Brain Surgery: What Kennedy Experienced

June 2, 2008— -- Surgeons at Duke University Medical Center in Durham, N.C., report that Sen. Ted Kennedy is doing well after nearly four hours of surgery today to remove a cancerous brain tumor.

For part of the surgery, the 76-year-old Massachusetts senator was awake and conscious, according to a statement issued by Duke University Medical Center.

This dramatic approach is being used by surgeons in cases when a malignant tumor isn't readily accessible on the surface of the brain.

So after cutting into Kennedy's skull, Dr. Allan Friedman — the surgeon wielding the scalpel — had to find a pathway through the brain to get at the tumor. For this he needed the patient's conscious help to avoid damaging brain cells essential for speech, movement and other important functions.

"I am pleased to report that Senator Kennedy's surgery was successful and accomplished our goals," Friedman said in a statement issued shortly after the operation. "Senator Kennedy was awake during the resection, and should therefore experience no permanent neurological effects from the surgery."

"Awake brain mapping surgery to remove a tumor can be very beneficial when indicated," noted Dr. Mitchel Berger, professor and chairman of neurological surgery at the University of California, San Francisco. Berger was one of the neurosurgeons involved in the Friday discussions in Boston about Kennedy's surgery.

Dr. James Chandler, neurosurgeon and director of surgical neuro-oncology at Northwestern Memorial Hospital in Chicago, Ill., said that when it comes to operating on "eloquent" brain — the parts of the brain that when damaged can lead to neurological impairment — the surgery "should be done with the aid of functional imaging, navigational systems and in capable and cooperative patients, awake with mapping of the brain surface. Such strategies optimize the probability of a favorable outcome."

But even now that the surgery is done, Kennedy now faces radiation and chemotherapy intended to help eliminate any remaining fragments of the tumor that the operation may have left behind.

"The bottom line is that no matter what technique is used, the critical issue is to remove as much tumor as possible prior to starting radiation and chemotherapy," Berger said.

"It is pretty well established that if you can remove the vast majority of tumor safely then patients will do better than if you don't take it out," agreed Dr. Gene H. Barnett, professor and director of the Brain Tumor & Neuro-Oncology Center at the Cleveland Clinic Neurological Institute in Cleveland, Ohio. "But you can't get every single tumor cell out when you remove the tumor, so [Kennedy will] need further therapy such as chemo or radiation."

Awake and Talking During Surgery

Surgeons often choose to perform an awake craniotomy, as such surgeries are usually done when the operation cuts close to a vital area of the brain.This approach usually takes between five and six hours — significantly longer than a conventional brain surgery.

"You have to stimulate areas of potential resection to note the response of the patient, all of which takes time," said Dr. Martin Weiss, chair of Neurosurgery at the University of Southern California. "A conventional procedure done with the patient asleep would take less than three hours."

But while such procedures are being used to help more and more patients, to many doctors the operation is still a source of wonder.

"It is just mind-blowing," said Dr. David Korones, associate professor of pediatrics, oncology and neurology at the University of Rochester Medical Center in Rochester, N.Y. "You walk into the operating room and see on one side of a sheet a person's brain exposed — it looks just like it does in the movies … and walk around on the other side and you can talk to the person."

While the procedure is termed an awake craniotomy, in reality patients are usually only awake for between 10 and 40 minutes of the procedure. This allows surgeons to "map" areas of the brain near the tumor before they cut to preserve vital areas.

The patient experiences no pain while being awake; though doctors dial down general anesthetic during the time that patients are awake, local anesthetic is still in effect. Plus, the brain itself has no pain receptors.

Central to the use of such an approach, however, is the comfort and sedation of the patient.

"Awake surgery is not always required," said Dr. Jeffrey Cozzens, associate professor of neurosurgery at the Northwestern University Feinberg School of Medicine in Evanston, Ill. "It can increase some risks and decrease other risks. It is very dramatic for TV — Grey's Anatomy, ER, et cetera — but is not always the best for the patient."

What Happens Now?

Many brain experts agreed that the fact that surgery went forward in the first place in Kennedy's case is already a good sign, as it indicates doctors believe that the potential benefits of the procedure warrant the risks inherent to the operation.

But now, Kennedy will face additional treatment. And while he will be able to take advantage of many of the newer radiation and chemotherapy regimens available, challenges remain.

The radiation treatment that Kennedy will get may bring about side effects including short-term memory loss. Chemotherapy and targeted treatments come with their own complement of potential drawbacks.

"It is not a free ride by any means," Korones noted. But he added that Kennedy's trademark white coif would likely be largely spared by the treatment.

"He would not lose his hair with this drug," he said.

Still, regardless of how well Kennedy's body tolerates these treatments, he will be facing a cancer with a high rate of mortality.

"With surgery his prognosis is better," Cozzens said. "But remember that in individuals his age, despite the best treatment, half of patients are dead in one year."

Audrey Grayson contributed to this report.