By Consultant Neuro Surgeon Dr. V. Balasubramaniam
Even today the diagnosis “Brain Tumor” sends a chill down the spine of the hearers and is often equated with a sentence of death. While a certain degree of fear is understandable (as it is for every illness) sheer panic is certainly not justified today. But there is a reason why is this so. For this it is necessary to glimpse briefly the history of management of brain tumors.
Queen of all specialities:
Neurosurgery which deals with brain tumor is the youngest of super specialities and is considered as the “Queen” of all specialities (atleast by the neurosurgeons). Until the end of the 19th century the there was no proper management of brain tumors. There were a few brilliant surgeons who made sorties into neurosurgery and removed successfully some brain tumors.
But then the overall management was neither systematic nor consistently successful. From the beginning of the 20th century thanks to the efforts of certain pioneers (like Harvery Cushing, Walter E Dandy and others) neuro surgery started to grow in full earnest and by the end of the 20th century it had come to occupy a high place. In this development, many ancillary inventions and discoveries helped neurosurgery.
In the early decades of neurosurgery the results of surgery for brain tumors was so bad that a pioneer neurologist said “He who cares for patients suffering from brain-tumor must bring to his problem much thought and stout action. There is also the need for a formidable optimism for the dice of the gods are loaded”. But now the situation is far from bleak.
What makes neuro surgery interesting, yet different?
There are some unique characteristics of the brain that make neurosurgery not only interesting but very different from other general surgical procedures. It would be interesting to take a look at some of them.
- The brain structure is so compact that no area however small can be ignored as superfluous or replaceable. For example, if a part of the liver or stomach is rendered functionless by diseases or removed by surgery, still the person can carry on without any significant disability. But in the brain even a structure as small as pea is vital. For example, the pituitary gland is one such. Such being the situation the neurosurgeons have to have a thorough knowledge of the microscopic anatomy (all surgeons today have to be like this) and proceed with surgery to effect cure with minimal neurological defect.
- The second, perhaps most important difference, is that the brain being the crest jewel of creation is kept in a bony cage (as we keep our jewels in a locker). While this confers safety, at the same time it sets up a limit to which anything inside in the brain can expand. A tumor which grows inside the brain (and so inside the skull) will press on the brain tissue quite soon. So even a simple tumor can kill if located in an important niche. In the rest of the body, tumors can grow unrestricted to a huge size and often we read in newspapers, reports of surgery on giant tumors removed from the abdomen or chest. This cannot take place in the brain.
- The third is the capacity of the brain cell to regrow and repair a damaged area. Till recently it was believed that regrowth (as happens in other areas) does not take place at all. But now it is being learnt that regrowth does happen through not so luxuriously as in other parts.
These are the main factors that make the brain a unique organ, and the neurosurgery a difficult speciality.
Brain tumors are common and as common as tumors of other parts of body. The mistaken notion that brain tumors are rare arose from the fact that they were not detected. There is a saying in medicine that “the incidence of any disease is proportional to the awareness”. Brain tumors occur at all ages. They can be simple non-malignant tumors or may be malignant But as indicated already though benign tumors may be considered less ‘risky’ they can be as serious in the brain where space is limited.
It had been said earlier that there is a compactness of function in the brain. This was pointed out there as a disadvantage. But it is a blessing in disguise for one can diagnose brain disorders and pinpoint (or what is called localize) the site of disease with great accuracy. Till the 20-30’s of last century, examination by the doctor and an ordinary x-ray of the skull were the ways in which a brain tumor could be localized. At about 1925 the electro encephalograph (similar to the more well known electro cardiograph) was introduced. This was useful to a very limited extent.
Then came air studies and later what is called angiography. In the former air is injected into the brain; in the latter a dye is injected and the blood vessels studied. These were the available diagnostic tools. Along with this, the increase in skill, the greater familiarity with surgical procedures led to a situation wherein brain tumors could tackled successfully in 70 – 75% of cases. In 1972 a big upheaval took place.
