Transcription:
Understanding Brain Tumors

Sean: Something that most people in the area don't realize is that Riverside hospital offers a wide array of services and specialties that may not impact them until they actually do And one very important area of that is spine care and brain care as well. So brain injuries and spine injuries. So today we're going to talk with Dr. Zakaria about brain tumors

I'm Sean. O'Connor. I'm a marketing communication specialist here at Riverside, and I'm joined by Dr. Jehad Zakaria, who is a neuro surgery consultant here at Riverside. How are you doing today, doctor?

Jehad Zakaria, MD: Thanks, Sean. Yeah I'm doing good. Thank you. It's a good day outside. And the Pronounciation at any was very good Jehad Zakaria. Sometimes you will say the cry that's also, okay. It's never an issue.

Sean: I always like to phonetically spell it out and check ahead of time to make sure that, Somebody with a unique spelling, Sean I've been called, Seen, I've been called Sean all my life. So I always try to make sure I get everybody's name as correct as I possibly can. So, you're one of, two neurosurgeons we have here at Riverside. Take us through your background as a neurosurgeon where did you go to school?

Jehad Zakaria, MD: Yeah. So I, you know, I'm 34 years old. And believe it or not, it takes just about 14 or 15 years of training to do neurosurgery. So I've almost Exactly spent half my life getting ready to do this and I grew up in Palestine. I've been in the states in multiple different areas, mostly the Midwest Wisconsin for about eight years before I came down to Chicago, I did my residency at Loyola, in the west suburbs of Chicago neurosurgery residency. Before that I did my medical school and undergrad at the university of Wisconsin. Madison. Yeah.

Sean: Growing up. Did you ever intend to be a neurosurgeon?

Jehad Zakaria, MD: It's an interesting question. I didn't even know what a neurosurgeon is or was really, I didn't understand the concept of it. I just never really came across you know, I knew patients would have stroke. A couple of my, one uncle had, and then some neighbors had strokes and things like that. And I never really knew that there's anything that can be done for the, so, I kind of wanted to be a doctor early on, but then later, once I started learning more about the. The possibilities and the different medical specialties. as soon as I knew there was some something called the neurosurgeon or somebody that actually operates in the brain, You know, was completely Intrigued. And then certainly pursued that yet.

Sean: That's excellent. So, when we talk about brains, one of the many things that can affect our brains are, brain tumors. So what really is a brain tumor at its core?

Jehad Zakaria, MD: Yeah. So word itself, tumor just means a mass, right? Like it's or a growth or swelling or something like that. Now a brain tumor. could be many different things. The vast, not necessarily the vast majority, but a good number of them are actually benign things and don't need anything. Except just saying hi to a neurosurgeon once a year or something like that. So, when we break them down, just kind of by what's malignant and what's a benign. Benign brain tumors. The most frequent, the most common one is called a meningioma.

And it's just a simple, a tumor that grows out of the covering of the brain. And it's actually typically on the surface of the brain. Sometimes it's deep in the brain, but it's on the surface and then it kinda, it grows over time. It grows very slowly. And in many cases, it can start pushing on the brain and may require a surgical intervention. So that's for benign things. There are multiple different other low grade or benign tumors, like, astrocytomas, apendamoma sub apendamomas, choroid plexus papillomas, chorid plexus carcinomas. These are malignant. There are different cysts in the brain that can cause problems.

All of these are more or less classified in the benign tumor category. The pineal region, pineal region by the pineal gland, pineal region tumors, or a cyst things like that. So that's one. And then the other category is malignant things. Now, most common of these is something called a metastasis. So, you know, somebody that has known lung cancer or melanoma, or prostate cancer or something like that, or a thyroid cancer or breast cancer for women, not uncommon. It can go to the brain and they already know for years typically.

