. I can look up at the screen and it tells me where I am in three different planes as well as the trajectory of where I'm aiming. When we are removing the tumor with the operative microscope, the focal point of where I am working is continually updated on the image guidance computer screen next to me. We went one step further in Erik's case and did a preoperative functional MRI scan which was also integrated into the image guidance system. This was one of the first times that this had ever been done A few days prior to his surgery, Erik went into an MRI scanner, with our neuropsychologist Dr. Leslie Baxter nearby. While he was in the magnet, she would have him do several motor tasks. By doing that, we can actually have that part of the brain light up. We could tell exactly where his tumor was in relation to the functional motor part of the brain.
What did that allow you to do for Eric?
Dr. Smith: It allowed me to recognize the margins of the tumor next to the functional part of his brain, and to be more aggressive than I would have been otherwise. It allowed me to tell him ahead of time what things he would likely experience after surgery, and what specific risks we were dealing with. We were able to talk about having an attempted complete resection of his tumor, which was usually thought of as impossible in this kind of tumor in this location. The type of tumor that he has is considered an infiltrative type of tumor. To remove the tumor completely you have to remove part of his brain, (infiltrated with tumor cells) permanently and that's the most difficult part of these kinds of tumors.
Was this a really extraordinary surgery?
Dr. Smith: It certainly was at the time. It is something that we now try to do just about every day here as far as these types of tumors are concerned, but unfortunately many of these tumors are in even worse locations than Erik's was and a radical resection is still not possible We're a specialized center to deal with these things, but when I hear these words and I hear myself talk to families and patients, I try to put myself in their position. It is a conversation no one ever wants to have. Hearing a doctor tell you that he has to permanently remove part of your brain and that you will risk losing part of your normal functions is a very scary thing.
What did you do to Eric?
Dr. Smith: We did a specialized technique that I was just becoming more confident with at that time, which is using the natural boundaries of the brain called the sulci as the borders of the tumor resection. The brain is full of hills and valleys called the gyri and the sulci Each gyrus is divided from the next one via a sulcus There's a double layer in each sulcus of what's called the pial margin separating the two adjacent gyri. The pia is the clear, thin membrane that holds the brain within itself that is kind of like cellophane wrapping. It's a microscopically thin layer that we're able to use as a boundary. So my belief is that surgeons should make every attempt to remove these kinds of brain tumors all the way to their natural borders if possible. I teach our residents not to leave part of the infiltrated brain behind unless it's removal would cause an unacceptable deficit for the patient. I try to take it out the tumor to the fullest extent possible. His case is one that I show in conferences because it's an example of when you use this technique, you really can get a complete removal, which isn't really thought of as being possible with this type of tumor. These infiltrative tumors are thought to just go off to where we really can't get all of them. I believe you should go right to those edges and peel the tumor and the brain off of the pia and remove it to its boundaries. Even with this technique however, I recognize that there is a deep margin within the brain that will still harbor some infiltrative tumor cells. But with the most aggressive surgical removal possible, the adjunctive therapies, like radiation and chemotherapy, have a much higher chance of working because they're working on a far smaller number of cells.
What happened after surgery?
Dr. Smith: After surgery we obtained the final diagnosis. We do a biopsy during surgery called a frozen section, and they told us it was glioma, but the grade was still unknown. A few days after surgery we found out that it really was a grade three tumor called an anaplastic oligoastrocytoma . With that, it was definitely decided that he needed both chemo and radiation therapy since it was a malignancy. He was treated with an oral form of chemotherapy called Temodar. Temodar was brand new at that time and it has since been proven to have good effectiveness for brain tumors like this one. It's been shown to be most effective when it's combined with radiation at the same time. It's kind of like kicking the cells and then hitting them when they're down with the radiation treatments. The tumors usually recur right along the edges of where we stopped removing them. If there are little infiltrative cells trying to crawl through the brain, which are multiplying and dividing, then the chemotherapy works against those dividing cells. The normal cells in the brain are not dividing anymore. We don't get any more neurons after we're about eighteen or twenty years old, so the ones that we do have we try to keep and protect. We can give radiation therapy around those neuronal cells without killing them or at least not harming them very much. He received that therapy of daily fractions of radiation for about six weeks.
What's his prognosis then?
Dr. Smith: It's excellent actually. We never think that we can cure these tumors. But now he's more than eight years out and his MRI scans are absolutely clean. It's essentially miraculous that he's still alive and with us with no signs of tumor and living a very healthy and active life with his family.
Could this tumor have been a death sentence for him?
Dr. Smith: Absolutely, in fact we really thought it was.
FOR MORE INFORMATION, PLEASE CONTACT:
Carmelle Malkovich Public Relations St. Joseph's Hospital and Medical Center Phoenix, AZ (602) 406-3319 Carmelle.email@example.com
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