Transcription:
Minimally Invasive Brain Tumor Surgery

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Melanie Cole (Host): Welcome to Back To Health, your source for the latest in heath, wellness and medical care; keeping you informed so you can make informed healthcare choices for yourself and your whole family. Back to Health features conversations about trending health topics, and medical breakthroughs from our team of world-renowned physicians at Weill Cornell Medicine. I am Melanie Cole and our topic today is minimally invasive brain tumor surgery. My guest is Dr. Theodore Schwartz. He’s the David and Ursula Barnes Professor of Minimally Invasive Neurosurgery and the Director of Anterior Skull Base and Pituitary Surgery at Weill Cornell Medicine. Dr. Schwartz let’s start with you. Tell us about yourself and how you came to be named the David and Ursula Barnes Professor of minimally Invasive Neurosurgery. 

Theodore H. Schwartz, MD (Guest): Well first of all, I just want to thank you for having me today. I look forward to talking to you and our listeners about minimally invasive brain tumor and skull base surgery. So, I have been at Cornell for about twenty years now, specializing in brain tumors and trying to develop new ways to take out tumors, particularly tumors that are hard to get to in less invasive ways using natural corridors. And some of the natural corridors that we use are things like the nostrils, which is a cavity that we can go into, up the nose. We can make little incisions in the eyebrow for example and try to avoid doing surgeries where large parts of the skull are opened up and big skin incisions are made, and the brain is sort of retracted out of the way in order to get to tumors that otherwise would be difficult to reach.

So, I have been working on these techniques for many years and a lot of the time we use illumination devices called endoscopes. And endoscopes are sort of like small thin telescopes about the diameter of a pencil and we can slide those endoscopes into small openings in order to see and look around. And previously, a lot of these surgeries were done with microscopes because we do need to magnify very small fine structures, nerves and arteries and things like that around the brain. And with endoscopes, you can go through small corridors because you can slip them in and look around. But with microscopes, you really need a big region that’s exposed because the microscope is very big and so it sits outside the patient’s head and you need to get all that light in there in order to see.

So, there was a particular patient, this gentleman David Barnes who lived in London and he had a very big brain tumor at the base of his skull. And he was starting to notice changes in his personality, in his decision making and issues such as that and so he went an got opinions all around Europe and went to London and went to Vienna and saw a bunch of surgeons and they basically said well in order to take this tumor out; we got to basically slice your head open ear to ear and make a big opening in your skull and move your brain out of the way and get the tumor out. And he found me through some of these surgeons who said there’s a guy in New York who is trying to do this a little differently and he sent me his films and he said is there a minimally invasive way for you to do this? And I said well, yeah, I think so. I think we can basically make a little incision in your eyebrow, in this situation, that was the best approach for him, put an endoscope in there and remove the tumor through that and the incision should literally be an inch long. And he flew over from London and we did his surgery and it went beautifully. You know just spectacular. He went home in a couple of days. He recovered in a week or two and he flew back to London.

And the story goes, I called him on the phone and he was a gentleman of means and so I said you know if you ever want to support our programs here; we like to train other surgeons as to how to do these operations and we have to sort of defray the cost of paying their salary and things like that. Let us know if you ever want to make a donation to that so we can help our educational program here.

And so, he thought about it a little bit and then eventually, he decided to go ahead. You know he is a very generous guy. He’s a wonderful guy. He and his wife are both just spectacular and they really wanted for other people to have the opportunity to be treated in the way that he was treated. Because he so appreciated the fact that he found a different way to do the surgery that was really scary for him. Which is this big traditional operation. So, he donated some money and allowed me to become the David and Ursula Barnes Professor of Minimally Invasive Neurosurgery and we used that money really to train other surgeons. So, we pay salaries and malpractice expenses for surgeons who come here to train and learn how to do these techniques, so they can then travel abroad or travel to their home institutions or anywhere else in America and be able to propagate the techniques that we have developed here and offer it to more and more patients. Because obviously, I can only treat so many patients, but the more surgeons I train to do this, then I’m able to touch many more patients around the country and around the world. So, we really try to teach as much as we can.

Melanie: What a wonderful story Dr. Schwartz. Thank you for sharing that with us. So, let’s talk about brain tumors themselves. Do we know what causes them and a lot of people have this question if cellphones are contributing to brain tumors?