That they already have that kind of malignancy. And then it goes to the brain and they may, this may be discovered incidentally, you know, if the say had a trauma or had a fall or had something like that, then they got an image of the brain and maybe discovered a way where there is a purpose, approach to try to screen out in a patient, say a small cell lung cancer, all of these patients get cranial imaging to rule out metasticies there. So metastatic disease is another rather common form of brain tumor. And that's dealt with slightly differently.

Sean: So, what are some early symptoms or signs that an individual might have a brain tumor?

Jehad Zakaria, MD: Vast majority of the time, nothing really. Believe it or not. So for benign tumors, because benign tends to grow really slowly, and the brain is. That's kind of smart and then, we are, or that the tumor is, it's certainly adapts with the tumor as it grows. So if I'm an angioma is growing over a period of say five to 10 years. You may never ever know that it's there and the brain is adapting to it over that entire length of time. And sometimes patients may develop a subtle headache. Sometimes it's nothing.

And they may have an image, like I said, for some other reason. And then it's discovered. Now, if you follow what we call the national history where you'll follow these things, a lot of them tend to grow over time. And when they do, it may reach the maximum of the compensation mechanism with the brain. So that's why you see patients you know with the five centimeter, six centimeter that's about two inches. That's quite a large spot in the brain. And they only have a mild headache. And they're kind of amazed when you tell him that, they have a large brain tumor. It's because the brain is able to compensate over a long period of time. So that's one.

For folks with metastatic disease that goes to the brain, sometimes the lesion or the brain spot or the tumor that met the cancer that has gone from elsewhere to the brain is actually the first presentation of a problem. So what that means is that. The patient's doing Perfect as they would be in their fifties, sixties, or seventies or whatever it may be. And they simply have a seizure on this. Very distressful stressing or distressing. It's a very disturbing kind of event to have. And they ended up of course having brain imaging and it shows that there's a spot there and it may be coming from elsewhere.

Headaches the vast measure of the time. Certainly everybody that has a headache should get a brain scan. But the majority of the time it's normal and there are many different reasons to have a headache and very low and that differential is a brain tumor.

Sean: So every time I have a headache, I shouldn't worry about it being a tumor. It's one of those where if somebody has persistent headaches over a long period of time, how long are we talking?

Jehad Zakaria, MD: That's absolutely true. So I personally have headaches all the time. Two things so on, you know, I don't want to kinda talk too much about headaches because it's slightly outside of my expertise and certainly we should get our neurologist here, Dr. Dah, Dr. Shaikh and Dr. Abducotter to talk about but headaches the way I, as a surgeon, the way I think of headaches as a brain surgeon, the way I think of him is the following. If somebody has always had a headache.

So, in their teenage years or early adulthood, and they've always had a headache and has some migraine type component. This should certainly get some image at some point of the brain to make sure there's nothing going on, but no, not every time they have a headache, they should get an image. Right. And not every year and not every two years, especially if the headache is reproducible with say, you know, if you're having had coffee or something like that.

So that's four things that are reproducible, but if you're the kind of person that never had headaches. And then all of a sudden your son had developed these headaches, say they're worse in the morning and they're not going away. Or you have to take a pill for it. And then it goes away and then the next day you have the same headache, and it's been a week or two or three. I certainly would talk to your PCP and get a picture. And again, even then that's okay.

Most likely it's going to be fine, but it's always okay, to get a picture. In the brain, we can treat things much better and the patient will have a much better story and much better result. When they have little symptoms or no symptoms when they have severe symptoms or how weakness or paralysis we do our best. But the brain again, really doesn't like to become symptomatic.

Sean: And you mentioned a cancer as being one of the causes of brain tumors. Are there other things out there that may cause brain tumors?

Jehad Zakaria, MD: Yeah. So the vast majority of the time, people will ask me so even cancer itself, right. So, suppose somebody has lung cancer and there are different groups of that, and. oR breast cancer, different groups of that. Some people are higher risk. Some people are not high risk. They're just kind of, they have a general population risk of say having breast cancer or lung cancer or prostate cancer. Whatever it may be. If that cancer goes to the brain. It's obviously coming from elsewhere. The reason why they have prostate cancer or breast cancer or lung cancer, I personally don't know, but there, obviously the cancer doctors can speak more clearly about that.

