Mercy Medical Center neurosurgeon, Dr. McIver talks about saving the life of a patient who had a bowel tumor that metastasized to her brain.
Interview conducted by Ivanhoe Broadcast News in 2023.
We met with your patient, Dorothy Baber yesterday. It was difficult for me to hear that it initially started with bowel cancer and it spread up to the brain. How often does a previous cancer migrate to the brain?
McIver: The incidence or the likelihood of cancer spreading from the primary source to the brain depends on the type of cancer. There are certain types of cancer that rarely, if ever, spread to the brain, but others are more common. Her type of cancer is in a category called adenocarcinoma. That type can frequently metastasize or spread outside of the confines of its source to either the bone, the spine, or even a brain.
What causes those adenocarcinomas to spread like that?
McIver: It’s our immune system. We have trillions of cells, and each of those cells can bypass the stop sign and the genetic material and become a cancer cell. But the body’s immune system detects that abnormality and stops or kills the cancer cell. Fundamentally, it’s a problem with the immune system.
We had a conversation yesterday because she mentioned having sepsis and I asked her if there was any connection between sepsis and cancer. Can you answer?
McIver: Probably not. Now, the challenge is, depending on where the tumor is, and where the cancer is, it can predispose the body to infection. Hers was in the gut, which is not a clean area. But she needed surgery, she had surgery in that area, and it was a complication of the treatment, unfortunately.
One of the things she shared with us, is that you have to leave a portion of the outside shell, it reminded me of a prostatectomy. Did you do that because she couldn’t take more than what was needed?
McIver: In terms of tumor surgery, you want to remove all the tumors. The reference in our discussion was really about that rim of the surrounding brain that was immediately on the outside of the border of the tumor. That’s the area that we wanted to minimize injury to. In terms of tumor, we wanted to remove all of the tumor.
Is there some fear that that’s going to be impacted and you don’t know anything about it at the time of surgery?
McIver: We have a good idea of the function of that region of the brain. Number one, because of the symptoms that she had, she had clumsiness, she had dizziness. In that part of the brain, those functions are mediated by that circuitry. The other advantage we had is the imaging. The imaging showed us how close this tumor was to important relays beneath the surface of the brain. We knew the areas and the functions that we had to be very careful about just by listening to her and also looking at our imaging.
Which important relays were close to this area?
McIver: These cerebellar relays are primarily known for balance, for fine-tuning movements, but also there is a role for cognition or thinking even in the cerebellum.
What causes a surgeon to keep the patient half awake and talking during that or playing the surgery?
McIver: It’s trying to understand the circuitry. If you are very close to what we call the eloquent cortex, parts of the brain that are immediately responsible for critical functions, like opening and closing my hand, I might advise that in addition to imaging, having a patient totally awake or partially awake. That way we can monitor the function of the brain circuitry for movement. The same relays are involved with speech, so the same scenario can be involved with speech as well.
Talk us through the surgery.
McIver: In her case, we first had to understand where is the problem. The problem was in the lower part of the brain on the right side, that’s called the cerebellum. The right side of the cerebellum. Then we had to understand how deep the tumor was. If it was on the surface or deeper within the substance? In her case, it was deeper. The next question was what the best way to access it was and where we made the incision. Then after the incision is placed, how to enter the brain. There are certain parts of the brain where it’s safer to enter with a horizontal or side-to-side incision. Then other parts where it’s better to enter with a front back incision. It depends on what is the human homunculus. The homunculus is the body’s representation on the surface of the brain and within it. It’s really amazing. You can touch or activate a region of my brain and know that it will cause my hand to function, to open, and to close. We do that sometimes with surgery, namely the awake surgeries that you mentioned. There is a way to minimize injury to limit disruption of circuitry by the way you access the brain.
Was she portrait or landscape?
McIver: She was landscape.
It must be a wider area is where my logic is going, that when you’re this way, you have access to.
McIver: You’d be surprised. It’s still through an incision about half to three-quarters of an inch in the surface of the brain. That incision enables you to access the tumor, and then the way we removed the tumor, if you don’t remove it, you don’t deliver it like a baby. You actually will decrease the volume of the tumor through a small incision. You core it out and then you enfold it to limit the disruption to the surrounding brain material and circuitry.
Dorothy told us yesterday that she’s got two additional spots, I believe, but you have those for a while to see what happens. We did a subsequent story yesterday on a doctor treating leukemia that said, “We don’t over-treat because we’re waiting to see how the body does.” Is that the same thing in this type?
McIver: In this type, there are areas where the tumor involved can be treated with less invasive treatments like stereotactic radiation, and highly focused beams of radiation. Our primary focus is not to harm the person in trying to help them. In her case, this tumor had to be removed because of its size. It was too large to be treated with radiation, Number one and number 2 were causing significant problems like elevated pressure, causing the symptoms that made it difficult for her to function.
What was the actual size of the tumor?
