In this episode we host Dr. Mazda K Turel who is a practicing Neurosurgeon at the prestigious Wockhardt Hospitals, South Mumbai, India. Dr. Mazda specializes in the treatment of diseases of the brain and spine and advocates an approach to neurosurgery that is both balanced and proactive.

We interact with Dr. Mazda about Brain Tumors.

  • Types of Brain Tumors
  • Symptoms of Brain Tumor
  • What causes a brain tumor
  • Diagnosis of the Brain Tumor
  • How a neurosurgeon treats brain tumors.

To hear more from top doctors and surgeons visit https://www.drstories.com

Visit https://www.rxoom.com/neurosurgery to know more about Dr. Mazda.

Transcript

What is Brain Tumor, its types and treatment

A talk with Dr. Mazda K. Turel

Speaker: Mr. Vivek

[00:00]

Hello, this is Vivek Dubey. Welcome to Dr. Talks. Here we chat with the best doctors about diseases and conditions they treat. Our special guest today is Dr. Mazda K. Turel. Dr. Mazda is a practicing neurosurgeon at the prestigious Wockhardt hospital, South Mumbai, India. He’s also an Honorary Assistant Professor of neurosurgery at the grant Medical College. and Sir J.J Groups of hospitals. He specializes in the treatment of diseases of the brain and spine and advocates an approach to neurosurgery that is both balanced and proactive. Welcome Dr. Mazda. It would be great if you can share more about your background in medicine.

Speaker:  Dr. Mazda

[00:53]

Hi, good morning to everybody. I did my MBBS at the Grant Medical College in Mumbai, and I did my neurosurgery training at the Christian medical College in Vellore. Following which I worked there for a couple of years as an Assistant professor in neurosurgery and went  to Canada to do a fellowship in skull base surgery and neuro oncology followed by another fellowship in Chicago in minimally invasive spine surgery and another fellowship in China in cerebral vascular surgery after which I returned in 2017 and have been working at Wockhardt hospital, Mumbai.  Then as a consultant neurosurgeon and assistant honorary professor at the Sir J.J Group of hospitals and Grant Medical College in Mumbai.

Speaker: Mr. Vivek

[01:53]

Today, I wanted to discuss and learn about brain tumors from you. Can you please share with us what is a brain tumor?

Speaker: Dr. Mazda

[02:04]

So, brain tumor is an abnormal growth of cells inside the brain. It happens when a cell decides to undergo mutation and an overgrowth takes place. 50% of brain tumors are benign, and the other 50% are malignant. Again, there are two types of brain tumors. One is a primary brain tumor, where the abnormal growth starts within the brain itself and it usually does not spread to other parts of the body. So, a primary brain tumor may be a benign brain tumor, which grows slowly, has distinct boundaries, and rarely spreads and removing it leads to a potential cure. Whereas a malignant brain tumor is what grows quickly, rapidly, it has irregular boundaries spread to nearby areas in the brain and referred to by the public or by the common person as brain cancer. The other kind of brain tumor that we see quite often is what we call a metastatic brain tumor. And now these are brain tumors or cancers that start elsewhere in the body, and then spread to the brain via the bloodstream. You can have brain tumors, malignant brain tumors coming into the brain from the lung, the breast, the kidney, the prostate, and several other organs. And that essentially forms 50% of brain tumors. So, 50% of brain tumors are primary brain tumors, either benign or malignant, and 50% of brain tumors are malignant brain tumors. These are brain tumors coming from other parts of the body and affecting the brain.

Speaker: Mr. Vivek

[04.01]

Now, are there further classification in terms of what these brain tumors are between primary and secondary brain tumors. Do you have specific names for them?

Speaker: Dr. Mazda

[04:11]

If you look at a detailed classification, there are actually over 120 different types of brain tumors. When you look at only primary brain tumors, we classify them into benign and malignant, and benign are primarily Meningiomas, Schwannomas, Pituitary adenomas, and craniopharyngiomas. However, these tumors also, in some sense, are graded based on their aggressiveness and may require varying forms of treatment. The other primary brain tumor that we widely talked about is called Gliomas. They are brain tumors that arise primarily from the brain cells and those are also classified as Astrocytomas, Oligodendrogliomas, Ependymomas. And each of these tumors also have varying grades from grade one to grade four, grade one being the lowest grade of the tumor are the least aggressive and grade four for being the highly malignant variety of brain tumor.