There's some people who are higher risk for these now for meningiomas for different benign. Really the most common is meningioma, but there are other benign or what we call low grade tumors of the brain and cysts. There are different populations. That's for the most part, there's really nothing that we know that causes them. Meningiomas tend to happen in, folks as they get older. There's a higher risk in women. And that's really about it. For example if somebody had childhood radiation suppose, somebody with a blood malignancy as a child or a teenager, and they had whole spine radiation or whole brain and whole spine radiation,

These people almost definitively by the time the 30 or 40, that will have a significantly increased risk of having multiple and large meningiomas. And these are somewhat, Aggressive the cold radiation induced meningiomas. So that's kind of roughly where it is there's certain things that we know, but most of the time really it's nothing that, that patient did. Even if a patient gets cancer and they're a small cried, really don't want to talk too much about that. One should always reduce the risk of having cancer.

But for the most part, it depends on a lot of different things, but a cancer patient almost all the time really never did anything get that cancer is just cancer. It's just, it's cancer, it's aggressive and we're here to kind of help them out. Yeah.

Sean: Yeah. you mentioned brain scan being one of the ways, what does a diagnosis look like?

Jehad Zakaria, MD: Typically because patients don't come to me with headaches, right. They come to me with already a CT or an MRI of the brain. And, we'll get a phone call by the regular doctor, their PCP that tells them, Hey, there's a spot on your brain or there's a tumor in your brain. And certainly if the MRI or the CT report is concerning, if it said large or it said recommend neurosurgical consultation. Especially now it is a lot of the pitches are on my chart and they see that it causes quite a bit of anxiety. And I'm here to relieve that anxiety for two reasons.

if it's very large and you're doing okay. It's almost always a good thing. It means it's a benign thing and we can take it out. You'll be fine. So that diagnosis specifically. It comes in typically beforehand, but they come to me, I see folks with these types of diagnoses. Even if they're small, even if I know based on the picture that I really don't need to do any operation, I see the patients within one or two days. And I certainly look at the pictures as soon as the regular doctor talks to me. And I make some recommendations, in a, kind of just a standard fashion.

But for the most part, I think the hardest part is probably the bit between the time that they get a phone call from radiology or the regular doctor that says, hey, you have a brain tumor. And then the time they see me, work very hard to make sure that that time is very, very short.

Sean: That's definitely beneficial as one of the nice things about My Chart is the patient does get control, but at the same time the patient does get control. And so now all of a sudden they've got the information, but they don't have the answers.

Jehad Zakaria, MD: Interpretation. Exactly. Exactly. Yeah.

Sean: It's kind of a double-edged sword in a way. You mentioned, your office neurosurgery specialists. you guys see brain spine, you see patients and Kinkeekee and Bourbonnais, patients that might be interested or just have a few questions. They can always call 815-932-7200 or visit Riversidehealthcare.org. So patients that receive a diagnosis of a brain tumor, what does treatment look like for them?

Jehad Zakaria, MD: So that really depends. So the first step, unlike spine where you treat exactly what's bothering the patient, what's kind of causing them pain, in the brain you treat definitely the patient, but a lot of the picture too, believe it or not. It's one of these things where you do treat the picture to some degree. So even before they comment, I will have reviewed the imaging. And a few things that I look at. One is the need for diagnosis. Does this thing look like a simple benign meningioma?

That's one or do we need to worry about a diagnosis? Do we not know what this is? That's one too. On all of these are radiographic criteria. So that's literally based on the picture. And I do that interpretation even before I see the patient. The other thing is, is this thing big? Is it pushing on the brain? And there are different ways. I look at it and I, there are different sequences on the MRI scan. That's why the MRI takes 45 minutes because they actually acquire a lot of different images. So I look at it. And I interpreted it in a very specific way to see if there's a lot of pressure on the brain and the patient may or may not, be feeling that that's one.

