Gadget Gobbles Brain Tumors -- In Depth Doctor's InterviewDr. Murali Guthikonda, Chief of Neurosurgery at Detroit Medical Center, talks about the new tool helping surgeons take out brain tumors that used to be untouchable.
How difficult it can be to remove tumors?
Dr. Guthikonda: Part of the exploration behind is being that I’m in a specialist position here with advanced training. Some of the patients that I get are actually seen already by other neurosurgeons. They feel that technically they’re challenging and so they make a choice of referring those patients to see me if they feel that the patient is going to get better care with the advanced technology.
By the time you see them other doctors have said we can’t get to these.
Dr. Guthikonda: Correct. They already saw them and they feel that it is high risk and also difficult to access. All those things combined together is the reason why they send them to see me.
Are we talking cancerous and noncancerous?
Dr. Guthikonda: Most of the patients that I see are patients without a cancerous type tumor. These are all benign tumors that have been progressively increasing in size for whatever reason and starting to cause symptoms. That also makes it difficult because the benign tumors grow slowly so the brain tends to accommodate to the point sometimes they can get pretty big before they even come to see the physician. That again makes it somewhat difficult for the average neurosurgeon who does the so called bread and butter neurosurgery.
Can people live with benign tumors without really doing anything?
Dr. Guthikonda: Correct. We do see a lot of patients with a tumor that are not causing any symptoms and that are small enough we continue to watch them. But if they’re in parts of the brain that’s eventually going to make them go blind or they have reached a size even though they are benign are causing to have a lot of symptoms then you can’t live with the symptoms even though you know you have a benign tumor. That’s when you end up having to deal with it and take care of it.
What kind of symptoms are we talking besides blindness?
Dr. Guthikonda: Depending on the location of the tumor. If the tumor is in an area of the brain that controls your thoughtful process and things like that, they can slowly cause confusion, loss of memory, and sometimes progressive balance issues. Most of the time, because the tumor is so close to the optic nerve, they can lose their eyesight and vision and things like that.
How do you remove them?
Dr. Guthikonda: The removal of these tumors is very tricky. Whatever you do you have to do it in a way that you’re not going to cause or create any additional deficient that they came to see you with. It is pressure simply because these are patients who are otherwise healthy. They are working up until the day they come into the hospital and they are doing different businesses. Attorneys, teachers and even physician. Now you’ve got to make sure they get back to their profession.
How has the NICO helped relieve some of that pressure and help you get to some of the tumors you see that may be more difficult?
Dr. Guthikonda: There are tumors that are for example deep in the center of the brain. What that means is in order to get to the brain now you have to go through five, six, seven centimeters thickness of the brain and then there are tumors that sometimes we do operate through the nose. What we call transnasal procedures. There’s no incision. We use an endoscope and a high def camera. We are not even looking at the patient, we’re looking in a camera trying to operate on the image from the high def endoscope cameras. With the NICO, because of its size and advantage, we can get this tiny instrument probably the size of four millimeters and get to the lesion and try to remove it. In that sense it has made a big difference.
Is it less invasive than traditional?
Dr. Guthikonda: It’s less invasive in that even to get to the target that’s the tumor you’re not going through a lot of brain tissue and causing a lot of brain damage. Once you get there you are able to remove it, peeling it away slowly you know bit by bit, piece by piece with the NICO.
How does the NICO work?
Dr. Guthikonda: We do a burro hole. Burro hole is the size of a dime size opening in the skull. We insert a camera with the endoscope and the lighting system. The system has multiple openings. One of them is carrying the light and the other one is ran for this NICO. The NICO actually passes through a tiny aperture through the endoscope. You’re visualizing through the endoscope and the camera. The cutting tool that is the NICO actually is working in your line of site at the tip of the instrument.
Is it shaving it down layer by layer?
Dr. Guthikonda: It’s a side cutting tool with a rotating blade. There is a shaft and then there is an inner tube within the tube and the inner tube keeps rotating with a suction at the other end of it. The suction sucks up the tumor into a little aperture and then as the blade is rotating it just keeps cutting and then sucking up the tumor.
