Principal Director & HOD, Neuro and Spine Surgery, Fortis Hospital, Shalimar Bagh, New Delhi
Part 9 of 9 in Diagnosis and Management of Brain Tumour
Real Brain Tumour Cases: Weighing Surgery Against Radiosurgery
June 9, 2024
Two cases discussed during the masterclass illustrate how treatment decisions are actually made when the tumour's location or a patient's clinical picture complicates a straightforward surgical approach.
A tumour in an eloquent area of the brain
A 23-year-old woman from Uzbekistan had suffered a bleed in the brain nine months earlier, with one-sided paralysis that had since improved, and a seizure that occurred during the bleed. The lesion was located in an eloquent area of the brain, meaning an area whose function makes any operation there inherently riskier. She had been offered radiosurgery over open surgery by other doctors, but radiosurgery would take about two years to shrink the lesion, during which time she would remain at high risk of further bleeding. She was instead offered surgery, which immediately removed the risk of haemorrhage; a neuronavigation-guided keyhole surgery lasting about three hours achieved complete removal of the tumour.
A 7-year-old with a high-grade glioma
A 7-year-old girl presented with headache and vomiting over two weeks that progressed markedly over the final three days. MRI showed a well-defined left frontal lobe mass with surrounding oedema and mild midline shift, with a differential diagnosis of metastasis versus high-grade glioma. Her local doctors were recommending an open frontal lobectomy. The alternative offered was neuronavigation-guided keyhole tumour surgery using a surgical robotic system, allowing near-complete removal that improves survival, though high-grade tumours cannot be considered fully curable. This would be followed by stereotactic radiosurgery and chemotherapy or immunotherapy depending on the biopsy and genetic study of the tumour, a genetic-based approach not offered by many centres worldwide.
This article is based on a Jivo Masterclass session conducted by Dr. Sonal Gupta, Principal Director & HOD, Neuro and Spine Surgery, Fortis Hospital, Shalimar Bagh, New Delhi. The article has been summarised with the assistance of an AI tool from the original masterclass recording. Watch the full Masterclass recording
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This guide is based on a live Jivo Masterclass: Dr. Sonal Gupta taught doctors across Africa on June 9, 2024.
FROM THE LIVE Q&A
Dr. Mali
After a complete resection of a cancerous mass, there is a void left in the brain. How does this void evolve during healing, and are there always neurological sequelae?
Dr. Sonal Gupta
A cancer tumour can never be removed completely; microscopic cells are always left behind. Because these tumours cause significant surrounding brain swelling, the surgical cavity fills in quickly on its own, so the void itself is not a concern.
Frequently Asked Questions
A 7-year-old girl presented with a two-week history of headache and vomiting that progressed over the last three days. MRI showed a well-defined left frontal lobe mass with a differential of metastasis versus high-grade glioma, and local doctors are recommending a frontal lobectomy. What would you recommend, and what are the likely outcomes?▼
Rather than an open frontal lobectomy, neuronavigation-guided keyhole tumour surgery using a surgical robotic system allows near-complete removal of high-grade tumours, improving survival, though high-grade tumours cannot be described as fully curable. This is typically followed by stereotactic radiosurgery and chemotherapy or immunotherapy depending on the biopsy, guided by genetic study of the tumour, which few centres worldwide perform routinely.
Is immunotherapy actually used in the treatment of brain tumours?▼
Yes. Genetic-based targeted immunotherapy is the latest advancement in brain tumour treatment.
For a 17-year-old patient showing several of these symptoms, what characteristics should guide a referral for further workup?▼
Symptoms alone do not distinguish a benign tumour from a malignant one; both can present the same way. A CT scan and MRI together can predict whether a tumour is benign or malignant with about 90% accuracy, though only a biopsy can confirm the diagnosis and grade. Any patient with these symptoms should be sent for an MRI.
How can epilepsy surgery be made practical and accessible for African patients?▼
Not every epilepsy patient needs surgery - only intractable epilepsy (uncontrolled despite adequate medication) or epilepsy caused by a visible lesion on MRI warrants it. To make this accessible, an online epilepsy clinic can review a patient's medication history and MRI findings remotely, and only call the patient to India for a surgical workup once epilepsy is confirmed to be intractable.
If an adult has a first-time seizure, is it correct to suspect a brain tumour as the cause?▼
Every patient presenting with a seizure should have an MRI under the epilepsy protocol with contrast, since a CT scan can miss small lesions responsible for epilepsy. However, not all seizure disorders are caused by a brain tumour.
Why was surgery chosen over radiosurgery for the Uzbekistan patient?▼
Radiosurgery would take about two years to shrink the lesion, leaving her at high risk of further bleeding in the meantime; surgery removed that risk immediately, and the tumour was fully removed via neuronavigation-guided keyhole surgery.
What was recommended for the 7-year-old with a high-grade glioma instead of a frontal lobectomy?▼
Neuronavigation-guided keyhole tumour surgery using a surgical robotic system for near-complete removal, followed by stereotactic radiosurgery and chemotherapy or immunotherapy guided by biopsy and genetic study.
In This Series: Diagnosis and Management of Brain Tumour
- 1.Brain Tumour
- 2.How Brain Tumours Are Classified: Benign, Malignant, Primary and Secondary
- 3.Brain Tumour Symptoms and Which Headaches Are Red Flags
- 4.Diagnosing Brain Tumours: CT, MRI and Beyond
- 5.Brain Tumour Surgery and Radiosurgery: Treatment Options Explained
- 6.Brain Tumour Surgery: Realistic Complication Rates and Recovery
- 7.Epilepsy Surgery: Who Needs It and How It Helps
- 8.Brain Tumours in Children and Newborns: Diagnosis and Management
- 9.Real Brain Tumour Cases: Weighing Surgery Against Radiosurgery