The Most Dreaded of Cancers

"It is like being in a room with the lights dimmed and having the lights turned on. That is literally what it [fluorescent-guided surgery] looks like."
"We probably do more awake surgery than any other centre in Canada ."
"This has been an awful year for those patients and their families, but what it has done is brought attention to something that is a devastating disease [helping to raise research funds to further advance extended survival patient rates]."
"The courage that [Tragically Hip frontman Gord] Downie [and former Ottawa MP Paul] Dewar have shown by trying to help other people by making their stories known is immense with what they are facing."
Dr. John Sinclair, oncologist, neurosurgeon, The Ottawa Hospital

Dr. John Sinclair has been trained on a new brain surgery technique, used for first time in Canada, that makes malignant brain tumours glow in fluorescent pink and orange. Wayne Cuddington / Postmedia

A dread diagnosis of Glioblastoma is quite rare but it is set to rise alongside an aging population, the aged being more at risk of acquiring malignant glioma cells in their brains. The condition is what took the life of, among others, American Senator John McCain, last month. Some people over 50 are are diagnosed with glioblastoma multiforme, the most common primary brain tumour, a devastating cancer whose average survival rate is twelve to fourteen months, with treatment.

A new technique has been introduced at The Ottawa Hospital, pioneered there by Dr. Sinclair, in an effort to make a complicated type of surgery more precise and therefore more successful in its outcome. The technique is common in Europe and some other parts of the developed world, but is just now making its debut in Canada. Several hours pre-surgery the patient consumes a beverage containing the drug aminolevulinic acid (5-ALA) which illuminates malignant glioma cells to appear fluorescent under blue light.

Fluorescence-guided surgery represents a huge assist to surgeons, enabling them to clearly identify cells in the brains of their patients so they can proceed in removing tumours far more exactly, distinguishing the cancer cells from ordinary brain matter. New treatments are expected to increase survival rates of glioblastoma patients, adding months, perhaps even years to their lives. Patients with the cancer have mere weeks to live without treatment consisting of surgery, chemotherapy and radiation.

The tumours have no discretely distinct edges, they grow by tentacles, so distinguishing their presence -- critical to be accurate so they can be successfully removed -- is beyond difficult; invariably some of the cancer cells get left behind because their presence is so amorphous and difficult to determine. Surgeons work with the aid of white light traditionally, a MRI scan taken preoperatively to identify the tumour, along with a intraoperative navigation system.

As surgery proceeds and tissue is removed the MRI scan no longer accurately identifies the diminishing shape of the tumour being laboriously removed. Realtime shape has been altered, leaving surgeons to rely on their eyes alone, given assistance by a large operating microscope and eyepieces. Distinguishing between brain and tumour tissue becomes frustratingly fraught. With fluorescent-guided surgery things change; malignant cells are brought to view in sharp relief, to be distinguished from normal brain tissue.

The process gives surgeons the opportunity to become more aggressive in removing malignant cells since they have gained confidence in being able to distinguish the crazed cells from the normal ones, the tumour glowing pink and orange whereas normal tissue has no glow. Despite the care taken and the hopes involved after surgery the cancer returns but the more of the cancer cells that surgeons manage to remove, the more optimistic the patient's prognosis; cancer return is delayed, the patient has longer to live.

Anesthesiologists at The Ottawa Hospital developed a technique allowing for longer surgeries where the patient is kept in a waking state. Surgery can take up to seven hours, the physicians and surgeons interacting with the patient throughout the lengthy process where the neurosurgeon stimulates areas around a tumour asking the patient to perform tasks to help identify and understand functional areas of the brain, and to avoid disrupting them.

It is this combination of awake surgery for primary brain tumours and the fluorescence-guided surgery in tandem that advances survival rates for patients, many of whom must undergo additional surgeries as their cancer recurs. The drug 5-ALA has a cost between $2,000 and $4,000 for each patient pre-surgery, a cost not yet funded through OHIP and just recently approved by Health Canada. The Ottawa Regional Cancer Foundation raises the funds to pay for the drugs.

"We have been looking forward to this surgical approach being available in Ottawa for a long time."
"We know it will be a complete game-changer for local patients facing brain cancer."
John Ouellete, vice-president of philanthropy, Ottawa Regional Cancer Foundation