2 Neurosurgical “Firsts”
words by Mary Ann Littell / photographs by John Emerson
Shabbar Danish, MD
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n the world of surgery, someone has to be first — the first to undergo an experimental, possibly risky, but potentially groundbreaking procedure, and the first to perform it. Shabbar Danish, MD, and his patient Susanna DeNude are such a pair of trailblazers. In July 2010, DeNude became the first person in the U.S. to have laser ablation
surgery for an intracranial ependymoma, a resistant type of tumor growing from the cells lining the brain’s ventricles. Danish, an assistant professor of surgery and director of functional neurosurgery at RWJMS, performed the procedure.
What does it take to be the first? For the physician, it’s a combination of training, courage, confidence and a bit of daring. The patient also needs courage and confidence in the surgical team. “Most patients would be frightened at the prospect of being the first to undergo a new procedure,” says Danish. “It took time to find the right person.”
That was DeNude. The 58-year-old teacher had been battling the tumor since 2003 and had two open surgical procedures to remove it, the second in September 2009. She underwent radiation, but the tumor grew back deep in her brain, amid a tangle of blood vessels. It caused her to have seizures. “An added complication was that following her surgery, she had problems with her scalp healing,” explains Danish. “For those reasons, we didn’t want to open the skull a third time.”
The image on the left is obtained via continuous MRI thermometry, in which all points within the brain are converted to temperature estimates. The thermal energy is delivered to the lesion, which is seen by the color change to yellow, then red. The image on the right represents an estimate of the thermal damage created by the laser. The area within the orange is the ablation zone.
Enter the laser. Danish did not set out to find a new surgical tool. “We had just obtained a state-of-the-art navigation system at Robert Wood Johnson University Hospital — I call it a GPS for the brain,” he explains. “The maker of the system said it was compatible with new laser technology from a company called Visualase. We met with them, completed a feasibility study, and determined that the technology and approach may be helpful to some of our patients. ” The hospital neurosurgical staff underwent special training to perform the procedure. The Visualase laser technology received FDA approval about a year ago.
Meet pioneering patient Susanna DeNude: She is the first person in the U.S. to have a groundbreaking new surgical procedure to eliminate a resistant brain tumor she’d fought for eight years.
“Because laser ablation is guided by MRI imaging, it’s more precise than prior ablation techniques, which makes it possible to perform deep in the brain,” says Danish. “This tool is not for everyone, and it’s not a replacement for any adjuvant therapy, such as chemotherapy or radiation, but is used in conjunction with them. We’re recommending it for people who have run out of other treatment options, either because of the location of their tumor, their age, or the presence of severe illness, such as cardiovascular disease.” For instance, he says an 80-year-old patient with multiple medical problems might not be a good candidate for open brain surgery but could potentially undergo laser ablation.
DeNude’s laser procedure was uneventful and much more easily tolerated than her two prior procedures. First, a navigation MRI determined the exact location of the tumor. She was then taken to the operating room and sedated, and the laser was inserted into her brain through a hole about the size of the end of a pen and guided directly into the tumor. She was then brought to the MRI unit, where the laser hardware and software were connected to a specialized computer system that would monitor the procedure and the brain’s temperature in real time. Once the tumor was destroyed, all she needed was a stitch and a Band-Aid. Total ablation time was three minutes. Total time in the hospital was less than 24 hours. Thus far, the tumor has not recurred and she is doing well.
“The concept of laser ablation is not new. It’s been around for 20 years,” points out Danish. “What’s new is that we can watch it continuously in real time on MRI.” He adds that small tumors can be ablated in as little as two or three minutes, while larger tumors can take longer. The entire procedure from initial MRI to completion takes several hours. “Fifteen years ago, it could take over an hour to ablate a tumor,” says Danish. “That was too long for patients.”
“Our program is growing,” says Danish. “We’re currently the busiest center in the U.S. using the Visualase laser for thermal ablation. Thus far, we’ve had very good results. ” About 100 adults nationwide have undergone the procedure.
Danish had another ‘first’ in October 2010, when he performed the first pediatric brain tumor ablation in the U.S. The patient, 8-year-old Madison Beggs of Howell, NJ, was diagnosed with a highly aggressive, and until now, inoperable tumor located on her brainstem, inaccessible for traditional open surgery. She was initially seen by Rachana Tyagi, MD, assistant professor of surgery at RWJMS. Tyagi consulted with Danish to see if Madison would be a good candidate for the laser ablation.
“In Madison’s case, her predicted survival would’ve been months,” says Danish. He explained to her parents that the procedure was new. Madison was the first patient with her pathology, and the first child with a brain tumor, ever to be treated with a laser. Her other options would’ve been to have chemotherapy and radiation without surgery.
“Using the laser, we were able to remove the entire tumor,” says Danish. “We’re watching her very carefully to see if there is a recurrence. So far, she is doing very well.”
Danish and the neurosurgery team are preparing a research study in conjunction with The Cancer Institute of New Jersey to use the laser for patients with inaccessible brain tumors prior to using chemotherapy and radiation, to see if that will make a difference in overall survival rates.
“This technology is in its infancy,” he says. “It’s going to take years before we really understand where it fits into the overall armamentarium of treatments for brain tumors.”
For more information on this procedure, visit rwjuh.edu/ablation