Doctors say Kennedy was awake during tumor removal

Bravery in the face of cancer? Sen. Edward M. Kennedy has given it new meaning. Few things require as much courage as being wide awake and aware, lying perfectly still for hours, while surgeons methodically slice out bits of your brain.

Kennedy did just that, in an unusual operation Monday at Duke University Medical Center to treat his cancerous brain tumor.

His surgeon said the operation met its goal: removing as much of the tumor as possible to give the radiation and chemotherapy he'll face next a better chance to help.

The 76-year-old senator now will likely be given medicine to prevent brain swelling and seizures - common complications - and watched for signs of bleeding that could lead to a stroke.

His doctors say no permanent neurological problems are expected - and that may be thanks to the daring surgery he chose.

Most people are out cold, or awake just for part of it.

It starts with surgeons cutting through the scalp, drilling into the skull to remove a bone flap, and slicing open the dura, a leathery membrane, to expose the brain. It's not known if Kennedy was awake during this part of the operation.

The tumor usually is not on the surface, so doctors must find a safe path through the brain to get to it, said Dr. Matthew Ewend, neurosurgery chief at the University of North Carolina, Chapel Hill.

To avoid cutting through vital areas controlling speech, doctors often return the patient to consciousness and stimulate tissue in the planned surgical path with a probe.

"We'll have them do language tests like hold up pictures, name objects, repeat words, hold a conversation," Ewend explained.

After that, the patient is usually put back under while the tumor is cut out, which takes about three to four hours.

However, Kennedy was awake for the removal of the tumor, his doctor's statement says. That usually means local rather than general anesthesia.

His head would have been in a vise-like device and he'd have to remain very still for hours while the doctors poked, probed and sliced away the cancer, using his responses to guide them.

"That's the best way you can determine if you're incurring neurological impairment" as the operation proceeds, said Dr. Kevin McGrail, neurosurgery chief at Georgetown University Medical Center.

"It's a safe way to do the operation, but it can sometimes be very stressful on the patient," who is aware of what's going on even though it is not painful, he said.

Kennedy's bravery is legendary, but this is a lot to ask of a 76-year-old man, doctors admit.

"Many surgeons would prefer to do this in an awake situation so they could actually stimulate the brain during the operation," even though that is tougher on the patient, said Dr. Richard Bucholz, director of neurosurgery at Saint Louis University School of Medicine.

He invented the Stealth Station, a 3D imaging system that helps surgeons plan and perform brain surgeries to avoid harming vital areas of the brain. It's not known whether it was used in Kennedy's case, but several surgeons said 3D planning probably was part of Kennedy's care.

What's next: Kennedy will stay at Duke for about a week, then return to Boston for further treatment.

"Almost no malignant gliomas are cured by surgery, but many of us believe that the more you get out, the next treatments, whether they be radiation or chemotherapy, have a better chance of working because there's less tumor there to fight," Ewend said.

Typical radiation treatment is five days a week for a month, using 3D imaging techniques that narrowly deliver the beams to the tumor, affecting as little surrounding tissue as possible.

Kennedy also likely will receive the chemotherapy drug Temodar during and after radiation. It can cause typical chemo side effects - nausea, vomiting and fatigue - but treatments are much better for these than even a few years ago, doctors stressed.

Kennedy also may be treated with Avastin, a newer targeted drug to deprive the tumor of its blood supply, though this is still experimental as initial treatment, rather than after patients have relapsed.

Median survival for glioblastomas is 12 to 15 months, but the range is wide, said Dr. Mark Gilbert, a brain tumor expert at the University of Texas M.D. Anderson Cancer Center in Houston.

He spoke in Chicago, where more than 30,000 cancer specialists are attending the world's largest annual conference on the disease. Dozens of presentations focused on experimental treatments for patients who have relapsed. So should Kennedy need more treatment, the pipeline is full of possibilities.

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Brain tumor info: http://tinyurl.com/ozjwn