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MRI, pathology and radiology done. Diagnosed with brain tumor. Should I go for surgery?

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Neurologist, Surgical
Practicing since : 1997
Answered : 96 Questions
Below is the link to the MRI reports, pathology and radiology.

The diagnosis based on the reports are that the lesion is a Brain Tumor and needs to be operated immediately. We are looking for an honest second opinion.

Below are the questions we are looking for help with.

- What sort of questions should one be asking surgeons and how do we decide which one to pick. I am looking for technical merit rather than their bedside manner.
- What's the state of the art equipment that should be used for performing such a surgery?
- By the reports can we tell if this is a primary or metastatic tumor?
- I know we need pathology to confirm the grade, but if one were to take a guess, what would be the grade for this tumor?
- After surgery what are the typical outcomes for someone considering her age, gender?
- Considering the area of the brain (temporal lobe) what are the risks/complications of surgery?
- We have been advised that these tumors typically recur. What are the rates of remission and the percentage of 5 year, 10 year, 10+years of survival for such patients.
- Is there anything we can do for the patient to pre/post surgery (Diet, Supplements etc..)?
Posted Sat, 13 Apr 2013 in Brain Tumor
Answered by Dr. Visvanathan K 14 hours later

I have gone through the dropbox files. Before answering the questions, I am confused there are blood reports of a 60 year old female and MRI report of a 61 year old female, both sharing the same surnames. Also, the MRI report says the lesion is in the frontal lobe and not the temporal lobe. Further, I am unable to see the MRI images. Would it be possible for you to send me jpeg files?

I can however try and answer a few generic questions you have posed.

The lesions look more like primary brain tumours and not secondaries. For operating on these tumours you need a unit with Neuronavigation equipment and an operating microscope. I am afraid that in India you have no objective means of assessing a surgeon's technical merit, as reporting surgical outcomes based on pre-op risk stratifications is not mandatory. Even across the world, except in Cardiothoracic surgery in the UK, this is not generally followed. So, what typically works in India is "word of mouth" and this is not necessarily accurate. Once thing that is good is if there is a team of experienced Neurosurgeon's available (like the centre I work in Chennai)

It is not possible to guess the grade exactly, but in a 60 year old the chances are that the lesion is likely to be one of higher grade 1.e, grade 3 or 4. But medicine is not an exact science, and unexpected outcomes are pretty common.

As for typical outcomes and risks and complications of surgery in this location- I can answer when you clarify if the location is frontal or temporal. Any brain surgery carries the risk of infection and bleeding, risk of stroke, paralysis, speech disturbances, CSF leak etc and risk to life. The risk of major complications including risk to life are in the order of less than 3-5%, and the other risk' probability varies according to the location.

The "prognosis" i.e what happens after treatment, survival etc depends on how much of the tumour has been removed, if any radiotherapy or chemotherapy has been given etc. Some locations make it possible for full removal, while others cannot be removed without paralysing the patient. If the tumour is Grade 4, the median survival is about 11 months which is extended to about 16 months after full treatment. If it is grade 2, then 5 and 10 year survival is possible, again depending on the factors mentioned above. Grade 3 behaves in the middle range.

I think there is nothing specific that needs to be done, except good family support and not letting your anxieties make the patient more worried than she is already. normal diet, plenty of rest helps.
Above answer was peer-reviewed by
Follow-up: MRI, pathology and radiology done. Diagnosed with brain tumor. Should I go for surgery? 6 hours later
Thanks for your reply. The tumor is in the frontal lobe and not the temporal lobe. It was a mistake on my part when I mentioned Temporal lobe. The pathology and the radiology reports are for the same person. The patient's pet name is Meenu that's why one report reads Meenu and the other one Manishi.