Speaker: Mr. Vivek

[05:27]

What are the causes of a brain tumor?

Speaker: Dr. Mazda

[05:29]

That is a very good question. Actually. Someone who finds that out, will be given the Nobel Prize, because we really don’t know what the primary cause of brain tumor is nor do we know how to prevent them after they start in the brain itself. But there are certain risk factors. If you have cancer elsewhere in the body, there is a chance that may metastasize to the brain. Some people say that prolonged exposure to pesticides, some industry solvents and some other chemicals can lead to cancer in the brain. There are other inherent diseases like neurofibromatosis, where you get certain spots on the body, and those patients are predisposed to having brain tumors. So it’s primarily a combination of genetic and environmental factors and some other unknown causes that trigger mutations in the brain that causes this abnormal growth to kick up, and then it’s just a chain reaction, and it continues to happen.

Speaker: Mr. Vivek

[06.38]

Are there any specific symptoms which a patient can look for?

Speaker: Dr. Mazda

[06:43]

So, brain tumors really differ in their symptomatology, based primarily on the location of the tumor, and probably the size of the tumor? And these symptoms can result from having no symptoms at all to debilitating neurological deficit. When I say no symptoms at all, it’s possible that you may do a brain scan for something completely unrelated, you may have a head injury, and you may do a brain scan, and you may find a tumor    sitting over there. So those are called asymptomatic brain tumors. And we can discuss a little bit about that further. But one of the common symptoms of a brain tumor is headaches. And the headaches do not necessarily have to be suggestive of something called as raised intracranial pressure. Because when a brain tumor grows inside the brain, it causes something called a pressure affect or a mass affect in the brain, and it causes a stretch of the normal structures resulting in headaches. So, the headaches that are typical of brain tumors are usually headaches that involve the whole head and tend to be worse early in the mornings. If headaches that wake you up in the middle of the night, or early in the morning, those headaches can suggest that you may have a brain tumor, if a headache is associated with double vision. If a headache is associated with blurred vision, if a headache is associated with occasional blackouts, it’s possible that these may be signs of raised intracranial pressure, and you may be harboring something sinister and it might be worthwhile to get yourself checked. So, headache is a very, very important symptom. The other symptom that really presents with brain tumors is seizures of fits or epilepsy as we know it. So that results in a brain tumor that irritates a part of the brain. The patient can have an epileptic attack or a seizure where there is an involuntary contraction of a limb or twitching of the face or slurring of the speech. And that comes in a short amount of time. One to two minutes, with some head deviation frothing at the mouth of rolling of the eyes. So, seizure is another common symptom that brain tumors present with. Occasionally again depending on the location if the brain tumor is located in the cerebellum or the balance area of the brain, you may have difficulty in walking, imbalance while walking in some amount of dizziness. If the tumor is located in the speech and language area, you may have speech and language problems, word finding problems, difficulty in reading. If the brain tumor is in centers that are responsible for vision, such as the occipital lobe, then you may have visual dysfunction. If a brain tumor is located in the area that controls hand and leg function on one side, then the right sided brain tumor in the handle-like area may actually present with left sided weakness in the left hand and like. So, it really depends on the location. Sometimes, tumors within the frontal lobe may cause behavioral problems, emotional changes, impaired judgment, some kind of impaired sense of smell, if it’s large enough, and it compresses the optic nerve in vision problems. A lot of elderly people, sometimes, you know, they tend to forget, or they behave abnormally. They’re passed off as having some form of Alzheimer’s and one should not resort to you know, just labeling them as having any of those diseases because they can actually be harboring a brain tumor, and nobody knows about it. So before labeling anybody as having Alzheimer’s, one should always do a scan of the brain. Similarly, we spoke about frontal lobe tumors, tumors in the parietal lobe that may cause again problems with speech and language spatial problems because the parietal lobe is responsible for that function. We discussed occipital lobe tumors may cause visual dysfunction. Temporal Lobe tumors may cause language dysfunction. Now, if you have a tumor within the brainstem, the area of the brain where all the nerve fibers congregate to then eventually pass into the spinal cord, you can have a multitude of cranial nerve policies on one side and many presses on the same side or the other side depending on the size and location of the brain tumor. And there are other kinds of brain tumors called his pituitary tumors and these tumors arise within the pituitary gland. And, you know, when they grow they compress the optic nerve so you can have a visual dysfunction or you may have a hormonal dysfunction where they secrete an excess amount of hormone, the hormone secreting tumors are cortisol secreting tumors which causes something like Cushing’s disease, where you can have, you know, obesity, hyperpigmentation in the skin, easy bruising, or you can have gigantism, if there’s an excess of growth hormone, that is the tumor that is secreting growth hormone and you can have features of gigantism, you can have big hands and big feet. Suddenly in someone who’s an anomaly, a growing adult can have a sudden spurt of coarse facial features, the voice becomes harsh and the joints become thicken. And that should suspect that you could be harboring a pituitary tumor and you could have other endocrine dysfunction such as menstrual irregularities. Abnormal secretion of milk or Galactorrhea, problems with erectile dysfunction or decreased libido or even infertility can be a result of tumor within the pituitary gland. So the symptoms are very varied. One should always be on high alert to suspect the possibility of this happening based on the clinical symptoms that a patient comes with the presentation has to be looked at with very detail and I don’t have very low threshold of doing some kind of imaging at least that way we are safe and we make sure that we are not missing something that can be treated when caught early.