The other thing is if this is something that has been known before, I always look again, even before seeing the patient. I look, if there are previous images of the brain, That I can look at and see if this thing was there. And if it was, is it growing? So I growing lesion or a lesion that is large and pushing on the brain. Or a malignant Lesion. All of these things favor some intervention. Now, if we look at a malignant lesion, so it doesn't look benign. They have a known history of cancer. You can more or less safely assume that this is coming from it.

And there are different criteria for intervention at that point in time. It's whether or not the patient is symptomatic. And symptoms would be headaches, but headache is believe it or not. What I consider a soft symptom. It's mostly neurologic deficit, numbness, tingling. Weakness is really the strongest thing that I consider or lethargy. And whether or not they have a diagnosis from before and then the size. So there are certain lesions, suppose it is a one and a half centimeter spot and it's metastatic that patient has no Cancer elsewhere.

You can assume that this is a mat, we call it from elsewhere and you can assume that, and simply reassess their overall systemic status of their cancer. How are they doing? You can consider getting a CT of the chest abdomen, pelvis, or their whole body to see where they're at. And then for that specific spot. We can do radiation for the most part and or chemotherapy. The size criteria for where radiation provides symptomatic relief or decreases the pressure on the brain in a rapid. The size criteria for that is about two and a half centimeters. So if it's something tiny little dots or one centimeter or half a centimeter That's just half an inch up to about an inch that can be treated with radiation and oral chemotherapy.

Sean: So radiation is kind of that, first step approach treatment?

Jehad Zakaria, MD: It depends. So I obviously see the patient, I give him all the options and I give him my recommendations. Again, unlike the other part of what I do was just spine. for the most part, I just say, this is the situation, this is what I'm thinking. And what would you like? And another thing that I look at is the functional status recall the functional status. So how is the patient doing overall? Have they had a long life and they're kind of comfortable and they don't want to pursue a lot of aggressive care? That's an option. And especially for metastatic lesions. For other patients, if their functional status is really good, if they're walking, talking. we can certainly help him in a way that gets him back to the regular activity. Yeah.

Sean: Okay. What are ways that people can potentially prevent a brain tumor? Is there any proactive steps they can take just way the body just functions as an?

Jehad Zakaria, MD: Yeah, I don't know of I mean, there are a lot of studies out there. Right? Avoiding any carcinogen, right? Whatever the carcinogen is any medication or any say pesticide or anything that is known and proven. Any chemical that is known and proven to increase the risk of cancer. But for these, that's a very, very, very small subset of the population. For patients with different like BRCA mutations in the breast and things like that, different gynecologic malignancies. So patients that have ovarian cancer and breast cancer.

Patients that have lung cancer and was smoking is definitely known to increase the risk of specifically small cell lung cancer. And that does have perpencity to go to the brain. So these are the really the big few things to look at. But for the most part, I don't know that there's anything to prevent. It's just a complex subject, but it's not always grim, you know, it's a difficult diagnosis to have, but it's not always, there are many, many, many, many, many, many cures where you get a teenager and they had their first seizure and they're terrified. And you take the entire thing out. It's a right frontal low grade, astrocytoma or ganglia neuroma or something like that.

And these things are there's other ones called pilocytic astrocytoma. And these kids are, these teenagers are cured for life. They don't have seizures, don't have anything. So it's not always a grim kind of thing.

Sean: And I think that's what's fascinating about the brain is, the sort of elasticity of it. As you mentioned, compensate for so long and then also heal itself. So, yeah. What does the future hold for brain tumor treatments?