Dr. Schwartz: Right, that’s a great question. And a lot of patients ask me that. I have a practice that focuses on brain tumors so as you can imagine, a new patient who comes into my office has already been told by their internist or their neurologist that they have now been diagnosed with a brain tumor and it’s terrifying. And they come to see me with that diagnosis already in hand. I’m usually not the first one to tell them. And they have a million questions about it and they are terrified about the fact that they are seeing a surgeon, that they may need brain surgery and they always want to know what caused this. And along with what caused it is does every member of my family need to get a scan in order to make sure that we all don’t have it, and can I give this to my children. A lot of adults are terrified that if they have something they can pass it on. So, what I tell most of my patients and it’s true here is that most brain tumors are not inherited. They are not genetically passed on. There are some rare genetic disorders where people do have tumors based on a genetic abnormality that can be passed on. But that’s extremely rare. That’s the exception. Most are really pop incidentally and have nothing to do with their genetics or can be passed on. And I also reassure my patients that there is nothing they did, and this is true in the vast majority of cases. There is nothing they did that caused them to get this brain tumor. There is no behavior that they did. There is nothing that they should have eaten. There is nothing that they ate that they shouldn’t have eaten. And it’s definitely not cellphones based on all the information we have.

And when you look at the literature on the relationship between cellphones and brain tumors; there certainly are some papers that have shown that there may be a link. But, there are just as many papers that show that there is not a link. And a lot of these studies are not that well done. The way scientists do research and the way studies are performed that allows us to really know something; is if you can do a randomized controlled study that is prospective, that follows a group of patients where half of them use cellphones and half of them don’t and you see how many of them develop brain tumors over the next twenty, thirty, forty years. Well that study has never been done. And it’s never going to be done. Most of the studies that have been done are retrospective where they take a group of patients with brain tumors and they say oh did you use your cellphone an dhow much did you use it or which side did you hold your cellphone, which hand did you hold it, the right or the left side and does that correlate with your tumor. And those studies are flawed. And the data from those studies are flawed and so when you pool all those flawed studies together; you have got a couple that show a positive link, but you have just as many that show a negative link and you pull them together and there ends up being no link.

And if you only look at the ones that show the positive link, you can get excited about that and journalists can write papers, oh this journalist can write an article saying this paper just came out showing a link. But they are only looking at one paper and they are not saying well how well done was this paper. And how does this balance out against all the papers that didn’t show a link? Because those don’t get reported. They are not excited. We don’t see them in the news. So, the link between cellphones and brain tumors really is very, very flimsy. I use my cellphone; my children use cellphones and I tell my patients that that is not the cause and they really shouldn’t worry about it.

Melanie: Dr. Schwartz people get a headache and right away, they worry about a brain tumor. What’s the clinical presentation? What are some of the first signs and symptoms of a brain tumor that would send somebody to see whether it’s their primary care provider or another physician in the first place?

Dr. Schwartz: Another great question. So, headaches tend not to be the first symptoms that someone has when they are diagnosed with a brain tumor. I can’t say it never happens because sometimes it does. But the vast majority of headaches are not caused by brain tumors. As we know, people get headaches all the time. And most of these people do not have brain tumors. So, when you have something in the brain, like a tumor that irritates the brain; you often get a symptom related to the brain being irritated and the brain has no pain fibers. So, you can touch the brain and you wouldn’t feel anything. So, the brain does not sense pain and it doesn’t sense even touch to it. But what happens is if you have a tumor that’s pushing on part of the brain that moves your arm; you will have weakness in that arm. And if it is pushing on part of the brain that’s important for vision; then you won’t be able to see on one side or the other side and if it’s irritating the brain, you could have a seizure based on the fact that the brain is sort of tickled by this tumor and can have some swelling in it and you can get a seizure.

So, it’s much more common to have things like double vision, loss of vision, weakness, numbness, trouble with your speech, language difficulty than it is a headache. A headache really is much less common, although not unheard of.

Melanie: Do you feel more people are being diagnosed these days because maybe they have had a brain scan after say a car accident or other traumatic injury and I appreciate you explaining the cellphone because people do have that question. But there are other reasons that someone might have a brain scan and if it’s caught early, are there more options for treating it?

