When the Air Hits Your Brain: Tales from Neurosurgery

by Vertosick, Frank, Jr.

  Sarah turned her eyes toward me and gave me a look of iron conviction. “Jesus is my Savior,” she intoned slowly, “and I believe He will let me keep my child. We’ve been trying for three years to get pregnant. So do your biopsy, but spare me the details of your ‘treatments.’ I will keep this baby. Please, I don’t want to be mean, but leave us alone for a while.”

  The husband produced a Bible and read silently as I stole away from the room.

  Dr. Sakren served as our “stereotactic” specialist. Stereotaxis is the art of placing biopsy needles and other customized tools precisely into the brain’s depths, using an awkward, expensive device known as a stereotactic frame. Before the widespread use of stereotactic techniques in the 1980s, tumors situated below the brain’s surface were biopsied “freehand,” with the surgeon’s intuition as the only guide to the tumor’s location. The surgeon might cut a large craniotomy flap over the suspected tumor site and take an educated guess as to where the lesion might be, often attempting a dozen or more blind needle aspirates before either achieving a positive diagnosis or abandoning the procedure altogether. “Freehanded” brain-poking carries a high likelihood of missing the tumor completely, and, worse, a significant risk of catastrophic bleeding.

  Nowadays, to perform a stereotactic tumor biospy, the surgeon bolts the aluminum stereotactic frame to the patient’s skull under local anesthesia and then takes the patient to the CT scanner. Brain and frame are imaged together so that brain lesions can be cross-referenced with the frame’s centimeter markings. Because the frame is held in place by graphite pins drilled into the skull’s outer layer of bone, the correlation of the frame’s markings with the internal structures of the head remains exact. The position of a brain tumor relative to the metal frame cannot change, even as the patient jostles from operating room to CT scanner and back again. Such accuracy could never be maintained with more civilized means of attaching the frame to the head (with Velcro chin straps, for example).

  After the scan, the surgeon chooses a biopsy point on the scanner’s video screen, using a light pen, cursor, or computer mouse. In Sarah’s case, our target would be one of the enhancing areas within her left frontal lobe. The scanner’s onboard computer provides coordinates of the biopsy point relative to the frame’s markings. Back in the operating room, a metal arm guides the biopsy needle to the target designated by the computer-generated coordinates. Because of the precision of this method, the biopsy requires a scalp incision and skull opening just large enough to admit the biopsy needle (less than half an inch). Since only one or two passes of the needle are needed, the chances of injuring the brain with this method approach nil.

  As valuable as stereotaxis has proven, their neurosurgical peers view biopsy surgeons as wimps—surgeons who do tiny operations because they lack the skill or stomach for “real” brain surgery. Stereotactic surgeons are the field-goal kickers of our specialty: skilled, well paid, and thoroughly indispensable on select occasions, but not true players in the eyes of the more violent members of the team.

  I presented the case of Sarah Clarke to Sakren the day after her first seizures. He looked at her scan with a squint. “So she wants to keep her baby. Fine, we’ll see what happens. But I know the type. ‘God wants me to live, He has a special purpose for me.’ If God wanted you to live He would not deposit a malignant glioma into your dominant frontal lobe. Personally, I think she should just get an abortion preoperatively and be done with it. What do you think?”

  “I think I wouldn’t waste my breath asking her to consider an abortion. I can tell you the answer to that question right now.”

  I had seen the answer in her eyes and heard it in the tone of her voice. Sarah would keep her baby, no matter what. Jesus, and her own iron will, would see to it.

  Cancer patients are told to direct anger at their tumors, to “fight” the disease as they would fight some evil, hateful enemy determined to rob them of all that is precious. A useful technique clinically, perhaps, but the emotional colorations should not be taken literally. Cancer is not evil, not the enemy. Cancer is a biological process which has evolved for a very useful purpose: to kill us.

  Although we look at ourselves as organisms, we are really societies comprised of trillions of specialized cells—blood cells, nerve cells, muscle cells, gland cells—cells which behave in accordance with communal laws developed for the good of the society. We are like giant hives and our microscopic cells the bees and wasps within.

