Cancer Of The Brain

[captioned by automatic sync technologies] >> i work in salemhospital in salem, oregon. it's a nice 300 bed hospital. i've worked therefor almost 20 years. >> deborah kelley is anoperating room nurse. in early august, after along stressful shift at work, deborah developedan intense headache. >> being a nurse sometimesthings are out of our control and i ended up in a case that iended up working a double shift,

16 hours, and then i had acouple hours off and then i had to come back and workmy regular shift. so i had gotten overly fatigued and the next dayi had a migraine. i've had migraines before,it wasn't that big of a deal, but i thought, whyam i suffering? >> deborah called her doctorand made an appointment hoping to get a prescriptionfor a painkiller. after a brief exam, herdoctor, instead recommended

that deborah be schedulefor an mri. >> he said it was a change ofthe headache pattern and wanted to get the mri and i arguedwith him that it was overkill and i now owe him a threepound box of chocolates. he scheduled the mri and iwas very surprised to find that there was a tumor there. >> the mri had locatedan abnormal tissue growth within the brain. a tumor, which is alsoreferred to as a neoplasm,

is tissue composed of cellsthat grow in an abnormal way. typically, the growth isuncontrolled spreading into several differentareas of the brain. >> what the mri saidwas a low grade neoplasm in the inferior frontallobe and it's right above my speech center whichis called the broca's area. actually when dr. leetold me what it was, i never heard anythingbeyond brain and neoplasm and that was it.

i pretty well had myselfdead, buried, you know. >> within three weeks of the original doctorsappointment deborah was scheduled to meet witha local neurosurgeon who could more preciselyevaluate her symptoms and her brain scan. based on his advice, deborahwas referred to the university of washington medicalcenter's neuro-oncology center in seattle, washington.

>> so this is miss kelley, she'sa 52-year-old, right-handed, operating room nurse fromsalem who had two migraines and she hadn't had one in years so her doc thought sheshould get an mri scan. >> at the university ofwashington medical center, medical cases are presented atthe neuro-oncology tumor board. this multidisciplinaryteam includes neurologists, neurosurgeons, neuropathologists, and neuro radiologists, aswell as radiation oncologists,

brain tumor researchers,nurses, and social workers. the department of neurologicalsurgery at the university of washington is one of the largest academicneurosurgery programs in the nation. the department's clinicalfaculty includes internationally recognized experts in neurosurgicaldisorders and diseases. >> i think that thereare a number of things

that we can provide thatare unique to the university of washington or tothe university setting. first of all, there's the factthat we have a group of people who have a very limitedsub-specialty practice who don't do othertypes of things. and so we have multidisciplinaryteams like the tumor board for brain tumors where we havemembers, that's all they do, that's all i operate on,that's all dr. spence treats with chemotherapy, that'swhat dr. rockhill treats

with radiation therapy. >> well it's absolutelycritical when we're taking care of patients with braintumors of any kind really to have a team approach toboth the evaluation up front so when we first see a patientin clinic or have a referral, we have a whole set ofcolleagues who will be involved in the care of the patientfrom the beginning to the end. >> the overall philosophyof our group is that, i mean it's not surprising, it'spreservation of quality of life

through sometimes disordersthat are pretty scary and harrowing for patients. so that has to be ouroverriding point of view when we're making decisionsabout patient management, whether that's surgery orradiation or chemotherapy or simply supportive carewith pain medications and anti-seizure medications. >> the interdisciplinaryteam really just amazed me. the fact that you havea neuro pathologist.

oh my gosh! because that was one ofmy concerns was, i wanted, you know, a specialistto look at my slides and that's part of your team. and to me, that'sreally important to know that you've got the best people and they're all workingtogether. >> so these are the filmsthat you got down in oregon and we're going to start withthese films because they're kind

of the easiest onesto see, okay? these are the ones wherethey've sliced things like this, like splitting a log,looking inside the log. so you can see the area righthere is where the tumor is and below the tumorare the blood vessels that go to the brain. behind the tumor in theback here is the area that's important for movement. and the lower part of thatmovement area is important

for movement of your faceon the opposite sides. so, since this is on theleft side, it's important for movement of your right faceand it's also the area up here, somewhere near thistumor or even in this tumor is the areathat's important for language. >> i was impressedwith the amount of time that dr. silbergeld spentwith me, went over everything in depth, went over the mris,answered all my questions, even the ludicrous onesthat you know nurses have.