What’s the advantage of not having to use that heat?
Dr. Guthikonda: The lasers especially if you’re working around white structure like optic nerve any heat that you generate can get transferred to the nerve and cause heat damage. But the NICO is working under water and basically creating no heat. It’s working purely by mechanical suction and cutting. As opposed to a laser which is basically evaporating the tumor. With the laser, the water content in the cells of the tumor interacts with it and then basically the cells explode. With the NICO, you’re actually seeing the tumor coming out at the other end.
Do you use both methods?
Dr. Guthikonda: We use both, yes. We use both lasers and there is a new device called fiber laser, it’s made by a from a company by MIT. We were the first ones to evaluate that. We’ve been using it for three years now at Detroit Medical Center.
What piece would you rather use, the laser or the NICO?
Dr. Guthikonda: The lasers don’t work under water. The laser is where you have a controlled situation where the tumor is close to some white structures and that you can carefully remove this tumor away from the white structures. They both have different purposes sometimes large big deep tumors are best dealt with the NICO. When we’re operating inside the center of the brain there is spinal fluid so the spinal fluid that does not allow the laser to go through so you have to use the NICO.
Before what did you do, did you have to do more invasive openings?
Dr. Guthikonda: Yes you had to open the skull and make a bigger opening in the brain and go down and look at it. Using the operating microscope you can see a three dimensional view as opposed to the endoscope.
Does the NICO have a lower risk?
Dr. Guthikonda: Definitely yes. There are tumors that you can’t even reach even if you go through the brain sometimes. We operated on a young gentleman that had been carrying around with the diagnose of a brain tumor nobody could take it out for about six or eight years. He came to see us and that was our first encounter with the NICO at Harper Hospital about two years ago. We were able to remove the tumor, all of it, from back to front completely going through a small opening of about one and a half centimeter space between the brain and the skull.
How did that make you feel?
Dr. Guthikonda: Very elated. The technology is what is making us look better and patients are happy.
Are there any risks with this or anyone that might not be right for this?
Dr. Guthikonda: It may not work if the tumors are really hard and firm or calcified. Most of the soft tumors can be removed with the NICO.
In Alice’s case she was miserable for a long time because of the tumor.
Dr. Guthikonda: Alice had a strange diagnose of multiple cysts in her entire central cavity of the brain, what we call the ventricles. They were just growing inside her brain and no explanation for it. She was having problems with walking, headaches and balance issues for a long time. She’s been going around with this diagnosis for three years and no treatment. She finally came to see us and we were puzzled by her whole MRI appearance with the cysts. We didn’t know which way we were going to go and luckily the NICO came to my mind so we thought that was the best ideal situation.
And she seems to be doing fine now.
Dr. Guthikonda: We had to do surgery in two different burro holes because the reason for her problem was in two different areas. With two tiny incisions, probably the size of a half a matchstick length incisions, and two dime size burro holes we were able to deal with all these cysts and leave her fluid buildup in the brain, the hydrocephalus. We saw her in the office, she was ecstatic her MRI after the surgery looks excellent.
How many of those cysts did she have?
Dr. Guthikonda: She had twenty or thirty cysts in each brain, each side. We didn’t have her take out all of those because we knew it was benign. We took out those that were causing the symptoms and the obstruction of the spinal fluid.
How many did you end up taking out?
Dr. Guthikonda: At least five or six on each side.
And that relieved all that?
Dr. Guthikonda: Yes. Plus we relieved the obstruction, the offending cysts that was the most important.
Do you think this is going to become more the standard of care?
Dr. Guthikonda: I think it’s probably one of the most useful tools in terms of the minimally invasive neurosurgery that has come about in the last five years. I think the tools that we have now in our, what we call armamentarium, are the lasers, the NICO and the endoscope. These are the three truly contributed to the minimally invasive neurosurgery.
Is it FDA approved?
Dr. Guthikonda: Most importantly you’ve got an FDA clearance. I think that makes a difference