Dr. Schwartz: So, the answer is no and yes. Or actually yes and yes. So, the first yes was that the MRI scan was developed in the mid-80s and before that, we couldn’t do MRI scans and so we couldn’t really see a lot of things that were subtle in the brain that might not show up on a CAT scan. CAT scan was developed in the 70s. And certainly, in the last twenty years, we get more and more MRI scans because there are more MRI machines, the cost of doing an MRI scan goes down and it’s much more common to order an MRI scan. MRI scan is a very sensitive test. And we often pick up a lot of small incidental brain tumors that would not be seen on a CAT scan and certainly that a patient would not know they had if they didn’t get an MRI scan. Even though they are getting their MRI scan for something completely unrelated to the tumor that is found. And then you face the interesting scenario where you have got a patient with no symptoms and a very small brain tumor; what do you do? The first thing you do is you try to figure out what kind of tumor it is based on where it is, and what it looks like on the MRI scan and often, you can figure that out just based on experience. Because certain tumors present in certain places and they look a particular way.

And once you know what it is, you can figure out what the best way to treat it is and often, for an incidentally picked up tumor like that, the best treatment is really to do nothing and just to follow it. And very often, that’s what we will do. We will say you know what, come back in three months, we will get another can or come back in six months or even a year and we will follow it and see what happens. Because it may be that this tumor is so slow growing that it really doesn’t need treatment. And let’s say you get the scan when you are 75 years old, you may never need treatment for the rest of your life. You get it when you are 20 years old, that’s a different matter. We may follow it, it may grow a little bit, we may say you are pretty young, if it keeps growing at this rate you are going to have issues, why don’t we deal with it now. Or why don’t we deal with it in a year or two. So, we do pick them up more frequently because of MRI scans and then we have to make a decision based on that sort of screening as to whether it’s worth intervening or not because every intervention that we have even minimally invasive things like radiation; have side effects, just like surgery has side effects and you have to weigh the side effects against the risk that that tumor is going to cause a problem in the rest of that patient’s lifetime or in the next five to ten years.

And that’s that risk benefit weighing that we do as physicians to try to figure out how quickly is this growing, how old are you, how likely is this to cause symptoms, do we need to treat it, what the best treatment is. So, there’s sort of a complicated algorithm that goes into making those decisions. Certainly, if you think it’s a malignant tumor, we might intervene much more quickly, but for benign tumors, it becomes a little bit more ambiguous as to whether to treat it and how to treat it.

Melanie: Then tell us about some of your procedures and what are the benefits for the patient using minimally invasive brain surgery and Dr. Schwartz what are the benefits for you, the surgeon with these types or procedures?

Dr. Schwartz: So, it’s a funny question. You ask in a way, what the benefits are for me because I often tell the surgeons that I’m training, the residents, the fellows, that minimally invasive surgery is easier on the patient, but it’s harder on the surgeon. So, the truth is, the benefits are really mostly for the patient, not for the surgeon. Because they actually can be technically in some situations much more difficult because you are working through a very narrow corridor with smaller instruments and less maneuverability and it can often take longer particularly if you don’t have a lot of experience in them. The patients almost definitely do better, if they are well selected, right, you have to choose the right patient for a minimally invasive approach. You can’t just do it on everybody just because you know how to do it. You have to make sure that it’s indicated for that patient with a tumor in that location. Otherwise, you may be better off using a standard approach, using a craniotomy; opening up the head.

So, when you start out, it obviously takes much longer because you are learning a new technique, a new approach and you want to take your time and be very careful and as you get more facile at it, you get more skilled at it; you can do it much more quickly then, it’s good for you and good for the patient, but ultimately, what’s good for the physician is not as important as what’s good for the patient. So, we do and I do what’s indicated for that patient regardless of whether it’s better for me. What’s better for me is if my patients are happier, my patients are doing better, they get out of the hospital more quickly. If they see me in follow up and they don’t have an incision and they don’t have any complaints and their tumor is gone; then that’s great for me as well. And so, these minimally invasive approaches allow me to offer those types of treatments for my patients with brain tumors to try to get them out of the hospital more quickly, try to get their tumors out more safely with less morbidity and risk to them.

Melanie: What’s the average recovery time for having a brain tumor removed with surgery and what is life like for the patient after surgery Dr. Schwartz? Tell us about not only the physical changes, but if there are any psychological changes that go along or cognitive changes that might go along with this type of surgery.

