CANCER, NEUROLOGY & NEUROSURGERY

Treating a Complex Meningioma: A Brain Tumor Case Not For the Timid

July 12, 2021 - Todd Ackerman

Before he got to Houston Methodist, Chris DeHart was told his grapefruit-sized brain tumor was so big and invasive it was likely inoperable.

The aggressive tumor, after all, grew through the skull all the way to his eye sockets, pushing his brain backward and causing swelling and pressure. It also descended into his sinus cavity and nose, an unusual spread that could ultimately threaten his ability to breathe.

"I have seen a number of large, aggressive brain tumors, but never one like this that involved so many critical structures, and never one whose removal would leave so many big holes to fill," says Dr. David Baskin, a Houston Methodist neurosurgeon and director of the Kenneth Peak Brain Tumor Center, who was sought out by DeHart in late 2020. "The enormity of it was staggering."

But Dr. Baskin, never one to shy away from a challenge, told DeHart he thought Houston Methodist could remove the tumor and return everything to normal. It would be a big undertaking, he conceded, but they could do it.

Six surgeries, three specialties and cutting-edge technology

In the end, they did it, but the case required six surgeries, the special skills and expertise of top surgeons in three specialties, and Houston Methodist's most cutting-edge technology. In the most striking moment, Dr. Baskin removed the tumor working from the top of the skull down, while Dr. Mas Takashima, the team otolaryngologist, removed all of the tumor in the nose and sinuses. The two could see each other through the holes left by the tumor's removal.

No one was happier with the results than DeHart.

"I'm happy that Houston Methodist gave me the confidence to go ahead," says DeHart, 68, a retired Lousiana offshore-vessel repairman. "I have my life back again."

In truth, DeHart never felt that bad, something that shocked his doctors, given the size of the tumor. In fall 2020, when it was first diagnosed, it's not like the tumor was causing, say, migraines, dizziness or blurred vision. It took his wife and friends to notice something was wrong.

They'd observed that DeHart's memory was off, that he was forgetting things he should know. He'd go to the store and return with something different than what he'd gone for. He'd take on a repair project, but couldn't get started because he didn't remember how.

He immediately feared Alzheimer's, but he passed all the testing for it. It was only after his family doctor ordered up a CT scan, then an MRI, that it was clear DeHart had a massive brain tumor, known as an atypical meningioma.

A meningioma that grew in all the wrong places

Meningiomas, which grow in the protective lining of the brain, are usually benign. They can cause seizures and other neurologic symptoms by putting pressure on adjacent brain structures and irritating surrounding tissue, but many can be easily removed with surgery — particularly those on the surface of the brain, in nonsensitive areas.

Surgery is more risky for meningiomas along the skull base because of the risk of damaging cranial nerves or arteries. That was the case with DeHart's tumor.

Neurosurgeons in Louisiana wanted no part of it. They told him if it wasn't inoperable, he'd need the best brain surgeon in the country.

For a time, no one seemed to want to take the case. Then a friend suggested DeHart seek out Dr. Baskin.

Dr. Baskin knew immediately he'd need to enlist others for DeHart's care — specifically, Dr. Takashima and Dr. Michael Klebuc, a Houston Methodist plastic and reconstructive surgeon. He'd worked with both on complex cases before.

Dr. Takashima said the most obvious challenge in removing DeHart's tumor was fixing the holes left behind.

Keeping sinus bacteria from reaching the brain

"How do we reconstruct that barrier that separates the brain from the nose?" asks Dr. Takashima. "There's a lot of bacteria that reside in the nose and the sinuses, and if we can't create a vascularized, stable, secure barrier between the brain and nose, the patient's going to have massive complications, such as meningitis, and possibly may die."

The solution: muscle taken from DeHart's thigh. The team removed a segment that they placed in the hole between the brain and nose, connecting one artery to bring blood to the muscle flap and one vein for it to exit. They united the vessels with stitches about a third of the size of a human hair.

Before any of the procedures, the three doctors plotted everything out in a Houston Methodist Surgical Theater that includes virtual-reality simulation — specifically, oculus rift 3D helmets the doctors donned to go inside DeHart's brain and tumor.

Such technology wasn't available five years ago.

"You can really move around the patient's head, diving inside the brain, flying through the tumor," says Dr. Klebuc. "It's powerful technology that's very helpful for planning."

Dr. Baskin adds that "it's like walking inside the patient's brain."

The simulations so far have informed five surgeries on DeHart, ranging from two to 15 hours. They included everything from removing huge tumor masses in the brain and sinuses and sealing an air leak to rebuilding the eye sockets.

The remaining treatments to come

DeHart isn't out of the woods yet. He has one last surgery, probably in a month or so, during which Dr. Baskin and Dr. Klebuc will fit a synthetic bone plate where DeHart's skull was removed. The plate will be created from brain imaging data fed into a 3D printer.

After that, DeHart likely will undergo radiation to ensure none of the tumor remains.

But the three doctors all say they're confident DeHart will fully recover.

Such a case could only have been treated at a handful or two centers around the country, says Dr. Baskin.

"The clear message from such cases is don't give up hope," says Dr. Baskin. "One surgeon telling you a case is inoperable may just mean that he or she doesn't want to take the case on. It doesn't mean someone else won't."