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Often times as neurosurgical residents we’re asked by faculty why we would (or wouldn’t) operate on patients. Therapies for cancer can have different goals. You, hopefully, don’t operate just because a brain tumor is there. Often times, surgery for malignant tumors that cannot be “completely” resected – in which a gross total resection cannot be achieved – has limited influence on cure or survival rates. I’m not a big fan of the idea of cytotoxic reduction.
In general then surgery can have any of three goals. It can have an oncological goal – if the tumor can be resected to a degree to influence survival. It can have a palliative goal – if debulking the tumor will relieve symptoms. It can have a diagnostic goal – if getting tissue will identify the tumor so that other treatments can be initiated.
Non-invasive therapies, such as chemotherapy or radiation therapy, can similarly have either an oncological or palliative goal.
All of these therapies can have significant morbidity and side effects and so the decision to undergo therapies merely as a matter of palliation should not be taken lightly. In many cases you can exchange current symptoms for other symptoms or increased risks associated with therapies.
Such makes a study published in the Journal of Clinical Oncology even more discouraging. In the study more than 380 patients with essentially terminal lung cancer with neuro or bony metastasis were surveyed as they underwent radiation therapy. The radiation therapy was solely a palliative therapy to relieve symptoms. And yet,
Seventy-eight percent of patients believed that RT was very or somewhat likely to help them live longer
The therapy was only palliative and had no oncologic goals and no hope of improving survival.
Twenty percent of the patients expected radiation treatments were “very likely” to cure their cancer
Its tough to relate these complex ideas to patients when there is such a disparity in information. Often times, in my experience, prognosis is discussed in vague terms. “This is not a curable disease,” or things along those lines without discussion that this is actually going to be fatal or discussion of numbers in terms of survival or what progressive symptoms and quality of life are likely to look like. Difficult discussions no doubt. But without such discussion it seems impossible to fully explain things like palliative therapy.
I know its just me but it seems the summer of Naegleria Fowleri, the “brain eating” amoeba, that each year makes headlines in the American south. In short order there have been at least three cases I can think of that have gotten significant media attention. It seems more prevalent in the news than I remember it in previous years. And yet the disease remains as rare as ever. Perhaps its just the coverage of Kali Hardig, the first survivor of the meningoencephalitis caused by the amoeba in decades.
I will say she looks remarkably non-devastated neurologically for having gone through this infection.
N. Fowleri enters the brain through the nose. It lives in warm, shallow, still, fresh water.
The symptoms of its meningitis occur within a week of infection. Rare cases of survival are probably related to early diagnosis. Mainstay treatments are highly ineffective but center on amphotericin B plus or minus steroids. The CDC is handing out miltefosine this summer as a new possible treatment for amoebic meningoencephalitis. But all three of the cases I know about got it and two of them didn’t survive. Not a massive shift in prognosis but considering where we’re starting from any other therapy options are probably welcomed.
Prions, the misformed proteins behind the various spongiform encephalopathies (including Mad Cow disease), are difficult things to sterilize for. They’re not “living” and so the typical techniques used to sterilize surgical instruments before they’re use in the next surgery are ineffective. These prions are infective. You can transmit these fatal, horrific encephalopathies from one patient to another via organ transplants or contaminated surgical equipment. Contaminated equipment may have exposed a number of people undergoing spinal procedures in Massachusetts recently, it was revealed earlier this month.
Five patients underwent spinal surgery at Cape Cod Hospital with the same potentially contaminated instruments used on a New Hampshire patient who likely died from CJD, a rare and fatal brain disease. Dr. Alfred Delmaria with the MA Dept of Public Health says, “The instruments are so specialized, they were carefully tracked, know exactly where they went.”
I remember once doing a stereotactic brain biopsy where, amongst the differential was Creutzfeldt-Jakob disease. It turned out not to be that but before the surgery everyone sat down in a conference room and talked about the steps we were going to take to only use equipment that could safely undergo the sterilization techniques needed to rid prions without destroying the equipment and the quarantine techniques that were going to be used to make sure all the used equipment got to the right place for proper sterilization.
This case in Massachusetts isn’t the first time there has been a scare over prion contaminated surgical equipment as a transmission vector. It won’t be the last despite commercial products coming on line to try to reduce such risk.