There are a total of 213 slices divided in 10 sections. What I have done is created a screencast that walks through each slice with a 1 second interval. You can pause at a particular slice through the screencast. If there is a specific section that you need to look at just let me know and I can create a specific screencast just for that.
Link to the screencast is WWW.WWWW.WW Once you have had a chance to review the imaging, can you let me know if removal of the entire tumor is possible or will the surgeon only be able to do a partial removal? Based on the location and other factors, is Radiation/Chemotherapy a possibility?

You are absolutely right about the word of mouth recommendations. That is what is so challenging for us as we have heard great things about many doctors. I am sure they are all good but without objective criteria its hard to pick one. Which doctor performs the first surgery and how much of the tumor will be removed will decide the outcome for the patient.
Can you tell me what hospitals in New Delhi have the latest Neuronavigation equipment. This will at least help us eliminate the others.


Answered by Dr. Visvanathan K 33 minutes later

Thank you for the screencast. I have gone through the images. While this could be any grade form 2-4, I would hazard a guess at it being either grade 3 or 2. The tumour looks like it can be removed radically. However, the only worrying factor is that it may be close to the motor cortex - the part of the brain controlling the movement of the opposite side of the body. Therefore, an FMRI of the brain with motor paradigm is one test I would personally get. Though I may be wrong, if the motor cortex is away from the tumour, then I can attempt to be as radical as possible.

Once the tumour is removed, depending on the pathology, radio +/- chemo is a distinct possibility.

I don't know much about the set-ups of major neuro centers in Delhi, but I am sure there are centers with neuronavigation equipment and the latest microscopes and microinstruments. I can only say that in the team I work in, we are a team of 5 consultant's working on a team under Dr XXXXXXX Ghosh- who you can look up online as he has his own website. We work as one team with shared responsibilities to give continuity of care. We have the South Asia's first installation of the Brainlab Curve neruonavigation equipment along with the latest XXXXXXX Ziess Opmi Pentero microscope + all the micro-instruments. I am not looking for you to travel to Chennai from Delhi, but if any one I know needs to have a brain op, I would look for a similar team of professionals.

Hope this helps.
Above answer was peer-reviewed by
Follow-up: MRI, pathology and radiology done. Diagnosed with brain tumor. Should I go for surgery? 18 minutes later
Dr. Visvanathan,

Thanks for the response. I am actually based in the US whereas my mother in law is in Delhi. We have not considered a hospital outside of Delhi but I will definitely look into Dr. XXXXXXX XXXXXXX

Doctors I have consulted in the US also believe that the mass appears to be poorly delineated and enhances with contrast faintly and uniformly. This brings up possibilities of low grade glioma, DNET.
The patient is not presenting with weakness in the left arm and typically in such cases an awake craniotomy with computer/image guided navigation would be the best option.
Does your team perform awake craniotomies and would that be something advised given the facts of the case?
Answered by Dr. Visvanathan K 17 minutes later

Thank you for the reply. Both myself and Dr XXXXXXX ( WWW.WWWW.WW have performed awake surgeries. i have done mine when I was working in the UK. Ours is a new and one of its kind team (for India-in the private sector), much like the teams in the US. Ours is also a team that is only 6 month's old and we haven't done any awake surgery yet. Before putting your mother-in-law through an awake craniotomy, which can be a challenge, we can consider it only if absolutely indicated as per fMRI results. A patient need not present with weakness, but if the tumour is very close to the motor cortex, the surgeon can damage the motor cortex when aggressively trying to remove the tumour. Therefore it helps the surgeon get his bearings right if fMRI data, neuronavigation, tractography etc are all available.

We do all our craniotomies at SRM with neuronavigation guidance and have recently also started integrating the neuronavigation with the microscope.....i.e when looking through the microscope, the outline of where the tumour is on the MRI is projected. I would say that it is pretty state of the art! That makes it more convenient for the surgeon and lessens operating time.

I hope all goes well with your mother-in-law and please do let me know if you have any further queries. Please give your feedback if you close the question.
Above answer was peer-reviewed by
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