Listen to the Patient Of Life and Neurosurgery by Ivan Ciric MD

Author:Ivan Ciric MD
Format: epub

The Curse of Primary Brain Tumors

N eurosurgeons generally enjoy the wide range of surgical interventions in their purview, from a nearly countless array of spinal procedures to a kaleidoscopic variety of cranial operations, from removal of brain tumors and repair of vascular lesions, such as cerebral aneurysms, to pediatric and functional neurosurgery. At the same time, such a diversity of neurosurgical procedures might also be a hindrance to mastering the entire repertoire of procedures to perfection. To my thinking, in neurosurgery, the adage of being the jack-of-all-trades does not necessarily ring wise, so in keeping with my proclivities, in time, I decided to shift my focus toward the operative treatment of intracranial tumors and spinal surgery and away from the vascular, pediatric, functional, and other subspecialty neurosurgical procedures. I had the luxury of doing so, as over time, I had surrounded myself with a team of experts across the spectrum of neurosurgery to whom I could refer a ruptured cerebral aneurysm or a pediatric patient who came my way while I was on emergency duty.

In keeping with my neurosurgical upbringing under Paul Bucy, I maintained a career-long interest in the surgical treatment of primary brain tumors. Primary brain tumors originate from the brain structure’s supportive cell lines, the brain matrix, and not from the precious neurons. The majority of primary brain tumors are, unfortunately, malignant in nature. Neuropathologists classify these tumors in four grades according to the degree of malignancy. The highest grade is the dreaded glioblastoma multiforme, or glioblastoma for short. Glioblastoma strikes mercilessly regardless of age or gender, although middle-aged individuals are the predominant victims. The central core of a glioblastoma, consisting of pure virulent tumor tissue, is bordered by an area where the tumor cells have infiltrated imperceptibly into the surrounding normal brain. The microscopic examination of the core of a glioblastoma typically shows numerous malformed glia cells that rapidly replicate into new malignant cells. As the rapid tumor growth outpaces the sprouting of new arterial vessels in a futile effort to supply the tumor with oxygen and nutrients, parts of the tumor undergo decay. The tumor causes swelling of the surrounding brain, resulting in symptoms of increased intracranial pressure. In accordance with Dr. Bucy’s seminal report on the surgical treatment of malignant brain tumors, the majority of neurosurgeons worldwide have adopted the adage of a “gross total removal” of the central core of the tumor that no longer resembles normal brain as the gospel for alleviating the patient’s symptoms and prolonging life. Following the surgical removal of the core of the tumor, the surrounding more-normal-appearing brain tissue, which nevertheless contains malignant tumor cells, is then treated with radiation and chemotherapies. The science and art of the surgical strategy involve recognizing the acceptable limits of a resection—how much of the surrounding brain tissue, which has been infiltrated by the tumor but is otherwise functioning, can also be removed in order to achieve the maximum short- and long-term benefits while still safeguarding brain functions? The neurosurgeon has more

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