>> so you can seeit's roughly about 3, 3 1/2 centimeters in diameter. so i think this is a tumor thatprobably started in the brain, not a tumor that camefrom somewhere else and went to the brain. >> the difficult thingabout these types of tumors in general, tumors thatstart in the brain is that they grow by invasion. and so when i look at a scan,an mri scan or a ct scan

if someone has one of thesetumors, what i ask myself is, can i remove that piece of brainwithout causing them a problem? because the tumoris not separate. it's not like blowingup a balloon, it's like spreading tumorcells all through the brain. and because of the locationof hers, it's in a tough area, an area where maybewe can get a lot out, maybe we can't get a lot out. but i think given the situation

with we don't know howmuch we can get out, it becomes a really toughdecision for the patient. >> the options are to donothing and the good thing about that is you don't haveto think about doing something, the bad thing is that wedon't find out what it is and it keeps getting bigger. the second option is to doa biopsy and the good part about that is, we find outwhat it is, the bad part is that we leave it all behind.

so the amount we takeout is really tiny. the bad part of doinga biopsy other than leaving some behindis that the carries a risk and that risk is somewherekind of three or four percent of something bad happening. the third option is to do abigger operation with you awake for part of the operationto find where your importantfunction is, to find out where the movementarea is and the language area is

and then knowingwhere the tumor is with our entropic navigationsystem and by looking at this, kind of put those two maps ontop of each other and we see where the good stuff isand where the bad stuff is and where those twodon't overlap, that's how much weget to take out. >> my biggest concernat this point after hearing the three options, obviously i can'tleave it there,

is the stereotactic biopsywith the lower percent of complications versusthe larger surgery. and i mean, my thought isthat i just want this thing out of here, but iwant to be realistic. if this was your head,completely subjectively, which of the two procedureswould you choose and why? ultimately it was my decision, but i felt like withthe information that he had presented that thedecision was just a progression

from the conversation. it was very comfortablewhich is an amazing thing to think you know, sure, sign me up for a craniotomy,i just would love it. oh gosh. >> for brain tumors, surgery hasthree goals: obtain a diagnosis, decrease the pressure ofthe growing tumor mass within the skull, andremove as much of the tumor as can be done safely.

>> here are the dates, here'sdr. silbergeld's schedule. >> as the neurosurgerynurse coordinator, cynthia is an important link between the physiciansand the patient. she answers patientquestions, arranges pre and post operation schedules andserves as the family contact. >> i like the one-on-one, theplanning, helping the patient and their family plannot just for the surgery but for their life at home.

i think it's an importantpart of my job to be able to assess the person. some people don't need as muchinformation as other people do. they want to wait, theywant to do it in baby steps and deborah we coulddo scissor steps. it was just openand just flowing. >> i had two pages of questions. and after spending a few minuteswith cynthia, the list kind of just migrated down tomy purse because i thought,

she's answering everythingbefore i have the chance to even ask it, just like sheknew exactly what i needed to know. >> the removal of a brain tumorrequires identifying the areas of the brain essential tospeech and motor skills. to do this, neurosurgeonsat the university of washington medical center usea technique called functional brain mapping. through brain mappingtechniques,

the neurosurgeon can maximizetumor removal while minimizing damage to areas important tolanguage and motor functions. the medical center's brainmapping program is the largest and busiest program ofthis type in the northwest. >> are you deborah kelley? >> yes. >> hi, my name's tony bell andi'm the end technologist here and i'll be doing somepreoperative preparation with you today and what we'regoing do is a slide show

and preparation fortomorrow's surgery. >> okay. >> before language or motormapping can be performed during surgery, the patientis first schedule for an assessment oflanguage function. this baseline assessment of herpre-surgery ability to recognize and name objects will becompared to her ability to perform the same testduring the awake portion of the surgery.

