The brain is the most complex structure in the human body, and on its optimal functioning relies all the functions in the body. All of this is massively disturbed when brain types develop and develop various types of tumors. Whether they are benign or malignant, they can affect important areas that are responsible for vital functions and can be a serious health hazard. Brain tumors are less common than other types of formations that occur in other organs, but their treatment requires the presence of complex medical teams, one of the essential conditions for complete removal of tumor tissues. There are many centers of excellence dedicated to the treatment of brain tumors in the world, including ACIBADEM Maslak Hospital. Due to medical expertise and cutting-edge technology, the neurosurgery team led by Prof. Dr. Ilhan Elmaci manages to solve serious cases of brain tumors and give patients a chance to live. Furthermore, Prof. Dr. Ilhan Elmaci explains how brain tumors can be successfully treated, despite the severity of the medical condition in many patients.
Prof. Dr. Ilhan Elmaci: Currently, we know precisely that at the human body level there is a system that shows us certain conditions, such as infections. In the same way, the central nervous system in the brain has the ability to repair itself when small problems occur. There is also a balance between dead and new cells that are being formed. If this balance is disturbed for some reason (sometimes, it can be genetic causes) then it can develop masses, tumors that may be benign or malignant. In addition, our lifestyle, stress, certain eating habits, electromagnetic radiation, smoking, alcohol can all increase the risk of brain tumors. Our resistance is influenced by these risk factors and thus, over time, tumors may appear.
Prof. Dr. Ilhan Elmaci: Symptoms include headache, nausea, epileptic seizures, short absences, numbness, loss of consciousness. These should be reported to the physician and should be investigated by tomography or magnetic resonance. Magnetic resonance is the best imaging method, especially for small-scale tumor masses. As I was discussing with other colleagues and patients, perhaps brain and central nervous system evaluations may be part of the check-up programs, and maybe they should be done every 3 years.
Prof. Dr. Ilhan Elmaci: As far as brain tumors are concerned, we can say that some localizations make them more difficult to treat. It is known that the brain is responsible for all important functions in the body. These are the so-called eloquent areas. But some of these areas are extremely important because they are responsible for vital functions. There are two large types of tumors: benign and malignant, and these are linked to normal brain tissues, eloquent areas. The first obstacle we must overcome is tumor localization, we must use the best paths and methods to locate and detect tumors in the brain. The second big challenge is to take them away. It is impossible to remove tumors through large-scale surgery. If we try to do this at the skull level, this would be extremely dangerous for the brain. As a result of this situation, we do to small interventions. To open our way up to the tumor level, we use fine access ways and we evaluate the tumor as if we were looking through the keyhole with a telescope. Clearly, we can not remove the tumor through these very fine access paths. That is why we are resorting to some technological opportunities to remove the small tumor piece by piece without damaging the surrounding healthy tissue. This is endoscopic cerebral surgery, actually. There are several methods: one is the microsurgical removal of the tumors and the other is the endoscopic extirpation of the tumor. Sometimes we also appeal to the microsurgical removal of endoscopically assisted tumors. The endoscopic approach has advantages in treating tumors at the level of the base of the skull, which we can not approach otherwise. Depending on location, we can approach tumors through certain anatomical orifices, such as those in the ENT sphere, from the nose. Endoscopy is a good solution because we approach tumors located very deep in the brain, and using the endoscope allows us to get to the tumor and have a better image of the area to be treated. We decide the technique we apply depending on the location and type of tumor. Our goal is to completely remove tumors and provide patients with good quality of life after surgery.
