Once you are diagnosed with a brain tumour your whole world turns upside down and inside out. You go though the emotional reactions of “why me”, “what did I do wrong” and “who do I trust”. It’s a roller coaster ride that you don’t wish upon your worse enemy.
Here are some helpful tips on how to navigate the minefield….
DON’T READ DR GOOGLE… and if you do, don’t trust everything you read or hear. Remember that information on the internet is not peer-reviewed and often anecdotal.
GET A SECOND OPINION….. one of my beloved patients wrote a book called “Three quotes from a plumber” which documented her journey after diagnosis when she innocently trusted her first and only opinion and was mislead, had inadequate surgery and paid a terrible price for not getting a second opinion which would have been diametrically opposite to the first.
ASK CONFRONTING QUESTIONS?…. many patients are too scared to challenge their doctors. There is no harm in asking about their experience with your type of condition. There is no harm is bringing up alternative treatment options. Indeed, if a surgeon is offended by a confronting question, such as “what do you think about Dr X or this different approach” then it invariably means that he/she is threatened. That means insecurity about his/her own talents or knowledge…..a RED FLAG!!
CHOOSE THE DOCTOR WITH WHOM YOU HAVE UTMOST FAITH AND CONFIDENCE…. if you feel immediate comfort and trust with your surgeon, then that is arguably the most important step in your journey. Remember, if things go wrong, you need to be able to find solace that it was your choice and you were “hoping for the best, prepared for the worst”.
A doctor cannot and should not make idle and unsubstantiated claims of their results. It is incumbent on a surgeon to publish their results showing honest evaluation of how their results compare with the standard outcomes. It is also imperative for a surgeon to report their bad outcomes, no matter how difficult this is to do.
The following are a few of Professor Teo’s publications in peer-reviewed journals comparing his results with the average:
CRANIOPHARYNGIOMA
Teo C “Application of endoscopy to the surgical management of craniopharyngioma” Childs Nerv Syst 21:696-700, 2005 This paper demonstrated a clear advantage of a keyhole eyebrow approach for the radical and curative resection of craniopharyngiomas. There were NO hypothalamic complications in “virgin” patients. Unfortunately, it showed a 95% incidence of post-op DI and some very poor outcomes with repeat surgery after previous radioRx.
TRIGEMINAL NEURALGIA
Teo C, Nakaji P, and Mobbs RJ. “Endoscope-assisted microvascular decompression for trigeminal neuralgia”. Neurosurgery 59(2):ONS-489, 2006. This small series of only 150 patients showed a higher than average successful microvascular decompression rate with the use of a 30 degree endoscope to examine the CPA. This paper was reviewed by Jannetta himself who conceded that the higher success rate was likely due to the identification of offending vessels that were seen with the endoscope but were hidden from the microscope.
COLLOID CYSTS
Greenlee JD, Teo C, Ghahreman A, Kwok B “Purely endoscopic resection of colloid cysts” Neurosurgery 62:51-55, 2008 This is one of the largest series of endoscopic resection of colloid cysts that shows that you don’t have to accept a lower complete resection rate when compared to open resection. We have only had 2 recurrences in 88 patients followed for an average of 7 years.
BRAINSTEM GLIOMAS
Teo C, Siu TL. “Radical resection of focal brainstem gliomas: is it worth doing?” Childs Nerv Syst Nov;24(11):1307-14, 2008
In this paper there is a Kaplan-Meyer curve showing excellent long-term survival with radical total removal of focal brainstem gliomas with excellent clinical outcomes. Most patients fell into the excellent or good outcome categories…
Faulkner H, Arnaout O, Hoshide R, Young IM, Yeung JT, Sughrue ME, Teo C.” The Surgical Resection of Brainstem Glioma: Outcomes and Prognostic Factors.” World Neurosurg. 2:S1878-8750(20)32349-4. Feb 202
This is the largest series of surgical patients with brainstem gliomas showing excellent results.
INOPERABLE TUMOURS
Teo C, Broggi M. “Surgical outcome of patients considered to have “inoperable” tumors by specialized pediatric neuro-oncological multidisciplinary teams” Childs Nerv Syst 26(9): 1219-1225; 2010
This is the small but impressive series of 47 patients all having been sent home to die with “inoperable” tumours. Some were in extremis/close to death. Of the 47 patients 32 were alive and well after surgery. Some have since died but there are over 20 who were cured !!!
PINEAL TUMOURS
Broggi M, Darbar A, Teo C “The value of endoscopy in the total removal of pineocytomas” Neurosurgery 67[ONS Suppl 1]:159-165, Sept, 2010
The OS in this series is greater than in any other published series of pineocytomas….100% !!!! Not a single patient had post-op radio or chemoRx. I believe the results were due to minimally invasive endoscopic-assisted resections ie. NO residual tumour within or hidden by the deep vein complex.
Of the patients who died, not a single one regretted having the surgery despite one of them only living an extra 6 weeks.
POSTERIOR FOSSA TUMOURS
Wait S, Gazzeri R, Galarza M, Teo C “Simple, Effective Supine Positioning for the Retrosigmoid Approach” Minim Invas Neurosurg 54:196-198, 2011
This paper looked at our series of 890 keyhole retro-sigmoid craniotomies for various pathologies. We only had 2 clinically-significant post-op collections and only a single case of post-PF craniotomy headache cf. 10% in the literature.
PITUITARY ADENOMAS
Teo C, Wait S “Endonasal Approach to Tumors of the Pituitary Fossa; a shift in the treatment paradigm” Clin Neurosurgery 58: 79-83, 2011
This was presented at the CNS in 2011 and was the first to show that cavernous sinus invasion by non-malignant pituitary adenomas does not confer a negative prognosis if one uses the extended endonasal approach. This has since been reproduced by the Chinese (Tiantan Hospital in Beijing). It’s all about the ability to look into the CS with angled endoscopes and instruments.