Speaker: Mr. Vivek

[13:26]

How do you diagnose a brain tumor once the symptoms are visible to you?

Speaker: Dr. Mazda

[13:32]

Some symptoms are visible, the first thing to do is imaging of the brain. And the most common kind of imaging of the brain that is available is an MRI scan. It uses magnetic fields and radio frequency waves to give a detailed view of the soft tissues of the brain. And you can view the brain three dimensionally in slices that can be taken from site to site or from top to bottom and then we inject contrast and it very nicely delineates brain tumors and the MRI is almost the gold standard for any kind of brain tumor. And then we also have a CT scan. The CT scan has its own benefits where it looks at blood and bone more carefully and correctly. And if you have a tumor involving bone, the CT scan gives a very clear idea of how much bone destruction has happened or if there is a bleed with the tumor. CT scan gives us good information regarding that it also allows us to follow up tumors in their temporal profile. So a combination of a CT scan and MRI, of course, PET scan, which is a slightly highly evolved metabolic kind of imaging that is required to assess the metabolism of brain tumors, but by and large, primarily, it’s either a CT scan or an MRI with contrast that really gives us all the information that we know or want to have from brain tumors, the MRI also has become very, very highly functional, where we can do a functional MRI and check the speech area, check the motor area of the brain, etc. And then we can also use fiber tracking to know whether these tumors have actually infiltrated the brain. You can obviously do additional tests for tumors arising from a vestibular hearing nerve. You can do an audiogram and that will help you add detailed endocrinology local evaluation will help in further understanding of a pituitary tumor. Similarly, visual field testing will help in understanding the kind of visual deficit caused by a pituitary tumor. And very rarely do we need a lumbar puncture.

Speaker: Mr. Vivek

[16:18]

Who treats brain tumors, as we know that there are different specialized doctors for different diseases? Who are the doctors one should go to?

Speaker: Dr. Mazda

[17:49]

So, ideally, a brain tumor is treated holistically by a multidisciplinary board, but in my opinion, the first person that patient interacts with should be a neurosurgeon, because most tumors require surgical excision. So, neurosurgeon is the captain of a ship as far as brain tumor care is concerned. And then obviously, depending on the nature of the tumor, you may need an oncologist, a medical oncologist, a radiation oncologist obviously a radiologist is a very important person to help us differentiate tumor from other conditions that could mimic a tumor, you can have a neurologist on board as well, and a neuro ophthalmologist and a neuroendocrinologist. So that forms the ideal spectrum of people taking care of brain tumors, but it’s primarily a neurosurgeon who takes care of brain tumors, but most patients initially present to a general physician because they’ll either have headache, or they’ll have some kind of neurological dysfunction, for which they go to the general physician and a general physician should be able to pick up these signs in order for an MRI or a CT scan, pick up a brain tumor and then refer the patient to a neurosurgeon who then goes ahead and takes care of the management of such a patient.

Speaker: Mr. Vivek

[17:51]

And once we know that a patient suffers from a brain tumor, then how is the treatment planned?

