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Kennedy Surgery Called Success
Operation on Brain Tumor May Prolong Survival

By Rob Stein and Paul Kane
Washington Post Staff Writers
Tuesday, June 3, 2008

Sen. Edward M. Kennedy was recovering last night after undergoing brain surgery to remove a malignant tumor, a risky and delicate procedure that offers the 76-year-old Democratic icon the best chance of extending his survival.

After spending a night in intensive care and then about a week at the hospital, Kennedy plans to return to his home state to undergo the next stage of his treatment: chemotherapy and radiation at Massachusetts General Hospital.

"I feel like a million bucks. I think I'll do that again tomorrow," Kennedy quipped to his wife, Victoria, after the 3 1/2 -hour surgery, said Stephanie Cutter, a family spokeswoman.

The surgery was "successful and accomplished our goals," neurosurgeon Allan H. Friedman, who performed the operation at Duke University Medical Center in Durham, N.C., said in a statement.

Kennedy was partly anesthetized but awake through most the procedure as surgeons monitored his responses to ensure that no crucial brain tissue was removed. Friedman said he should "experience no permanent neurological effects from the surgery."

No additional details were released about the senator's treatment, condition or prognosis. But experts who were not involved in his care said the decision to undergo surgery indicated that he and his doctors had opted for the most aggressive treatment, and that the surgeons thought they could safely remove a significant proportion of the tumor.

"It's a sign that there's hope that something could be done," said John H. Sampson, a neurosurgeon who works with Friedman. "It almost certainly won't be curative, but it should enhance the chances that additional treatment will be effective."

A successful surgery would be the removal of at least 90 percent of the tumor without major neurological damage, several experts said.

"If you are going to operate, you have to get 90 or 95 percent; otherwise you haven't made a difference in terms of survival," said Vivek Deshmukh, director of cerebrovascular and endovascular neurosurgery at George Washington University Medical Center.

Even after successful surgery and follow-up radiation and chemotherapy, Kennedy's prognosis remains fairly grim, experts said. Most patients with his type of tumor do not survive more than a year or two after diagnosis.

"If you didn't do the surgery, you're looking at a much shorter survival period -- on the order of a matter of months," Deshmukh said. "If you can go from three to six months of survival to a year or a year and a half, I think that's making a difference, particularly if he's not injured from it."

Others noted that some people with similar tumors have survived for years.

"Every patient is different. We have a bunch of new treatments that are looking pretty good," said Matthew G. Ewend, chief of neurosurgery at the University of North Carolina at Chapel Hill. "You just have to keep fighting year by year."

Kennedy found out last month that he has a malignant glioma, a common and often lethal brain tumor, after having a seizure May 17 at his home in Hyannis Port, Mass., on Cape Cod. The tumor is in a part of his brain known as the left parietal lobe, which is involved in aspects of speech, sensation and motor control.

The decision to operate was made on Friday, after a meeting in Boston of experts from around the country, a Kennedy aide said, speaking on the condition of anonymity. The senator flew to Duke over the weekend with his wife and were joined there by son Patrick J. Kennedy, a Democratic congressman from Rhode Island, and his sister Jean Kennedy Smith, the aide said.

Although the senator's medical team released no details about the procedure, other experts described the typical course it would follow:

After undergoing an MRI brain scan to provide Friedman with a detailed image of the size and location of the tumor, Kennedy would have a small part of the left side of his head shaved and then would be sedated. Friedman would make an incision probably about four to six inches long to pull back the scalp so he could drill one or more pea-size holes in the skull to insert a second drill bit to cut out a larger piece of bone, probably about three inches in diameter. Friedman would then use a scalpel to cut through the dura, the layer of tissue covering the brain.

About half of such operations at Duke are done as an "awake craniotomy," which involves doctors waking the patient by reducing the levels of anesthesia. Doctors then conduct tests to determine the best path to the tumor, methodically stimulating discrete areas of the brain and asking the patient questions to find out, for example, which parts are involved in speaking, recognizing words or feeling pain. That way, surgeons know what areas not to cut.

"Every patient is a little different. This enables the surgeon to say, 'This is where the speech area is' and 'This is where the motor area is,' " Sampson said. Stressing that he was not commenting specifically on Kennedy, he added that such operations are usually performed on patients whose tumors are in sensitive locations.

Because the brain has no nerve endings, the process is painless.

"It's not a painful, frightening thing," said Sampson, noting that patients have no memory of the experience.

After determining a safe route to the tumor, Friedman would use a high-powered microscope to begin painstakingly cutting into the brain to locate the cancer and remove tumor tissue, usually guided by a computerized system. "It's sort of like a GPS system for neurosurgeons," Ewend said.

The cancerous tissue can be excised with several devices, but Duke surgeons usually use a "bipolar coagulator," which uses heat to cut and coagulate the cancerous tissue, which is then suctioned out with a small tube, Sampson said. A tiny, scissors-like scalpel is used to cut blood vessels.

After removing as much of the tumor as possible, Friedman would cauterize blood vessels to stop bleeding, which is one of the biggest risks in brain surgery. Some surgeons also apply a foam-like substance that promotes clotting. In some cases, wafers containing chemotherapy drugs may be left at the site, Sampson said.

The skull bone would be replaced and fastened with titanium plates and screws, and the scalp stitched back in place.

Kennedy was expected to be kept in intensive care for at least one night. In addition to bleeding, brain surgery patients also face risks of infections and seizures.

The follow-up radiation and chemotherapy are aimed at trying to destroy as much of the remaining tumor as possible.

"These tumors have fingers that infiltrate into other parts of the brain that you can't see on the MRI," Deshmukh said. "You can't physically remove everything."

After deciding Friday to undergo surgery, Kennedy began preparing for his extended absence from the Senate.

On Saturday, he called Senate Majority Leader Harry M. Reid (D-Nev.) to discuss a pair of measures Kennedy hoped to lead to passage this summer: a reauthorization of a higher-education bill that would reform the student-loan process, and a bill to require that health insurance coverage for mental illness be comparable to the coverage offered for medical disease.

On Sunday, Kennedy phoned his closest friend in the Senate, Christopher J. Dodd (D-Conn.). Dodd, who stayed in contact with him last week while leading a congressional delegation to Central America, said Kennedy had grown agitated while waiting more than a week to decide on a medical course of action, a feeling that subsided over the weekend.

"He's very upbeat, tremendously positive," Dodd said in an interview yesterday. "All of a sudden, he's fighting back."

Staff writer Debbi Wilgoren contributed to this report.

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