CEREBRAL METASTASES
Gazzeri R, Nalavenkata S, Teo C “Minimally invasive key-hole approach for the surgical treatment of single and multiple brain metastases” Clin Neurol and Neurosurgery 123;117–126, 2014
This was not a very impressive paper because numbers were small, but it did show that most patients were discharged within 24 hours of surgery, whether there were single or multiple lesions removed.
RECURRENT BRAIN CANCER
Sughrue M, Sheean T, Bonney P, Maurer A, Teo C. “Aggressive Repeat Surgery for Focally Recurrent Primary Glioblastoma: Outcomes and Theoretical Framework” Neurosurgical Focus 38-3, Page E11, 2015
This series is the MOST important for supporting the practice of offering surgery to those patients with recurrent malignant tumours who are facing certain death invariably within days to weeks of being diagnosed with their recurrence. The old dictum of second surgery only buying you half the time as the first surgery is incorrect. Aggressive, pro-active surgical management of recurrent GBM is worthwhile. What is NOT clear is which patient will benefit and in which patient it will be futile.
THE ADVANTAGE OF A KEYHOLE APPROACH
Sughrue ME, Bonney PA, Choi L, Teo C. “Early Discharge After Surgery for Intra-Axial Brain Tumors” World Neurosurg;84(2):505-10, Aug, 2015
This is a simple paper that demonstrates that rapid discharge after uncomplicated craniotomy is feasible. Our average LOS is 1.5 days !!!
INSULAR GLIOMAS
Sughrue ME, Othman J, Mills SA, Bonney PA, Maurer AJ, Teo C. “Keyhole Transsylvian Resection of Infiltrative Insular Gliomas: Technique and Anatomic Results” Turk Neurosurg; 26(4):475-83, 2016
This is one of the largest series of insular gliomas in the literature. Although my complication rate is higher than Dufau and Berger, 8% vs 3%, my complete resection rate is significantly higher. If you include all the insular gliomas that I have done at AIIMS in Delhi, NUH in Singapore and Duke in the USA, it is the largest in the world.
Sughrue M, Bonney PA, Burks JD, Othman J, Baker C, Glenn CA, Teo C. Multilobar Insular-Involving Gliomas: Results with Hyperaggressive Resection. Cureus;9(8):e1623. Aug 2017
This shows the same results in a larger series.
GLIOMAS OF ALL GRADES
Hoshide R, Teo C Neuroendoscopy to Achieve Superior Glioma Resection Outcomes. Neurosurgery 1;64(CN_suppl_1):139-143; Sept 2017
This is a technical/feasibility paper showing that complete resection rates are better than the published literature, using endoscopic assisted techniques
ACOUSTIC NEUROMA
Hoshide R, Faulkner H, Teo M, Teo C. Keyhole retrosigmoid approach for large vestibular schwannomas: strategies to improve outcomes. Neurosurg Focus;44(3): Mar 2018
This paper was researched and written by my fellow, who worked with some of the best acoustic neuroma surgeons and thought my technique was good. When he asked me to review my results, I reluctantly agreed thinking it might show inferior results. This series looked at facial preservation rates and degree of resection rates for large acoustics >3cm. Our facial preservation rate was better than Samii’s !!! ALL surgeries were done through a keyhole (<2cm diameter opening) retrosigmoid approach.
OLIGODENDROGLIOMAS
Profyris C, Chen E, Young IM, Chendeb K, Ahsan SA, Briggs RG, Sughrue ME, Teo C. “Anaplastic Oligodendroglioma – Is Adjuvant Radiotherapy Mandatory following Maximal Surgical Resection? Grade 3 Oligo Radiotherapy”. Clin Neurol Neurosurg;200:106303. Jan 2021
This series is probably the one of which I am most proud. For the last 20 years I have had a percentage of patients who are philosophically opposed to radiotherapy and who elect to be treated with surgery alone, which is against all recommended guidelines. Rather than coerce them to have adjuvant therapy, I have supported their decision and have offered repeat surgery for recurrence multiple times in several patients. This paper shows very clearly that with aggressive and accurate surgery, the long-term survival is as good as and arguably better than BST (best standard treatment). They do not have the quality-of-life issues of patients who have had radiotherapy and the Kaplan-Meir curve in this series shows that most are still alive and functional at the current time. Therefore, survival curves will likely show OS (overall survival) figures better than BST.
MALIGNANT SKULL BASE TUMOURS
Yeung JT, Caminer DM, Young IM, Sughrue ME, Teo C. “Radical exenteration of the skull base for end-stage, locally advanced sinonasal malignancies: Challenging the dictum of unresectability.” World Neurosurg. 26:S1878-8750(21)00285-0. Feb 2021
This series ianswers the question “how worthy is surgery in the management of futile cases that MDT’s have determined are inoperable?”. It showed that there is a role for surgery but with a predictable associated greater risk of complications and even peri-operative death.
PINEAL CYSTS
Yeung JT, Young IM, Profyris C, Katsos K, Sughrue ME, Teo C. Resection of Symptomatic Pineal Cysts Provides Durable Clinical Improvement: A Breakdown of Presenting Symptoms and Lessons Learned. World Neurosurg. 23:S1878-8750(21)00457-5. Mar 2021
This is the second publication on the efficacy of surgery for pineal cysts. It is the largest series in the world and demonstrates the same excellent results with minimal morbidity. It is likely to change the management paradigm for this controversial disease entity