Speaker: Dr. Mazda

[17:57]

It’s a very broad-based question. Treatment options really vary depending on the type of the tumor, the grade, the size, the patient, whether it has spread, whether it’s a primary tumor, whether it’s a metastatic tumor. The goal of treatment is actually whether the goal of treatment is to cure the tumor or are you only trying to relieve the symptoms? Is the goal curative or is the goal palliative and sometimes treatments are used in combination with one another. For some brain tumors you may just want to observe that they have just been diagnosed with a headache and they don’t have any other symptoms and they look like a benign tumor, slow growing tumor. These can actually be watched on an MRI because it’s possible that 20 to 30% of them may never grow, especially an 85-year-old person incidentally detected with a benign tumor. You may not want to do anything because the tumor might have been present for several years in that patient. So observation or not doing anything is a line of treatment for a very, very select and definite form of tumors. We also call these tumors incidental Lomas. So, these are incidentally detected tumors, or tumors detected with mild symptoms, when we feel confident on the MRI are benign in nature and we can easily observe them. Then as far as medication is concerned, there are certain drugs that you give to reduce raised intracranial pressure. If it is a malignant brain tumor with a lot of swelling around it, you give steroids that is the most commonly used drug, and then you have drugs to prevent seizures. Anticonvulsant drugs so those are the medications that form part of tumor treatment but they only form part of the treatment they actually are not responsible for treating tumors. Surgery, in my opinion, is the mainstay of most tumors and the goals of surgery are multifold, it can help refine the diagnosis once and for all give you a clear cut hundred percent answer, we can remove as much of the tumor as possible without compromising neurological function and we can release the raised intracranial pressure that develops within the brain and the skull, we typically perform a craniotomy to open the skull and remove the tumor. Depending on the location, we can either remove it completely, or we can remove it partially. In some circumstances, if it’s in an extremely low point area, then we may just be able to do a biopsy, which we can do either with the help of neural navigation or stereotaxic, where we don’t have to open the whole head like we do with a craniotomy. But just make a small two millimeter hole in the skull and take a piece of tumor and send it for testing, following which depending on what the result shows, we may have to treat it with radiation plus or minus chemotherapy. Now, if the tumor is benign and you’ve removed it completely, there is no other adjuvant treatment that is required. However, if either the tumor is malignant even if you remove it completely, or you have left behind some tumor, depending on the grade, radiation forms a very important adjuvant therapy. Radiation uses controlled high energy x rays to treat brain tumors. And that damages the DNA inside the cells of the tumor making it unable to divide and grow. So, the benefits of radiation are not immediate. It is not like removing the tumor, but they occur with time. So aggressive tumors whose cells divide rapidly they tend to respond quickly to radiation. And over time, these abnormal cells die and the tumors may shrink. So a very, very pinpoint accuracy is required to treat these tumors so that the radiation doesn’t spill over to the normal part of the brain and cause side effects on a healthy brain around the tumor. There are several types of radiation. one form of radiation is called stereotactic radiosurgery, which delivers a very high dose of radiation in a single session and it’s precision radiosurgery. Sometimes this is used even for benign tumors in locations where we cannot remove it or where removing it can cause undue damage or in certain tumors where we removed most of it in a small piece has been left behind as a residue for which stereotactic radiosurgery is useful. Another kind of radiotherapy is fractionated radiotherapy which delivers lower doses of radiation over many visits. Patients either returned daily or over several weeks to receive the complete radiation dose. And that typically happens with malignant brain tumors where we give them radiation for about six weeks, from Monday to Friday, every day with Saturday Sunday as a break And then there’s a slightly more advanced proton beam therapy, which delivers accelerated proton energy to the tumor at a specific depth. But it’s not really widely available still in our country, except because for the exceptional cost of that treatment, and then you have gold brain radiation therapy, which delivers radiation to the entire brain, and it may be used to treat multiple brain tumors or multiple metastases, that’s radiation therapy. And then we also have chemotherapy. So, radiation and chemotherapy are sometimes given together. And both act by different mechanisms of action and chemotherapy drugs work by disrupting cell division. And over time, chemotherapy causes these abnormal cells to die and the tumor may shrink. So again, treatment is delivered in cycles with rest periods to allow the body to rebuild. Again, there are certain adjuvant therapies now that are available to treat malignant brain tumors. You can talk about immunotherapy or gene therapy, even hyperbaric oxygenation is used, and something called us tumor treating fields which use some form of magnetic waves. Using a cap that delivers electromagnetic energy to the scalp has also been used and has shown some success in clinical trials. So that just gives you an overview of how tumors are treated. Either you can leave them alone or observe them with routine MRI scans or You can treat them with surgery, or you can treat them with radiation and chemotherapy. There is only one rare type of pituitary tumor called prolactinoma, which is a hormone secreting tumor, secreting prolactin. And that tumor is what can be effectively treated with medication. But for other functioning pituitary tumors, we haven’t had that kind of success with medication.

