Neurology

Brain Tumor Surgery
by Prof. Nejat Akalın, M.D.

Broadly speaking a brain tumor is an abnormal growth of tissue in the brain or central spine that can disrupt proper brain function. Doctors refer to a tumor based on where the tumor cells originated, and whether they are cancerous (malignant) or not (benign).

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Prof. Nejat Akalın, M.D.

Neurosurgery

Primary brain tumors begin when normal cells acquire errors (mutations) in their DNA. These mutations allow cells to grow and divide at increased rates and to continue living when healthy cells would die. The result is a mass of abnormal cells, which forms a tumor.

Secondary (metastatic) brain tumors are tumors that result from cancer that starts elsewhere in your body and then spreads (metastasizes) to your brain. These tumors most often occur in people who have a history of cancer. But in rare cases, a metastatic brain tumor may be the first sign of cancer that began elsewhere in your body.

Symptoms & Diagnosis

Brain tumor symptoms can vary according to tumor type and location. There are times a person may have no symptoms when their brain tumor is discovered, however symptoms can be:

  • Recurrent headaches
  • Issues with vision
  • Seizures
  • Changes in personality
  • Short-term memory loss
  • Poor coordination
  • Difficulty speaking or comprehending

Diagnosing a brain tumor can be a complicated process and involve a number of specialists, depending on many factors. A brain scan, most often an MRI, is the first step. A biopsy may be necessary, so a pathologist can be brought in to help identify the brain tumor type.

Treatment options vary:  Surgery, Radiation Therapy, Chemotherapy and Targeted Therapy and combination of those.

Surgery

If the brain tumor is located in a place that makes it accessible for an operation, your surgeon will try to remove as much of the brain tumor as possible. In some cases, tumors are small and easy to separate from surrounding brain tissue, which makes complete surgical removal possible. In other cases, tumors can’t be separated from surrounding tissue or they’re located close to sensitive regions in your brain, making surgery risky. In these conditions, your doctor will remove as much of the tumor as it is safe. Even removing the brain tumor partially may help reduce your symptoms and with the help of complementary treatments, cancer can be handled completely.

Surgery to remove a brain tumor carries risks, such as infection and bleeding. Other risks may depend on the part of your brain where your tumor is located. For instance, surgery on a tumor near nerves that connect to your eyes may carry a risk of vision loss. These risks can be reduced by an experienced surgeon and medical staff, performing in a well-established facility.

Radiation Therapy

Radiation therapy uses high-energy beams, such as X-rays or protons, to kill tumor cells. Radiation therapy can come from a machine outside your body (external beam radiation), or in very rare cases, radiation can be placed inside your body, close to your brain tumor (brachytherapy).

External beam radiation can focus just on the area of your brain where the tumor is located, or it can be applied to your entire brain (whole-brain radiation). Whole-brain radiation is most often used to treat cancer that spreads to the brain from some other part of the body and forms multiple tumors in the brain.

Side effects of radiation therapy depend on the type and dose of radiation you receive. Common side effects during or immediately following radiation include fatigue, headaches, memory loss and scalp irritation.

Radiosurgery

Stereotactic radiosurgery is not a form of surgery in the traditional sense. Instead, radiosurgery uses multiple beams of radiation to give a highly focused form of radiation treatment to kill the tumor cells in a very small area. Each beam of radiation isn’t particularly powerful, but the point where all the beams meet — at the brain tumor — receives a very large dose of radiation to kill the tumor cells.

There are different types of technology used in radiosurgery to deliver radiation to treat brain tumors, such as a Gamma Knife or LINAC, Linear Accelerator.

Chemotherapy

Chemotherapy uses pharmaceuticals to kill tumor cells. Chemotherapy drugs can be taken orally in pill form or injected into a vein (intravenously). The chemotherapy drug used most often to treat brain tumors is temozolomide (Temodar), which is taken as a pill. Many other chemotherapy drugs are available and may be used depending on the type of cancer.