  In any society, certain individuals choose to ignore the societal constraints and march to their own drummers. Likewise, in our own bodies, rogue cells arise which do not respond to the laws regulating their growth. These aberrant cells divide endlessly, creating dysfunctional masses of tissue which compress other organs and commandeer nutrients. The cells escape their normal habitats and metastasize to other parts of the body. Like human miscreants, misbehaving cells have little regard for the society in which they live and will destroy it if given the chance. Indeed, cancer evolved for precisely this reason—to destroy the host.

  Cells which grow beyond their normally defined limits are neoplastic; neoplastic cells which invade and destroy tissue, or which detach and spread to other parts of the body, are cancerous. While all cancers are neoplasia, not all neoplasias are cancerous. For example, common warts are neoplastic, but not cancerous.

  Most of the scourges of aging arise from neoplasia. In addition to cancers, male prostatism, eye cataracts, degenerative arthritis, and atherosclerosis (hardening of the arteries) result from unchecked proliferation of normal tissues. Even dementing brain illnesses, such as Alzheimer’s disease, stem from neoplastic overgrowth of brain cells called astrocytes. As our cellular society grows senescent, neoplastic behavior becomes rampant until our bodies fall, like ancient Rome, into anarchy and ruin. Ubiquitous in the elderly, neoplasia is more a form of planned obsolescence than a disease.

  To understand cancer’s role in evolution, we must remember that we are built to die. Just as automobiles roll off the assembly line with a predetermined lifespan, the fertilized ovum programs us to decay and perish in an immutable sequence.

  The long-term viability of multicellular creatures on this planet demands that each generation enjoy its finite day in the sun and then be thrown from life’s stage to make way for a new cast of players. A continuous turnover of organisms, with mixing and mutations of genes occurring in each new generation, gives life flexibility to survive a wide range of climate shifts. There is no biological reason why we could not be immortal. Indeed, we form the tail end of an unbroken chain of protoplasm, five billion years long. However, immortal species would have to stop replicating, else they would smother themselves.

  Nature chose not to populate the earth with static, immortal species. To do so would place all of life’s genetic eggs in one basket, running the very real risk that some drastic geological event could wipe out all life on earth. To prevent this, the gene pool must be in constant flux, changing at a rate fast enough to keep pace with any environmental perturbations that might arise. Thus, all things must die. Death is not a flaw, a failure of biology, but an essential design feature for constant existence on an inconstant earth. Our downward spiral from youth to old age, like the upward spiral from fertilized ovum to developed infant, is stamped into our genetic code.

  The wheel of life: one generation rises like summer wheat, then withers and falls to seed. The wheel turns—birth, youth, adulthood, parenthood, senescence, death—driven by genetic machinery set in motion so many eons ago. For all its subtleties and infinite beauty, life has but one purpose: to keep the wheel turning. Turning without the least regard for individuals, species, or ecosystems. The destination of the living wheel as it travels through geological time is unknown, perhaps not even important to us. Yes, each generation grows infinitesimally better than the one before it, but better at just a single thing: keeping the wheel moving. The vibrant colors of a bird’s plumage, the complexity of a spider’s web, the grace of a huntin
g lioness—all are variations on the single theme of birth, procreation, and death. Adapt, be ready, survive.

  For those lucky enough to escape death by predators or accidents, neoplasia in one of its many forms—cancer, dementia, heart attack—will come, a message that all individuals, no matter how worthy they may seem, must give way to the next generation. Regardless of how cautiously we live, our arteries will eventually clog with hardened tissue, our minds grow weak from excessive brain astrocytes, our eyes dim from corneal overgrowths, our organs fill with malignant growths. This is as it should be. Biology doesn’t consider these diseases enemies, just as General Motors does not consider rust a flaw. Decay is a necessary process for any business dealing in renewable goods.

  We cannot accept our personal dispensability in this scheme. Cancer may be a threat to us individually, but poses no threat to our species. The vast majority of those afflicted by neoplasia are far beyond child-bearing, or even child-rearing, age. Moreover, cancer is a uniquely human affliction. Animals in the wild rarely survive long enough to suffer the neoplastic illnesses of senescence. The same was true of homo sapiens prior to the advent of civilization. A death at eighty from colon cancer would have been a worthy goal for cavemen daily pitted against mammoths and saber-toothed tigers.