Prof. Dr. Ilhan Elmaci: Metastases are the most common, they are a large category of brain tumors. But we also operate primary cerebral tumors, such as glial tumors, especially astrocytomas. There are 4 degrees of glial tumors, grade 4 being malignant, that is, cancer. At present, we have the possibility of early diagnosis of these tumors. For example, patients with grade 1 glial tumors can be successfully treated by removing these tumors using advanced techniques. It's not a good idea just to monitor them without having to intervene quickly. Our advice to all our neurosurgeon colleagues is to remove these tumors as soon as possible. Often, these tumors are in eloquent areas, and patients are advised to return after 6 months for magnetic resonance. And it happens that the tumors reach grade 4 in this interval. So where possible, we recommend removing these tumors, with the mortality rate being very low, 2 percent, due to our experience, technology and teamwork. If necessary, we do the intervention with the patient awake for 30 minutes of the 4 hours of the operation. With neuromonitoring, we evaluate eloquent areas and we know precisely which areas are responsible for movement, speech, etc. We awake the patient, and she is closely monitored by the entire team of neurophysiology and neuropsychology specialists. We work with the patient and so we can remove the tumors avoiding any patients’ sequelae.
Prof. Dr. Ilhan Elmaci: I have been a neurosurgeon for 30 years now, and at the beginning of my career, it was impossible to completely remove the tumors located in the depths of certain areas of the brain or the spine without having to deal with various complications. One of the most important aspects of my career is that this situation has changed over time: our experience has grown, the technology has developed, so did other facilities and study groups - all have made it possible, in time, to treat difficult tumors.
Prof. Dr. Ilhan Elmaci: If we refer to the eloquent areas of the brain that control vital functions, we can operate even 6-8 hours depending on each case. But on average, the intervention takes about 4 or 5 hours.
Prof. Dr. Ilhan Elmaci: Tumor extirpation is our primary goal, but also maintaining the patients’ quality of life. Data and literature support the idea that the best outcome depends on total tumor removal. It also helps with angiographic treatment by blocking the blood supply to some tumors, but this treatment has limits, so we must remove the tumor without complications. There are two aspects: First, we aim to remove tumors without complications, and this is possible due to neuromonitorization that allows us to see what happens in real-time in the brain. Another aspect relates to how we can predict whether we have completely removed the tumor, and this is possible due to radiological examinations. We use intraoperative ultrasonography to help us be hundred percent sure, and this is also possible due to our experience. For someone who has been using these methods for just a while, it is impossible to control them perfectly, but our team has experience, and based on the imaging assessments made by the neuro-radiologist, we can know exactly how the step-by-step intervention takes place. There are situations when we use intraoperative computerized tomography, depending on the location. The technologies assist us in all interventions to remove brain tumors to avoid complications.
Prof. Dr. Ilhan Elmaci: It is clear that the medical decision is taken depending on the patient's situation and the primary tumor that generated the metastasis. If the primary tumor is under control and the life expectancy is good, we can remove the metastasis if it is resistant to radiotherapy. There are situations when the primary malignancy directs us to radiotherapy. For example, if there are 3 or 4 cerebral metastases and the patient suffers because of the biggest because it causes a strong brain compression, then we extirpate it. We can treat the others with radiotherapy. We adapt the treatment according to each case, we personalize it.
Prof. Dr. Ilhan Elmaci: At this time, the risk of complications of brain surgery is 2 percent. 15 years ago, this risk was 10-15 percent. Also, the mortality risk is less than 0.1 percent. The figures are very good, the results of the operations are excellent, but the case selection and the choice of the best therapies for each case matter a great deal. If patients improve their condition due to surgery, we recommend it. Otherwise, if the best therapeutic decision is not taken, the risk of complications may be high. We need to be sure that patients need or do not need a certain type of intervention.
Prof. Dr. Ilhan Elmaci: For operations involving brain tumors, one hour after surgery, we do a CT scan. The next morning, before the patient is taken out from intensive care, we do a magnetic resonance scan. We need to know exactly how the case evolves and whether there are any other tumoral debris, even if we did this by ultrasonography during surgery. And according to the anatomopathological report, we do a re-assessment at 3 months or 6 months. If the patient has a grade 4 tumor, we do a quarterly follow-up to see what other types of therapies we can further apply. If the patient has a benign tumor, we do the evaluation at 6 months, then one year and then the patient is considered healed.