>> i want you to moveforward to about 18 inches or so, right up to here. so this will be aboutthe distance that the slides willbe from you in the or. â  >> stove. >> this simple language testwill help dr. silbergeld avoid critical areas for speech as heattempts to remove the tumor. >> there are differentlanguage areas in the brain.

one that's important forusing or expressing language, one that's importantfor understanding or taking the language in. and it just so happens that bothof those areas can be tested by looking at objects and namingthe objects because you have to take it in, think about whatit is, and then say the name. >> fork. >> so that's the set of slidesyou're going to see tomorrow. >> if he's stimulating, you'llknow that he's doing stimulation

because after he stimulates,he'll tell me and dr. farrell and the group a number. he places little numbersand letters on the brain to help them identify locations. so if you make a mistake, orwhen he's stimulating the brain, he'll say a number afterwards. "11 anterior" forexample and that tells me that i should writethat number down here. and especially ifyou make a mistake,

we'll have this score sheetwith a number associated with the incorrect answer. so there's a number ofthings that can occur. you can have simply one slidethat you name incorrectly, you can have cessationof speech, or you can have perseverativespeech where you say the name, it's a barn, it's a barn, it'sa barn, it's a barn and you may in fact recognize thatyou're making the error, but don't let that bother you.

his job is to identify languageand that's how he does so, by interrupting that area. >> the way we stimulate thebrain is we have a little electrode which iscalled a bipolar electrode because current has to flowfrom one place to a ground and those are about5 millimeters apart so when we touch the brain, theonly part that sees the current, the reason it doesn't spreadthrough the rest of the brain which is a big conductor,it's really good

at conducting electricity because that's what it does allthe time, the current just flows between those twolittle ball electrodes which are 5 millimeters apart and we don't spread thecurrent outside of that area. >> a patient who qualifies for an awake surgeryis highly motivated, functionally competent, andable to remain cooperative and calm while they areawake during the surgery.

>> doing it as a localprocedure, i'm being awake, even though it's absolutelyterrifying is the best thing to do because you havea better prognosis if you don't loseyour functions. and it just made more sense, because i tried alldifferent angles to get around that awake thing. you know, isn't there anotherway that we could do this? but it wasn't goingto work that way.

>> you're all set. >> she had this realgrace about going in there and a really positive attitude and she obviously hadgotten herself to a place where she felt like she could be in the best place shewas going into it. >> language mappingrequires the patient to be awake during a specificportion of the surgery, however the patient isasleep under anesthesia

as the skull is openedand the brain exposed. when it's time towake the patient up, the general anesthesiais turned off and the patient awakensquickly and coherently. >> hey katie? >> yeah? >> it's time to wake her up. >> deborah has been insurgery for nearly two hours. the surgical team is now ready

to begin the most delicatepart of the operation. >> hey, deborah, hi it's katie. dr. domino and tony are here. we're all here. you're just waking up. >> once deborah is fully awake,dr. silbergeld will begin to electrically stimulatespecific portions of her brain usingthe bipolar electrode. the stimulation of the brain

with the electrodeis not painful since the cortexitself has no sensation. the mapping will beginwith stimulation to areas of the brain thatcontrol movement. >> hey, deb? you ready to go to work? >> yes, sir. >> so the first thing i'm goingto do is i'm going to say on. and then i'm going to say off.

and when i say off you tellme if you've felt anything or if anything moved okay? >> okay, i'm ready. >> here we go. on, off. >> face movement. >> stop? >> can you feel that deb? did you feel yourface pull there?

>> yeah. >> when we stimulatethe movement area, we cause movement. we evoke movements of theopposite side of the body. when we stimulate the sensoryarea people feel things, either tingling or somepeople say it feels like a blanket brushingagainst them. when we stimulate thearea that's important for language we do the opposite.

we turn that small area off. >> let's do a littlelanguage mapping. we need to put somenumbers on the brain because unfortunately thebrain doesn't come with labels, so we're going togive it some labels and this way we'll knowwhere we stimulated. >> the brain is complex and notwo brains are exactly alike. the areas of the brain thatcontrol speech and movement and touch are inspecific locations.

by using number plottingand electrical stimulation to map these areas,the surgeon is able to identify functioningregions of the brain in relation to the tumor cells. >> okay. let's roll. >> we're ready to go. >> what's this one deborah? >> fish. >> fish, good.

