Stacy’s story: Anaplastic Astrocytoma

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In the eyes of Dr. John M. Tew, Stacy’s journey is a story of hope and something more.

“Her story marks the culmination of one of the most important developments in brain tumor surgery in the last 100 years,” says Dr. Tew, a neurosurgeon with the Mayfield Clinic and Clinical Director of the University of Cincinnati Neuroscience Institute.

That is no small statement, coming from a man who has operated on an estimated 12,000 patients over a period of 45 years.

In February 2009, after specialists at two other brain tumor centers said they could not safely operate on Stacy, Dr. Tew successfully removed a fist-sized tumor from Stacy’s brain at Cincinnati’s University Hospital.

The operation, which involved eight members of the Brain Tumor Center at the UC Neuroscience Institute, was performed with the help of a new, imaging technology that fused four separate imaging techniques. The data was then installed into a surgical guidance computer whose function is similar to a global positioning system.

By revealing the tumor’s relationship to all of the functional centers, electrical pathways, and arteries and veins in Stacy’s brain, the technology enabled Dr. Tew and his team to map out a safe pathway to Stacy’s tumor.

Dr. Tew and his team had previously used the fusion of magnetic resonance imaging (MRI), functional magnetic resonance imaging (fMRI), and diffusion tensor imaging (DTI) as a guide to stereotactic surgery. MRI creates detailed pictures of the body by detecting differences in magnetic signals between different types of tissues; fMRI creates a series of images that capture blood oxygen levels in parts of the brain that are responsible for movement, perception, and cognition; and DTI provides a map of critical white-matter tracts, which facilitate electrical connections between different parts of the brain.

“And now, with Stacy’s case, we’ve added a map of the blood vessels through computed tomography angiography (CTA),” Dr. Tew says. “The ability to completely map the brain and to understand -- before we operate -- where the tumor lies in relation to important structures, is a milestone in our use of digital computer technology to heighten patient safety during complex brain tumor surgery.”

Fused MRI, functional MRI (fMRI), diffusion tensor imaging tractography (DTI) and CT angiography images in 3D representation. Shown is tumor tissue (yellow), the tracts connecting the movement and sensation areas of the brain with the spinal cord (purple, DTI), the vision areas of the brain (light purple, fMRI), the tracts connecting the vision areas of the brain with the nerves from the eyes (orange, DTI), and the areas controlling hand movement in the brain (green, fMRI). On the right image, the surface skin has been removed, showing the blood vessels (red), derived from CTA, and their relationship to the tumor.

Image processing and fusion of the MRI, fMRI, DTI, and CTA images was performed by  James Leach, M.D., Associate Professor of Neuroradiology at the University of Cincinnati College of Medicine, Cincinnati Children’s Hospital Medical Center, and the UC Neuroscience Institute, using the BrainLab iPlan system.

Assisted by the three-dimensional brain-mapping, Dr. Tew was able to navigate a trajectory through Stacy’s brain and to remove 90 percent of the malignant tumor, an anaplastic astrocytoma, without harming the healthy brain tissue – including the deep nerve-fiber tracts -- that surrounded it. Stacy was talking normally right after surgery, and she was walking the halls and able to take a shower without assistance one day after surgery.

“I feel better now than I’ve felt in years,” Stacy says. “When we were sitting in Dr. Tew’s office that first day and he was talking to us about the surgery, he said there were two main risks: I could be paralyzed on my left side, and I could die. And, I thought at the time, I’m pretty much not living a life right now, so I might as well take that risk. But I don’t think anyone expected me to recover the way I have. And I certainly didn’t expect it either.”

Dr. Tew had planned to remove the remaining 10 percent if the tumor in a second operation. But he and his team decided to apply a course of 33 computer-guided, fractionated radiotherapy treatments as a first approach. During fractionated radiotherapy, a small burst of radiation is delivered to the lesion every day over a period of weeks. Delivering radiation in this way, rather than in a single, concentrated session, allows healthy tissue to recover in between treatment sessions. Stacy is undergoing those treatments at the Precision Radiotherapy Center in West Chester, Ohio, under the care of Jessica Guarnaschelli, M.D., Associate Professor of Radiation Oncology.