McIver: The actual size was slightly larger than three centimeters, and we think in terms of centimeters, slightly longer than an inch-and-a-half.
What was the tipping point and the size?
McIver: About three centimeters. Now, the tipping point determines, or depends on, whether you are talking about radiation.
Was there a need for surgery?
McIver: Well, it’s not just size, it’s also location. Is whether the diagnosis is understood. Do they have history of a cancer or tumor or is this the initial diagnosis opportunity? Also, how was the person affected by this?
One thing we noticed that was clear from the moment we walked in was her attitude, and her husband’s support, and her kid’s support. How much does that matter to the patient in question
McIver: That’s very significant. Studies have shown that a good attitude of involvement and a faith community helps increase a person’s likelihood to have increased survival.
How does that happen? Are good vibes going through?
McIver: It’s good vibes, I don’t know that any other researchers were able to explain this, but I think it goes back to the immune system.
What is her prognosis?
McIver: I don’t know the prognosis. But we do know that surgery makes a difference in helping a person. If you can decrease the tumor volume, you increase a person’s chance for a good outcome.
Can you walk us through what you’re doing during a microscopic surgery? I think once you pass the scan, most people feel like you’re in their brain.
McIver: Yes. I think of the brain as a pillow and it’s covered by a pillowcase, and then it’s in a suitcase covered by a carpet. I think of the scalp and hair as the carpet. We make the incision and then we do need to make a puzzle piece opening in the suitcase, the suitcase being the skull. Once that’s performed, we then have a view of the pillowcase that’s called the dura. That’s not the brain, but it’s a covering of the brain. We make an opening in that pillowcase, and then we see the surface of the brain. The next task is to determine how best to access, to enter the surface of the brain. The brain is covered by a layer that looks like Saran wrap. It’s called the pia. We make a very small incision in the pia and then we can travel through the brain separating pathways until we find the tumor.
All of that stuff, the Saran Wrap included, does it flow back up?
McIver: You know it does. It may not be a perfect closure, but that area where you operate might start out as being relatively large. If you take a scan and about a month, two, maybe three, it’s significantly smaller involvement. The body and the brain have a way of just filling these spaces.
What does the fill look like?
McIver: It fills it with a brain that was displaced by the tumor mass, but it also fills with cerebral spinal fluid that is produced by the brain.
She mentioned that yesterday and that she had swelling below the tumor. Is that correct?
McIver: Yes. That’s caused by abnormal blood vessels and the tumor. The tumor recruits blood supply from the brain. Those blood vessels were created hastily, so they don’t have normal integrity. Those blood vessels in aware, you can consider them as leaky pipes that cause fluid to seep into the surrounding brain and that swelling we call edema.
What is it in brain surgery that is the latest and the greatest?
McIver: The latest and the greatest is pairing surgery with immune therapy. It’s a multidisciplinary approach. Though surgery makes a difference, the real key to survival and treatment of tumors is understanding how to prime the immune system to recognize the tumor cells as foreign, as invaders.
What did you use with her in terms of immune therapy? Was it plasma?
McIver: In our case, we focused on the surgery. Dr. Ledakis and the oncology team will focus on the immune therapy and Dr. Okoye will focus on the radiation. It’s really a multi-disciplinary approach trying to affect these tumor cells through several ways to try to help the body recognize them as abnormal.
To assuage any patient concerns out there you guys meet as a team, I guess periodically. You have the same patient but in different areas?
McIver: Yes. This is a great opportunity for teamwork and patient care. Interestingly, Dr. Ledakis ordered the scan. Dr. Okoye noted the scan called me and I went down to the cancer center and met with the patient. We communicate through the electronic medical record, but when necessary, in addition to team meetings, we’ll also pick up the phone and call for help.
Is that so you know as much as you can possibly know when you do the surgery? What’s going through your mind as you’re doing that? Are you solely focused on that?
McIver: The most important information is what the patient said is important to them. Meeting with the patient first and understanding what they consider a good outcome, what they consider as their optimal goal, and how much they’re struggling now. We carry that information and formulate the identity of the patient and that is primary in our efforts to help them. When it comes to surgery, most of the planning has been done before we even see the patient in the operating room. We have that understanding that these are the risks that we delineate and lay out with the patient and their family. We know whether this surgery, this care is a high risk, moderate, or low risk. That takes a lot of the pressure off when we’re actually in surgery.
Anything you want to add?
McIver: It’s just a great opportunity to be part of the team at Mercy and to be able to help people and impact their lives and be of service to them.
END OF INTERVIEW
This information is intended for additional research purposes only. It is not to be used as a prescription or advice from Ivanhoe Broadcast News, Inc. or any medical professional interviewed. Ivanhoe Broadcast News, Inc. assumes no responsibility for the depth or accuracy of physician statements. Procedures or medicines apply to different people and medical factors; always consult your physician on medical matters.
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