Dr. Schwartz: So, it’s hard to generalize about brain tumors as a group because it’s all about location. It’s like real estate; it all depends on where in the brain your brain tumor is and how much it’s impacting your function at the moment. Right, so we know that there are parts of the brain that are important for memory and there are parts of the brain that are important for language and vision and hearing and touch and every sensation that there is and complex cognitive thinking. And if you have a brain tumor that’s in a very sensitive location and it’s already impaired that function; then that function may not come back when you take the brain tumor out because sometimes the tumor has already impaired that function to the extent that removing it will not make it better. Other times, the tumor is just pushing on an area and when you take the tumor out, the patient recovers. And that recovery may require rehabilitation, it may require a week, it may require ten months. It all varies on the degree of the disability, the size of the tumor, the difficulty of taking it out, how stuck it is to everything else.

So, as much as I would love to give you a generalization of the recovery from brain tumor surgery; I really can’t because there is such a gamut based on the location, size of the tumor, the success of the surgery, so many different factors weigh into that. But what I will say is that brain surgery is incredibly safe. The vast majority of patients will not only recover from the surgery, they will leave the hospital and they will go home and the vast majority of those will return to their baseline function at least for a period of time and so, it’s really not the surgery that’s the worry for most patients. The really scary thing is if it’s a malignant brain tumor, if it’s a tumor that can’t be cured with surgery, if they need additional therapy afterwards and how effective that therapy is going to be is usually more of a concern than just the surgery itself. Th surgery – we have been doing this for a long time. It’s evolved dramatically. It’s not like a caveman surgery. It’s very, very sophisticated, computer driven surgery that has been honed over the years so that someone who has been doing it for several years acquires the necessary expertise to really do a great job and get patients home and have them recover.

Melanie: As you wrap up, in this absolutely fascinating topic, Dr. Schwartz, give the listeners your best advice, information or hope about minimally invasive brain tumor surgery and if there’s some promising new therapies for brain tumors that you see on the horizon.

Dr. Schwartz: Yeah absolutely. You know I think that it’s such an exciting time because the way we treat tumors is evolving rapidly and dramatically. And those dramatic changes are not only in how we do the surgery because we do have these minimally invasive approaches to get patients in and out of surgery much more quickly and there’s many more techniques that are being developed whether it’s robotic surgery or the use of fluorescent dyes that we can inject into the bodies that will make the tumor light up so we can very clearly see the margins of the tumor. Those are all brand new innovations that we brought to the field of neurosurgery to make it safer.

But in addition, there are therapies for example immunotherapies or vaccine therapies for tumors that allow us to treat tumors with chemotherapy and more targeted radiation in a more delicate way, in a more tumor specific way. We can now do very specific testing of tumor types looking at their genetics so that we can learn everything about that tumor and which chemotherapy is the best chemotherapy or immunotherapy for that specific tumor in that specific individual. It’s becoming much more patient oriented, precision medicine that we can apply to the treatment of tumors. And with every new innovation that we see in the world around us; if you think about it, cell phones and electric cars and the internet and all this. All of that is moving into surgery and moving into the operating room and the use of three D technology to help prepare surgeons for a surgery to help reproduce the locations of the anatomy, all of that that we see in the world around us, is also infiltrating into our ability to treat patients with brain tumors. So, it’s a very exciting time to – for a surgeon, it’s certainly not exciting time to get a brain tumor. There’s never a good time to get one. But if God forbid that does happen to someone, they should know that there’s so many treatments out there and there are so many people working on moving the field forward and not just making the surgery better, but all the treatments associated with brain tumors better, safer for every patient.

Melanie: Wow, thank you so much Dr. Schwartz for being with us today, for sharing your stories and your expertise and explaining this to the listeners so very clearly so that we have an understanding and even a sense of hope of what’s on the horizon for brain tumor surgery and minimally invasive and as you have described, so many of the new technologies that are helping you as a surgeon to really advance this field forward. This concludes today’s episode of Back To Heath. We’d like to thank our listeners and invite our audience to download, subscribe, rate and review Back To Health on Apple Podcast, Spotify, and Google Play Music. For more health tips go to weillcornell.org and search podcasts. Parents – don’t forget to check out Kids Health Cast!