  Scientists and spiritualists who insist that our bodies harbor some hidden potential to conquer all cancers ignore the trivial effect cancer exerts on our species. Nature does not care if I get cancer, since the wheel of humanity will turn just fine without me. Biology could have easily endowed me with a foolproof method of defeating cancer. And a tire company could make a tire that lasts for a million miles. The awful truth is that neither nature nor a tire company has any motivation to provide unreasonable longevity.

  So Sakren, in essence, was right. Whatever entity, divine or earthly, deposits malignant brain tumors into our heads does so not to test our resolve, to challenge our faith, or to prove our strength, but to make us die. This does not mean that we should not use our intellects to prevent this fate when we can. Such is the very business of the medical arts. Nature discards individuals; surgeons do not. Let nature worry about the species; we must care for individuals one at a time.

  At this moment, the individual in question (individual plus one-quarter?) was Sarah Clarke. Her biopsy confirmed the presence of a malignant mixed glioma, a small lump of cancerous cells that were to become grains of sand binding up the gears of Sarah’s reason. Over time, her mind’s clockwork would slowly grind to a halt. Would she let us throw our backs into her wheel of life and push it further along? Would she let us try to extend her life?

  “No way.” Linda, the university’s chief radiation physicist, shook her head vehemently. We were discussing Sarah. “I’ve done some preliminary calculations and, even with the most coned-down fields and maximal shielding, the scattered dose to the fetus is unacceptable. Third trimester, maybe, but even then there is the liability issue. There is no way we can deliver any meaningful amount of radiotherapy to this tumor unless the pregnancy is terminated. Period.”

  “What liability problem is there in treating her in the third trimester?” I asked. “I would think that a fully formed child should be able to tolerate the small amount of radiation that would leak through the abdominal shielding.”

  “Medically, none. There really isn’t even that substantial a risk in the first trimester, either, but try and tell that to a jury. There have been some goofy cases which have produced milliondollar malpractice awards. In Texas, a child is born without a leg and the mother’s lawyer successfully argues that an inadvertent occupational exposure to radiation in the ninth month was responsible. You don’t have to be too sophisticated in embryology to know that the legs are fully formed in the ninth month of pregnancy and that whatever caused this child to be born with only one leg must have occurred in the first trimester or in the fertilized ovum itself. Yet they bring this little crippled child into the courtroom, sit her in the arms of her crying mother while some expert waves his arms and says that magic word ‘radiation,’ and the jury gives the kid seven million dollars. Add in the fact that the statute of limitations in children doesn’t run out until they are over eighteen, and our department will assume responsibility for the baby Clarke forever if we treat this woman. If the baby doesn’t get accepted into the college of its choice, it can come back and sue us for brain damage. No thanks. If the patient aborts, we’ll do it. Otherwise, forget it.”

  Sakren ran his fingers through his thinning hair. “Goddamned lawyers.” A phrase repeated almost daily by neurosurgeons across the country. Lawyers have pretty much determined when we should scan people, when we should operate upon them, and how much better we should make them. To believe that legal issues don’t alter the practice of medicine is to know nothing about the practice of medicine in the late twentieth century.

  The radiation risk to Sarah’s fetus derived as much from the fear of litigation as from tumor biology. Because a fetus is a blank slate, almost any jury award can be conjured up for a pregnancy gone bad. Sarah’s unborn child represented a financial burden that no one wished to bear.

  Sakren approached the Clarkes about the refusal of the radiation oncologists to give Sarah radiotherapy. “With radiation therapy, you have maybe a one in ten chance of living five years or longer. Not great, but people waste hundreds of dollars a year on much longer odds in the state lottery. Without it, on the other hand, the median survival is only about three to five months, which means you have a ‘50 percent or greater chance of not carrying the baby to term. I recommend a therapeutic abortion be performed and radiation therapy commenced immediately thereafter.”

  Sarah’s face became serene granite. “I am not a statistic, doctor. I’m not interested in odds. I will not abort my baby.”