Speaker: Mr. Vivek

[26:36]

What are the success rates of these treatment options?

Speaker: Dr. Mazda

[26:41]

So, success is a very relative term. If you remove a benign tumor or a grade one tumor completely, the chance of it recurring is very, very less than the success rate is close to 100%. You’ve cured the patient but that is again a small percentage of tumors that are like that. If you remove a high grade malignant tumor, which is a grade four tumor, which is the last stage of brain cancer, even if you remove the tumor, and you’ve given radiation and chemotherapy, the survival rate is about one to two years in a vast majority of patients, yes, there are outliers that survived three to five years. But in high grade brain tumors, the survival is about one to two years even with the current technology that is available. So, success depends on the kind of tumor that you have, the location of the tumor and the biological behavior of the tumor, how aggressive it is. Those are the factors that actually determine success in treating brain tumors and at some point, it just becomes a question of not enhancing life to a great extent but improving the quality of whatever life is still left.

Speaker: Mr. Vivek

[28:03]

How is the recovery plan for the patient?

Speaker: Dr. Mazda

[28:23]

So again, it depends on whether you have a primary brain tumor or a benign tumor or a malignant tumor. And most often, patients who have brain tumor surgery of any form are discharged from the hospital within less than a week’s time. And most patients remove sutures, get their sutures removed anywhere between one to two weeks. And then if there is no further treatment that is required, then most people can get back to work in a month’s time. Completely. Back to normal, you know, they will have some lingering pain or headache for about a week or two, that’s about it. But the scar is usually healed very well because the scalp is an extremely vascular structure, and patients go back to work. Now if those who are having radiation and chemotherapy, they may have a slightly prolonged recovery because radiation does affect your overall well-being a little bit and you may feel excessively tired and you may have left out and you may have some nausea, etc. So that treatment is usually about six weeks or so. And during that time, recovery takes a little longer and those patients if all goes well go back to work in about three months’ time. And then really for the recovery just depends on whether there is any recurrence of the tumor.

Speaker: Mr. Vivek

[29:53]

Thank you doctor for you inputs; they were very informative. Any other thing you would want to add about brain tumors that are not covered yet?

Speaker: Dr. Mazda

[30:02]

No, I think the real key is in diagnosing these things and not missing them and letting them fester inside the brain and just neglecting a headache, or just neglecting some blurred vision, or neglecting some amount of giddiness and saying and say it’s nothing. You should go ahead and get an MRI done. And even if an MRI is normal, it is okay. As long as you’re not missing out on something that, you know, if you catch a tumor earlier, a malignant tumor, if you catch it in stage two, rather than catching it in stage four, it makes a big difference in survival, you can probably add 10 to 12 years to your life and live life in it with a good quality of life, rather than missing it and catching it and that transformation. Really, nobody knows how quickly it happens. And it again varies from person to person. So early diagnosis and treatment is the key. So if anybody has symptoms headache and that’s not going away in one or two weeks of having taken some treatment, it’s just best to do an MRI to make sure once you have a clean MRI that doesn’t show any problem, then you’re fine to go ahead with any form of treatment because you’re not as a danger of endangering your life. So just early diagnosis and treatment really helps in picking up these brain tumors. And then really, it is a matter of what the final diagnosis is. Sometimes you may have an early diagnosis also, but it may be your last stage brain tumor, and then there is really not much you can do. But overall, I would say that early diagnosis helps in early aggressive treatment and probably better quality of life.

Speaker: Mr. Vivek

[31:42]

Great. Thank you, doctor. It was a pleasure talking to you.

Speaker: Dr. Mazda

[31:46]

It was my pleasure entirely. Thank you so much. Have a good day.

Speaker: Mr. Vivek

[31:51]

Dear listeners, we come to the end of this episode. Thank you for listening. Please share the podcast with your friends. Do rate and review it. Cheers till we meet next time.

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