>> sofa, doll. >> twelve. >> pot, cell phone, tiger, foot. >> five. >> car. >> ten. >> door, uh, window. >> >> silence <<

>> four. >> when they make a mistake,we can tell right away. either they misname itor they can't name it or they can't getany words out at all. so we know that's an areathat's important that they need for language function. >> so two superior. >> two superior? >> what else?

>> thirteen. >> you hanging in there? >> uh-huh. >> good. >> now i have a littleslurring in her speech and whatever else,i didn't catch that? >> four. deborah,you're doing a great job. >> your hired. we'll do it again tomorrow.

>> no. >> deborah's really easybecause she's really calm, she knows what to expect. she woke up from her anesthetic and did a great job youknow naming the slides and participatingin the mapping. >> so, this is what wecall the central sulcus that separates sensationfrom movement so this is the movementarea, the sensory area.

this is her face movementarea down here, speech is here and here, and a littlebit here also. the tumor is outlined by thisthread here, right like that. so we're going to keep her namein while we start working here. >> knowing where the brain tumoris using our navigational system and using an ultra soundlike we look at a baby in a pregnant woman, usingour eyes under magnification, that helps us delineate theborders of the gross tumor or where the tumor is denselyinfiltrated into the brain.

deborah's tumor was locatednear movement and sensation and language, but other tumorscan be located near any function that we think of as beingattributable to the brain. when a pathologistlooks at a tumor like deborah's he sees brainwith tumor cells in it. so he doesn't see a solid tumor so we're literallyremoving a piece of brain that's beeninvaded by the tumor cells. >> and you can see ourtumor's still outlined

and when we startedtaking this out, this is how much resectionwe got of this whole tumor because she started havingsome problems with her talking. there's always some littleaspect in the background of disappointment whenwe could have done more. like in deborah's case, we saythat's the amount we can do. she's starting to havelanguage problems, we did all we can we're done. so sure i wish i could take outmore, but i'm not disappointed

in the sense that i think i didas much as i can that's good for the patient or that'ssafe for the patient. >> you're all finishedwith the surgery now. you did very, very well. >> hello. >> hi there. >> how are you guys doing? >> we're alright. better when we see you.

>> everything went fine. she's in the recovery room. she's doing fine. she does have just a littlebit of language trouble, kind of a little bit ofdysarthria in finding her words. >> while deborahwas in recovery, a patient service representativekept deborah's family updated on deborah's conditionand notified them when dr. silbergeld wason his way to tell them

about the outcomeof the surgery. >> about how longshould we anticipate that the languageis going to be-- ? >> well everyone's different. i mean, we'll just have to see. i mean her whole languagearea is full of tumor, which means that the swellingmay take longer to go away. as we started taking some outshe got just a little dysarthric so we had her say no ifs, ands,or buts, and she was starting

to say no ifs, ands, or-- kindof like that, kind of like if you have cottonstuck in your mouth. but her language whenshe went to sleep, she was naming the slidesfine which is a good sign. >> i felt like i justhad the best care. i felt i was neverlacking for anything. the biggest thing was theinvolvement with my family. my sister and my daughters; thenurses included them in my care. they're input was asked,

they really asked thefamily their perspective and it was good. >> thank you. >> okay, you're welcome. >> okay. i think we all as physicians acknowledgewe are limited. everyone's going to die,we're all on that path, that's who we are,we're all mortal, but did we do everything wecould to make everyone's life

as long as possible andas healthy as possible? and i think that'sreally the goal. >> you know, we'd like to think that there are clearcut answers in medicine. unfortunately it's not. a lot of times thereare shades of gray and sometimes getting differentperspectives allows you to sort out those shades of gray ofwhat may be the best treatment for that individual patient.