Jehad Zakaria, MD: So it's a multidisciplinary approach. It's never really surgery only again, if for some of the low grade lesions. When, I mean, low grade Legion. So, I guess low grade meningioma is grade one and grade two. Aggressive surgical resection. I say the word aggressive, because you do want to be able to get as much of the tumor as you safely can, because that is known to reduce the risk of recurrence. For some of these lesions, then that's a one-stop shop, you have the surgery and you just have follow-up with imaging over time and the risk is essentially very little for recurrence.

It's a surgical cure and it's quite rare in neurosurgery. Quite rare in medicine, in my opinion, to have a surgical cure where you have an operation and you're cured for life. So that's in some of these, the vast majority are a mixture of intermediate grade. So be it intrinsic brain tumors, like gliomas or glioblastoma, astrocytoma and, appendamoma as an old other ones, I mentioned. These are intrinsic brain tumors versus extra axial tumors or meningiomas or things like that higher grade, meningiomas like a great two or a grade three, all of these, we treat.

Again, maximum safe, surgical resection. Follow up. And if they record, sometimes you can take him out again and you do molecular testing. So when I sent the pathology, there's a reason it takes sometimes a week, sometimes two to three weeks and it's a very classic thing. We process it here. We have an excellent pathology department, I have worked with them personally. they give me a diagnosis or a preliminary diagnosis during the operation. I know that I got the spot that I need to get. And, we know what to tell the patient at that point.

And then sometimes it takes 10 days or so, and really the future of medicine in general, but certainly for oncologic, including a brain tumor, even benign disease has molecular testing. So what they do is very, this studied the tumor. And it's all in the live. It's really not even in the hospital, in the laboratory they look at it. Okay. Well, what kind of tumor is it? And what code deletions does it have or what different genetic markers? Or variations does it have, and based on these. There's some prognostic factors that arise.

And then certainly treatment implications. The certain tumors that have, particular variations are more likely to respond to certain chemotherapies or not. So that again goes even for metastatic diseases. So for example, melanoma, there are multiple different immune therapies that are being used for it, etcetera, etcetera. And I think even compared to when I started in training, there are some additional options. There's really an explosion of big data they call it. And molecular analysis side, once they sequence the human genome, there's a lot more molecular work that they can do. I'm personally, not an expert.

You really need to be. Run on cologists and epigeneticist etcetera to study this. But what has become of it is that as the folks in the lab, are doing all of this. Every few years, there's essentially a benchmark that they reach and they produce a particular medication or they alter the treatment guidelines. And our surgeons and certainly our radiation oncologist, and most importantly, our medical oncologists pick up all of that information. If you talk to a medical oncologist, they have so many details. About how to treat what tumor based on exactly what that tumor is.

So a lot more variation in the medication. It's a medical condition. Really surgery is simply to relieve the pressure for the most part and get a diagnosis. But cancer is a medical, in my opinion, a medical condition, really not a surgical thing for the most part. Yeah.

Sean: Sure. So anything. Additional that we should know about brain tumors that, you know, obviously I know you're very passionate about brain tumors and study of the brain. So, anything that people listening should know?

Jehad Zakaria, MD: So, just because you're coming to see a neurosurgeon. It doesn't mean you're going to just you know, you can always just come around and take a look. We look at the pictures, you go for the most part, I don't really recommend surgery unless I feel that it really is the best option for the patient. For the most part, I give them options and I tell them what I think a reasonable person based on the standard of care would do And very often they say hey doc I'm okay with this you know.

I'd rather come back in six months and get a repeat scan. That's fine for a benign tumor, that is perfectly fine. I give them that option. For a malignancy, I tell them this is really not the standard of care. It's definitely their option. And I fully support their decision. But I do tell them what I think is again, the standard of care, what most reasonable people and most reasonable doctors would do.

Sean: Well, thank you doctor for your time. Appreciate it again. Doctor Zakaria with Riverside Neurosurgery Specialists, and they treat brain spine in both Kankakee and Bourbonnais. And you can reach them at 815-932- 7200, or just by visiting with your regular, primary care provider. So thank you again, doctor.

Jehad Zakaria, MD: Thank you. Thank you very much.