7(a): biopsy, surgery, repeat surgery
See also Section 5: Terms.
Removal of tissue for examination by a pathologist (biopsy) is essential for proper diagnosis and the pathologist needs as much tissue as possible as the tumour status will often vary throughout the material. You also generally need, in malignancy, to have as much tumour as possible removed as a best first step in treatment. This is a subject where different surgeons may have different views of what is appropriate. Some will be more cautious of damage to other tissue (healthy brain cells) than others. Some parts of the brain have lots of cells that can take over if others are injured or removed. Others do not, and these latter are generally in more critical function areas – controlling movement, controlling speech, controlling above all, functions such as the heart.
You have a right to a second opinion but a more radical and aggressive second opinion is not automatically a better opinion. Ask fierce questions.
Neurosurgery does not always attract the meek and modest, you deal for the most part with proud men. Proud often for very good reason. You need to know what they plan to do and why, and you need it in your language, in terms you can understand. Take charge of discussion, with respect for professional skills. The more you ask the more you are likely to be told. The more concern you express for action, the more likely may be the willingness to act for you. It is not the business of surgeons to rush people to things that the patient may not want and which will entail risks. You will be asked to sign consent forms acknowledging that risks have been explained to you. If the situation and the risks are NOT clear to you at this point, do not sign until you have asked enough and been told enough so it is clear. Risks are to be understood and evaluated in deciding whether to proceed, they are not to be brushed aside... This time you can't say: “It's not exactly brain surgery.”
One important value of surgery is the reduction of mass to be impacted by later treatments with radiotherapy or chemotherapy, giving those potentially more value, also meaning, with the reduction in mass by surgery, that inflammation and swelling are less problematic when they occur as a result of tumour cell death from radiation or chemotherapy.
Until relatively recently, a second or third operation was a most unusual option. It has become more common in tertiary centres in recent years.
When are additional operations sensible? They will be considered in circumstances of regrowth or recurrence. Considerations including where the recurrence may be, new issues of surgery... Also including the question why? There is a situation that recurrence can occur with tumour much more aggressive and there is an issue of time gained versus time spent recovering factoring in increased risk with each operation. So while it is possible to find a surgeon who may favour re-operation for its own sake, generally there will be consideration of whether that new operation would open the way to more favourable prospects for another line of treatment, e.g. change of chemotherapy regime.
Before an operation a patient will generally receive an elevated dose of the corticosteroid Dexamethasone (everyone refers to dex) to reduce inflammation and swelling caused by the tumour. However, as well as being anti-inflammatory, the dex opposes wound healing, so that after the operation the dose will be dropped swiftly. It may be, especially in later operations, that a patient can then be overwhelmed by symptoms while in recovery... and this may make further larger doses of dex appropriate.
You must avoid aspirin, ibuprofen, Celebrex and other non-steroidal anti-inflammatories before surgery as they reduce blood clotting. Inhibition of natural clotting creates risk of uncontrolled bleeding during the operation or haemorrhage afterwards, all bad news. To check there is no bleeding after an operation it is normal to have a CT scan.
Hospitals are places where people can get infections. Good to focus on recovery and getting away. Good to get up and exercise as soon as possible, in consultation with nursing staff.
From before the operation and while in the hospital bed you wear TEDs. TED stands for Thrombo-Embolic Deterrent; you may be the only one in the ward to know this now! In simple terms, these are long or short tight white stockings which stop blood pooling in the legs and reduce prospect of deep vein thrombosis (DVT) – development of blood clots in the veins rising from the legs. This is a precautionary step for all surgery where a person will spend time in bed. It is also a major concern for brain tumour patients, who suffer a high rate of DVT. The risk with DVT is that the bits of clot may break away and travel to and block and damage heart, lung (pulmonary embolism) or brain (stroke). So wear the TEDs all the time and get up and start a bit of walking as swiftly as possible.
There are some rarer tumours which can be removed entirely from the brain, but this is not so with most brain tumours. In breast cancer, you can remove the tumour, study it and, if necessary then remove the whole breast... this is of course not an option with the brain. (As noted in earlier sections) removal of a small sample (biopsy) for examination may lead to error in diagnosis, as the tumour mass may not be all one type or grade of tumour.
With even the most modern forms of imaging it is not possible to see the full extent of tumour. There will always be a few rogue cells left behind. The only tools for treatment after surgery then are radiotherapy and chemotherapy.