Tests of your brain tumor cells can determine whether chemotherapy will be helpful for you and also to determine the type of pharmaceuticals to be used.  Side effects depend on the type and dose of drugs you receive.

Targeted Therapy

Targeted treatments focus on specific abnormalities present within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die. Targeted therapy drugs are available for only certain types of brain tumors yet, but many more are being studied in clinical trials,  many different forms of targeted therapy are being developed.

One of the most common surgeries: Glioma Surgery

Glioma is a type of tumor that occurs in the brain and spinal cord. Gliomas begin in the gluey supportive cells (glial cells) that surround nerve cells and help them function. A glioma can affect your brain function and be life-threatening depending on its location and rate of growth.

Symtomps

Most common symptoms:

  • Headaches
  • Seizures
  • Personality changes
  • Weakness in the arms, face or legs
  • Numbness
  • Problems with speech

Other symptoms include:

  • Nausea and vomiting
  • Vision loss
  • Dizziness

Glioblastoma symptoms and other symptoms of glioma appear slowly and may be subtle at first. Some gliomas do not cause any symptoms and might only be diagnosed when you visit a doctor because of another health problem.

Surgical Procedure

Surgery is the most common treatment for gliomas and requires craniotomy (opening of the skull). It is sometimes performed via intraoperative MRI or intraoperative brain mapping if the tumor is close by sensitive areas of the brain.

The biopsy sample is taken during/ before surgery that provides tissue samples to the pathologist. The pathologist will then be able to make an accurate diagnosis of the tumor’s composition and characteristics so your neurosurgeon can decide on the course of the following treatment.

Prof. Nejat Akalın, M.D.

Neurosurgery
  • Medical School, Ankara University
  • Specialty, Hacettepe University, Neurosurgery
  • University of Washington
  • H-index 32
  • Medipol Mega University Hospital, Head of Neurosurgery

Having 35 years of experience in the field of Neurosurgery, Prof. Nejat Akalan describes the level of neurosurgery in Turkey as compatible with the most experienced and developed countries of the world. He underlines in his center there is almost no disease that cannot be treated due to lack of knowledge or lack of technology.

He places particular interest in sub-specialization within Neurosurgery and in his team, he has established a sub-specialty-based concentration among his team members. There are physicians that concentrate on epilepsy for example, which is a very specific surgery that requires a certain type of knowledge, and physicians who deal with oncological tumors that require a totally different type of know-how. Radiosurgery, pediatric neurosurgery, oncology, vascular diseases, functional neurosurgery, spine surgery, etc. all require special attention.

“In a lifetime of a neurosurgeon, it’s impossible to give all your attention at the same time to all these subgroups”.

While Prof. Akalan is more focused on Pediatric Neurosurgery and Epilepsy Surgery, there is always a medical discussion among colleagues about cases, that concludes with the most experienced physician in that particular field of treatment taking the responsibility of the patient.

Dr. Nejat says 40 years of experience brings many different cases to learn from. Performing a specific type of treatment many times sure has some benefits, but more important is to learn the basic skills properly, being able to perform it in a good manner and to adapt yourself to the progress in surgery.

“You should be knowing what you are doing. In that way, whether you do 10 times a case or 100 times a case doesn’t make any difference”

Academic titles and surgical skills are different and Prof. Nejat Akalan considers them to be complementary to each other. A practical example is how a surgeon is assessed in a clinic that is both with academic capacity and surgical skills.

Prof. Akalan states that standards of Turkish Medicine is above the level of other infrastructural systems of the country, probably because of handpicked physicians who are sent to developed countries in 40s to 50s to be trained properly. These physicians established medical departments and more importantly the culture that let medicine improve day by day. Another chance of Turkey according to Professor is having a crowded population which is around 80 million, which provides an enormous variety of different cases for surgeons to acquire more and more experience when compared to smaller countries.

From a patient’s point of view, Dr. Nejat thinks that there is more than enough data to make a comparison among alternatives for an international patient while picking up a doctor or a facility. He recommends all patients do internet research to evaluate the experience of the physician, the facility in terms of possessing adequate technology, instruments, and technical know-how.

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