Concurrently, Stacy is undergoing treatment with a chemotherapy agent (temozolomide). If the radiotherapy and chemotherapy are not effective, she could face another operation.

Stacy was working as an administrative assistant and raising two children in Ft. Wayne, Ind., when she first became ill.

“I’ve always exercised and eaten right,” Stacy says. “I always get up early to work out. But one morning in the summer of 2006 I didn’t feel good. I was dizzy and nauseated. Instead of working out, I went back to my room to lie down. My 17-year-old son woke up for school and found me having a grand mal seizure. He called 911. No one knew why I was having the seizure.”

An MRI performed at a local hospital revealed a tumor 2.5 centimeters in diameter.

“They thought it was a slow-growing tumor that had been there a long time,” Stacy recalls. “They did a biopsy and gave me the impression that I didn’t have to worry. They thought if they removed it I would be paralyzed on my left side. They prescribed anti-seizure medications and told me to get an MRI once a year. They said it was benign, but they said we should keep an eye on it.”

A followup MRI in February 2007 showed no change.

Stacy says that, in retrospect, she and her husband, Jeff, relaxed too soon. “We got a false sense of complacency and had no additional MRIs. We were not expecting any more problems.”

But on Mother’s Day 2008 Stacy had another seizure, and within a few months her life was beginning to spiral downward. In October 2008 she visited her neurologist, Victor Matibag, M.D., of Jeffersonville, Ind., who ordered an MRI. The tumor had mushroomed from 2.5 centimeters to 7. Because of the tumor’s size, two prominent clinics declined to accept her as a patient. “Then,” Jeff says, Dr. Matibag had an epiphany. He said, ‘Dr. Tew!’ ”

Stacy’s films were sent to Cincinnati, and she was put on a fast track to see Dr. Tew. The night before their appointment, Dr. Tew’s nurse, Nancy McMahon, advised Stacy and Jeff to pack overnight bags. They would end up staying several weeks.

Stacy was struggling by the time she got to surgery. She could no longer sit up straight, and she was hallucinating. “She saw wings coming out of the back of my head,” Jeff says. “I told her, ‘Maybe I am an angel,’ and she said, ‘No, they’re not angel wings. They’re black butterfly wings.”

In the days immediately following her surgery, with 52 staples in her head and no hair, Stacy had many tearful moments. But she amazed everyone associated with her care with her almost instant recovery. She was not merely alive: she was breathing, thinking, conversing, and moving. During her second day in intensive care, Jeff asked Dr. Tew what he thought of her recovery. Dr. Tew put his arms around Jeff’s shoulders and said, “nothing short of a miracle.”

Stacy and Jeff returned home to Indiana for a short while, then came back to Cincinnati for her radiotherapy treatments, which were overseen by Jessica Guarnaschelli, M.D., a radiation oncologist at the Brain Tumor Center at the UC Neuroscience Institute.

As before, she and Jeff stayed at the American Cancer Society’s Musekamp Family Hope Lodge, a beautifully renovated former school that provides no-cost lodging for adult cancer patients who travel to Cincinnati for treatment.

“Stacy and Jeff are beautiful people with a loving and supportive family and a perfect attitude that will help them to heal this complex tumor,” Dr. Tew says. “Here at the UC Brain Tumor Center, we are indeed fortunate to have a team of highly dedicated and learned experts who work seamlessly together to provide patients like Stacy with the most scientifically based and caring therapy.”

While facing their future with hope and energy, Stacy and Jeff are also grateful for the lifesaving care they have received. “From the first call, I’ve seen nothing from the Mayfield Clinic but world-class care,” Jeff says. “That includes the neurosurgery that they provided, and also the radiation therapy. Every aspect of her treatment, from beginning to end, has been overseen by Dr. Tew and his staff, and we are extremely thankful to everyone involved.”

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Hope Story Disclaimer – This story describes an individual patient’s experience.
Because every person is unique, individual patients may respond to treatment in different ways. Outcomes are influenced by many factors and may vary from patient to patient.