About Author: Dr Anandh Balasubramaniam is a Neurosurgeon, Neurologist and Spine Surgeon in Hyderabad. With overall experience of 28 years in these fields, Dr. Balasubramaniam currently practices at Yashoda Hospitals. He holds an MBBS and MS – General Surgery degrees from Jawaharlal Institute of Postgraduate Medical Education and Research (JIPMER), Puducherry. He is a member of Member of the Neurological society of India, NeuroOncology Society of India, Stereotaxy and Endoscopic Society of India, Congress of Neurological Society of India, Intra Op Imaging Society and World Society of Stereotaxy and Functional Neurosurgery.
Brain tumors are common tumors in children and less common in adults and they could be benign (ordinary tumors or non-cancerous) or malignant (cancerous). They usually are silent till they grow in size to produce increased pressure symptoms with complaints of headache and vomiting which is most likely during early morning hours, and with progressive worsening in severity, along with visual blurring, with vomiting eventually help in relieving the headaches.
Some tumors next to important nerves can cause weakness of the action of the particular nerve and result in diminished function of a particular part of the body – like eye movement, visual impairment, face muscle movement, hearing loss, swallowing difficulty, weakness of hands or legs, difficulty in walking etc or seizures.
In young children there could be an abnormal increase in size of the head, apart from loss of function. These days due to increased awareness and availability of medical services, tumors are detected early and in large numbers. Due to advances in technology and understanding of the disease, the treatment methods have also become safer, minimally invasive and more effective than ever before. Some tumors which were considered inoperable can be safely operated upon now, some can even be cured without surgery.
MRI scan is usually the gold standard investigation of choice to localise and characterise brain tumors, both for diagnosis and treatment planning. MRI is also the gold standard for assessing treatment with surgery or radiotherapy/chemotherapy as the case may be. Higher field magnets give more critical valuable information not only of the tumor but also of the functioning areas in the brain that need to be preserved for normal function 3T intraoperative MRI (iMRI) is a revolutionary technology for neurosurgery, especially for brain tumor surgeries. The most advanced 3T intraoperative MRI helps doctors to do neurosurgeries safely as well as accurately. Intraoperative Magnetic Resonance Imaging or IMRI is used by neurosurgeons to visualize the patient’s brain during surgery without the need to move the patient out of the operation theater. This cutting-edge technology helps to create accurate pictures of the brain that guide the neurosurgeons to remove tumors of the brain and other abnormalities during operation in a single setting. Intra operative imaging with ultrasound, or Intra op MRI have become invaluable in improving the efficacy and safety of the surgery in most tumor surgeries thereby improving the outcomes and avoiding unnecessary second treatments.
Methods of treatment may include surgery and excision, with post-operative radiotherapy and chemotherapy as needed. Some tumors can be directly treated with Stereotactic Radiotherapy without open surgery. Surgery can be endoscopic or minimally invasive as required with the use of microscope for better visibility. Newer anaesthetic techniques with the ability to operate with a patient being awake but without pain, to monitor the neurological functions like hand and leg movement or speech can be done safely and effectively these days. This also includes intraoperative neurophysiology monitoring and stimulation to preserve function.
Tumor patients could suffer even more during COVID-19
Due to the pandemic, the patients with brain tumors too are suffering due to lack of timely intervention. The fear of contracting COVID infection and the logistics for patients to reach multispecialty hospitals equipped with the best of facilities which is ideally needed to treat such cases are some of the causes for delay in seeking attention. If and when these patients develop the COVID infection, it may be harmful to operate during the period of infection as the complication of COVID could increase and be fatal too (especially if the surgery needed is through the nose as in some cases of tumors like pituitary tumors).
Since brain tumor surgeries are sometimes very critical and may need postoperative ICU care with ventilation for a longer period of time, there may be hesitancy on the part of doctors to undertake major surgeries during this period due to lack of ICU beds and ventilators (which are already in great demand for COVID patients). So, in more ways than one, the brain tumor patients are not getting timely care as needed. If the tumor is benign (non-cancerous) there is no harm in waiting for a few months till the situation is suitable and safe for such hospital admissions and surgeries.
If the tumor is malignant (cancerous), waiting may result in further progression of the tumor and perhaps make it untreatable at a later stage. Some benign tumors pressing on nerves (vision nerves by pituitary tumor) or spinal cord and causing loss of function too may need to be attended to early to preserve important function. One needs to weigh the pros and cons of immediate surgery in the given circumstances with attendant risks involved versus delayed surgery after a few weeks to even months risking growth of the tumor. The decision needs to be taken with due diligence and in discussion with the patients and their relatives or caregivers with an individualized approach,
If surgery is likely to be delayed due to the pandemic situation, some cases may be amenable to direct treatment with radiation as possible and such options need to be discussed and availed as possible for example the Stereotactic Radiosurgery in a vestibular schwannoma which is a benign tumor that arises from the neurilemma sheath of the auditory vestibular nerve, also known as the eighth cranial nerve which transmits sound and equilibrium (balance) information from the inner ear to our brain.
Post-operative treatments like radiation and chemotherapy that are needed also become difficult to administer in the current scenario where patients may have to stay in different cities closer to a hospital for prolonged treatment for over 6 to 8 weeks. Where the treatment can be postponed, it can be considered suitably, or referred to a centre near their home, as per availability. Giving chemotherapy also lowers the immunity of these patients and makes them susceptible to infections. These considerations too need to be kept in mind and extra precautions need to be observed by the patient and relatives to keep more trouble at bay.
Some tumor patients who have already undergone treatment and are under follow-up care are also facing the difficulty of timely follow-up consultations that need to be done. Some are skipping yearly investigations that need to be done to check that the disease is under control, as they are unable to travel or visit a hospital in the present scenario. Thankfully technology is helping with telemedicine where patients can contact their specialists online and take expert advice. A few patients are also getting the scans needed closer to their homes, and consulting the status with their doctors online. At all costs one should not postpone regular checkups due to this pandemic, and should reach out to their doctor online or telephonically and get the much needed expert advice as feasible. Neglect can lead to harm later.
*Views expressed by the author are his own.