>> final radiationrecommendations will be pending pathology. >> the university of washingtonmedical center neuro-oncology tumor board receives patientcases from other physicians and medical facilitiesproviding a unique opportunity for a wide range of medicalcases to be reviewed. >> often times we will getcases referred to the university because of this comprehensivecare program than more physical problems

that require more extensiveevaluation work-up and either from a diagnostic standpointwith our expertise in radiology, neurology, and so forth. we have it all available here,so that people can get all that taken care of at once. and nowadays, since there areso many other treatment options, not just surgeryradiation and so forth, we can look into all theseoptions together in terms of treatment protocols,experimental protocols,

and standard care and seewhat other experts think of what the besttreatment plan is. >> we also have thegamma knife center which is stereotacticradiosurgery which has another tumor board, but the two tumor boardsactually share a lot of patients in common as well, sothey get reviewed not only at neuro-onc tumorboards sometimes, but also at gamma knife tumorboard if they're a candidate

for stereotactic radiosurgery. so it adds just yetanother level where cases are being reviewedand input is being solicited as to what's the best treatment. >> the tumor board isalso important as a forum for medical experts to sharetheir research methods as well as their experiencesin clinical practice. >> we're part of theuniversity of washington and fred hutch cancerresearch consortium

as a neuro-oncology affinitygroup and so our core group of basic scientists andclinical scientists are working on discovering newpathways to treat tumors. >> participating in the researchconsortium allows the university of washington medicalcenter to be a leader in implementing clinicaltrial results and in bringing newtreatment plans developed by medical facilitiesthroughout the nation to the pacific northwest.

>> we have severalnew discoveries in the laboratories associated with the neuro-oncologyaffinity group that are likely to translate in the near futureinto potential either theraput-- diagnostic or prognosticimportance or even therapeutic. >> go ahead and havea seat in there. >> deborah's doinggreat right now and so i think it'sreally a matter of getting her thetreatments that are best

for this time of tumor. >> this is dr. rockhill who'sgoing to be talking to you too. he's from our radiation team. >> deborah kelley hada low grade glioma. it was an oligodendrogliomagrade two and there's actuallyquite a bit of controversy as to the best way to managelow grade gliomas in terms of the role of radiationtherapy, whether it's up-front or delayed and whether or notthere's a role for chemotherapy.

so there's actually a needfor quite a bit of discussion about what are thepotential risks and benefits of radiationtherapy. >> this is a kind of tumor thattends to shorten people's lives, but people tend to live foryears and years with this and we have people who's beenaround a really long time and people who don't liveas long as we expect, but this isn't something that'slike a more malignant tumor like i'm sure you've seenoperated on down in salem.

>> and somebody that'shad a biopsy-only, grade two oligodendroglioma, we general recommend agimentradiation therapy to try to slow the growthof this tumor. >> question: uh-- ? >> some of her specificquestions were what are some of the impacts of treatmentwhether it's up-front or delayed, especiallywith radiation therapy. radiation is quiteaffective in brain tumors,

but it's not the complete answer and it also has some sideeffects and patients need to be able to balancethose side effects with the potential benefit. >> you may start tonotice some skin redness, even some hair loss,and there is a chance that that hair lossmay be permanent. the other side effect thatradiation causes is fatigue and unfortunately there's nota pill or a shot that will help

with that fatigue, it's justpart of going through treatment. you can also have worseningneurological signs and symptoms so you're speech problemcould come back, okay. your headaches could get worse. >> if i have-- see changes,um, are those always permanent, or is that just temporary? >> during treatment they're more than likely goingto be temporary. we do know that radiationcauses neurocognitive changes,

but it's multifactorial,it's not only the radiation, it's also the fact thatyou have a brain tumor and you've had surgery. okay? and while therewill be some changes, more than likely you'llbe able to continue to do what you want to do. >> but you may need tomake some adjustments. >> okay. and chemoduring radiation or-- ? >> well that gets back to theoriginal controversy, okay.

so, we know that radiation cancause neurocognitive changes. my opinion is that yes,those are something that we can deal with, butwith good 3d conformal therapy, that's less of an issue. however, not everybodyagrees with that and so some people have goneto up-front chemotherapy, in other words, justdoing chemotherapy now, and waiting until you haveprogression before they will do the radiation.

we have done the opposite and we've had relativelygood success with that. we know that as braintumors go, when you look at all brain tumors, notonly oligodendroglioma, but all types, thebiggest impact has been radiation therapy. so our standard here has beenradiation and then at the time of progression toconsider chemotherapy. >> okay. sounds good.

>> great. >> i feel better. i prepared myself ahead oftime that all i was going to do was find out what it was. pathology was alreadydetermined a long time ago and i feel encouraged out ofall the tumors i could have. we can work with this,you know, we'll go on. >> alright.