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Operation: Wide awake

May 15, 2006
Mike Schwartz

MRI "slices" of Roger Stites' brain pinpoint language areas in the left frontal lobe (red areas) during a preoperative reading test.

UCLA Medical Center gives brain cancer patients a cutting edge -- literally.

It is one of a handful of hospitals offering "last-chance" treatment that combines high-tech surgical, scanning and neurological-testing modalities.

Even the Mayo Clinic refers patients to UCLA.

Moreno Valley resident Roger Stites counts his blessings that he is scheduled next week for an "awake" craniotomy on a malignant brain tumor that could prove fatal in several years unless it is taken out.

"This surgery will help them not damage anything that potentially might affect my quality of life," said Stites.

The procedure has one daunting goal: to remove as much of a tumor as possible without damaging brain areas vital to speech or other functions while the patient lies fully conscious on the operating table.

What makes UCLA unique in Southern California is a high-field magnetic resonance imaging scanner installed in the surgical suite. The MRI allows doctors to check and recheck their progress in slicing out malignant tissue, often just fractions of an inch away from healthy nerves and brain matter.

"There's no question UCLA is a major center for this modality," said Dr. Frank PK Hsu , assistant professor of neurosurgery at Loma Linda University Medical Center. "We do awake craniotomies but don't have an intraoperative MRI. I've been asking for one."

Some centers wheel portable MRI units into the operating room.

"But the resolution is much poorer than our diagnostic scanner," said Dr. Linda Liau, director of the malignant brain tumor program at UCLA Medical Center.

"Currently I'm doing about one a week," said Liau. "But I don't work alone. This requires a whole specialized team."

Hard to Remove

Stites, 48, will undergo the technologically advanced operation to remove an oligodendroglioma, a malignant tumor in his left frontal lobe. Doctors diagnosed the condition 2 ½ years ago after Stites suffered a grand mal seizure.

His tumor is a type of glioma, which grows from brain cells, said Liau.

If this low-grade tumor is slow growing, patients can survive for many years even after symptoms begin, especially because the disease often responds well to chemotherapy.

"But 75 percent of the time, the tumor degenerates to a higher grade with a much worse prognosis," Liau said.

Brain surgery at Riverside Community Hospital in 2004 got much -- but not all -- of Stites' tumor. Surgeons did not remove more for fear they might damage healthy brain tissue.

Greg Vojtko / The Press-Enterprise
Moreno Valley resident Roger Stites, 48, already has one scar from a brain surgery. Next week, he'll undergo a second brain surgery, and this time, he'll be awake.

"That's why you need high-resolution MRI during surgery," said Liau. "If there's any question, you can turn the bed, get a scan and know how much tumor is left, if any."

Stites' initial operation involved a conventional craniotomy, in which surgeons temporarily removed bone from the skull to allow access to the brain itself.

Thirty-five radiation treatments followed, then four months of chemotherapy. In January 2005, Stites suffered a second, minor seizure while driving. He was able to pull off the road.

Another year of oral chemotherapy and anti-seizure medications helped control symptoms. And an MRI in March showed that his tumor, which tends to recur, had shrunk to a grade two on a scale of four.

Even so, because doctors suspected the glioma was heading for "grade three," they referred him to UCLA for decisive intervention.

Specialized-Team Approach

Moreno Valley resident Roger Stites, 48, already has one scar from a brain surgery. Next week, he'll undergo a second brain surgery, and this time, he'll be awake.

Last week, Stites had outpatient preoperative diagnostic tests at UCLA. An MRI scanner created a 3-D model of speech, motor and other "eloquent" areas of his brain. This will allow "neuronavigation" during surgery, explained Liau.

"We'll be able to point to certain areas and it will appear on screen," she said. "It's like (a global positioning system) for the brain."

The awake procedure Stites will undergo next week has one major difference from the previous surgery: Once Stites' brain and tumor lie exposed before the surgeons, Dr. Barbara M. Van de Wiele, a neuroanesthesiologist, will reduce the general anesthesia level.

Because the anesthesia is short-acting, his return to consciousness will take only minutes and Stites will quickly be able to comprehend, talk and move normally, said Van de Wiele.

"He won't be just awake but wide awake," she said.

His head, however, will be immobilized with a halo-like clamp to prevent even slight movements that could injure delicate tissues.

While he is conscious, the team will stimulate brain tissues and nerves around the tumor with a wand-like electric probe to identify regions controlling speech, movement and senses. These tests help reduce the risk of damage that would result from cutting into healthy brain matter.

During the testing, clinical neuropsychologist Susan Bookheimer will ask Stites to speak, count, identify flashcards and perform other tasks.

"I'll ask him things like 'What do you call a tall pink bird?' and he'll have to come up with 'flamingo,' " Bookheimer said.

If the probe touches a language area, a mild electric current will short-circuit cells and the patient will momentarily not be able to respond.

Local anesthetics will ensure that Stites feels no pain. What's more, brain tissue itself has no pain receptors. He'll be put back to sleep before surgeons close his skull.

If intraoperative MRI has any downside, it's the need to ensure scalpels, scissors and other portable equipment are made of non-ferrous materials due to the machine's powerful magnetic field.

"Otherwise you'd have all these blades and oxygen tanks flying around the operating room," said Hsu, of Loma Linda.

After the operation, Stites' head must remain immobilized by the skull halo and straps must restrain him on his bed. Barring complications, he'll remain in the hospital three or four days.

"It's not uncommon to have speech problems for a few days as the brain heals," Liau said.

Stites figures the results will be well-worth any discomforts.

"Right now, I feel great and positive," he said. "I just want to get this stupid bug out of my head so I don't have cancer any more."

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