  Sakren’s irritation grew. The surgeon turned to her husband. “For God’s sake, man, talk to her. If she was my wife, I know what decision I would urge her to make. I wouldn’t want to lose her.”

  James Clarke was unmoved. “Don’t talk to us about what we should do or not do ‘for God’s sake.’ My wife has made her decision. She’s in the Savior’s hands, not yours.”

  “The Savior’s hands didn’t do this”—Sakren laid his finger on the small wound on Sarah’s left temple—“mine did. And I’m telling you that she needs to have some therapy if she is to have any chance at all of surviving the next six months! I’ve been in this business for twelve years, and I haven’t seen Jesus come and lift one of these things out of a head yet.”

  “Doctor,” Sarah said calmly, “we’re telling you that I will not have an abortion. What Jesus does to my head is not important, but what I do to my child is. So you might as well send me home now. I’ll have no further therapy.”

  Sakren frowned. “Frank, get a serum phenobarbital level on Mrs. Clarke today and discharge her on a Decadron taper. If she’s forgoing therapy and wants to save her baby, we might as well get her off the steroids, too. Have her come back in one week to have her sutures removed. To residents’ clinic.”

  “Residents’ clinic?” I asked.

  “Yes, residents’ clinic. There is nothing more I can offer her now.” Residents’ clinic was the dumping ground of patients the staff surgeons no longer wished to follow in their private offices. Although technically overseen by the attendings, the care was relegated to residents.

  “But…”

  “Residents’ clinic is fine with us,” James said.

  Sakren hustled from the room. I cast an embarrassed look at the Clarkes. “He’s a little high-strung, I guess.”

  “Don’t make excuses for the man, son,” James admonished me. “He has his views, we have ours.”

  “Do you want to die, Mrs. Clarke?”

  “No, I want to have this child.” The tears welled in her eyes, the first I had seen. “When you first came in,” she continued after a pause, “you said these tumors could be either pretty good or very, very bad. Where does a malignant mixed glioma fit in?”<
br />
  “Somewhere in between.”

  “How much in between?”

  “Well…drop one ‘very’ in the ‘very, very bad’ category.”

  “Fair enough. Fair enough.”

  Two days after her biopsy, Sarah went home. The race was on. Which would grow faster, fetus or glioma?

  Cancers and embryos are kindred spirits, both composed of highly mobile cells dividing at full throttle. A fertilized ovum changes from a single cell to a miniature human body in a matter of weeks. During this period of high-speed construction, cells migrate freely from one region of the embryo to another as complex organs are assembled from amorphous cell clusters. The ability of cancerous cells to metastasize to distant sites is a throwback to the migratory properties of embryonic cells.

  The similarity of cancer cells to embryonic cells goes deeper than a simple capacity to migrate. Proteins and hormones produced in fetal tissues suddenly reappear in cancerous tissues of adults. Carcinoembryonic antigen, a protein normally present only in fetal colons, resurfaces in adult colon cancers; a serum test for this protein allows early detection of the disease. Mechanistically, cancer results not from the degeneration of adult tissues into decrepit forms but from their regression into juvenile forms.

  Cancer cells relive the heyday of their fetal youths, chucking the staid responsibilities of mature tissues and reverting to the time when they could grow and travel as they pleased. In this way, cancer reflects a symmetry of life. From dust we came and to dust we shall return. The cancer patient ends life as she began it: an amorphous mass of nomadic cells.

  While adult tumors arise from differentiated cells lapsing retrograde into prenatal behavior, pediatric tumors arise from islands of embryonic tissue which never matured in the first place. These ‘“Peter Pan” cells won’t grow up, acting like embryonic tissue even after birth. Rebecca’s PNET was one example of a Peter Pan tumor. Composed of refractory fetal-nerve cells, the PNET endlessly tries to build a new cerebellum—ignorant of the fact that the job has already been completed. The child with a PNET is literally born with brain cancer. The fetal nature of these tumors explains why they are so refractory to treatment. Fetal cells have a mission: to create a child. Their drive to complete this mission is so strong that only killing the patient will stop them. The wheel must turn.