This was the discovery of the computerized axial tomography (called a CAT scan or CT scan). To say that this revolutionised diagnosis of neurological condition is but a small tribute. The two discoverers of this shared the Nobel prize. This was followed by magnetic resonance imaging. (MRI) Based a very different concept. This gave an accuracy of 99%, Can we ask for more? We did not.
How is brain tumor diagnosed?
The diagnosis of a brain tumor is easy if its occurrence is kept in mind (remember incidence is equal to awareness). Unfortunately in the earlier days when people and the doctors thought (and thought wrongly) that brain tumors are rare the diagnosis was delayed to the point when only Divine intervention (death) could help the patient.
Just what are the symptoms that would make the patient go to the doctor and which would make the doctor suspect a tumor?
Any brain tumor produces symptoms (which the patient has e.g. headache) and signs (like paralysis) arising out of the location of the tumor. Except for a small percentage there are no symptoms and signs characteristic of the nature of the tumor. The exception is tumors of the pituitary. This produces various unique effects due to disturbances of hormone function like excessive body growth.
When a tumor grows it presses on the brain, stretches the coverings of the brain and diminishes the blood supply by pressure on blood vessels. Often the first symptom is headache. This may be followed by vomiting in later stages. Later depending on the actual location of the tumor specific symptoms would appear.
Thus a tumor arising in the area concerned with movement might either produce fits or paralysis. This will progress at various rates. When the tumour becomes big enough there is rise in the pressure inside the skull. This rise in pressure is felt by the nerves to the eye.
These nerves swell and if the pressure is very high the nerves die and vision is lost. Loss of vision in most of these tumours is thus a sign of advanced disease. In the early days of neurosurgery most patients with benign tumours came with blindness and even after successful surgery of the tumours the vision did not come back. Fits may occur due to brain tumors. They have to be differentiated from the well-known idiopathic epilepsy.
When should a patient see a doctor?
If headache is a sign of brain tumor does it mean that every one with headache must see a neurosurgeon? Certainly not. If this headache is persistent, unusual or does not respond to ‘ordinary’ medicines then the doctor must ‘think’ the possibilities of the headache arising from other causes. In other words the onus of deciding when to investigate a patient and when not to do anything further is entirely on the doctor.
In the earlier days of neurosurgery the surgeon proceeded with the tests only when the evidence was strong, because these investigations introduced something into the body. They are known as invasive investigations. But today the various scanning techniques are not only accurate but are non invasive. Hence if the suspicion is high these tests can be ordered and diagnosis established.
When a brain tumor is diagnosed, the pronouncement of the diagnosis will be devastating to the morale of the patient and the relatives. But it need not be so. The situation is not always so bad.
Pic courtesy: newcastleuniversity
Today there are many options available for the management of a patient with a brain tumor. Only the general principles can be discussed. The available alternatives are
- Immune therapy etc
Surgery: The general opinion among neurosurgeons is that surgical removal of a tumor still offers the best hope of a cure. But as indicated already complete removal of a tumor cannot be done in all cases. If the tumors arise from the speech area then a ‘blind’ total removal will leave the patient without speech.
So neurosurgeons are resorting to newer techniques to identify important areas by a method called functional MRI. More than this even as the operation is being done MRI is performed to find out any tumor that is left behind. Sometimes surgical removal can only be partial for technical reasons. Then we go to next
Radiation: Radiation is employed either in place of surgery or in addition to surgery. Actually for some tumors only radiotherapy is employed Immuno therapy, chemotherapy etc, are still to prove their total merit. Now a new method of giving radiation by stereotactic method has been introduced. (called bloodless ‘surgery’)
What about the results?
The outlook for a benign tumor is almost rosy expect in certain special conditions. The only catch here that is the tumor must be diagnosed early. Then the results would be good.
For malignant tumors the rate of success depends on age, the nature of malignancy and the method of treatment. In some cases a good life can be assured for a variable time. In some, (it must be accepted) it is not possible.
The aim of this piece is to indicate that brain tumors are curable under certain conditions. The most important being the awareness among doctors and patients.
Pic courtesy: independent.co.uk