The surgical five

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Preeti was just 40 years old, but she walked into the office holding her elder brother for support. Her right leg swerved around the ground with every step, the kind of walk you see in people who have had a stroke. Nonetheless, she sat down comfortably with a surreal smile on her face, rearranging the dupatta of her purple salwar kameez for propriety. Her speech was slow, but purposeful and penetrating, as she insisted on telling her story rather than allowing her brother to do it.

"I was operated for a brain tumour in 2006," she started, mentioning the name of her previous doctor and hospital. "They told me it was benign," showing me the biopsy report of a grade 1 meningioma - a tumour that arises from the outer covering of the brain, the meninges. Not a malignant tumour for sure, I confirmed. "But one year later, it came back," she continued with a disarming smile. "I had my second surgery in 2007," she confirmed, the precise date clearly etched in her memory. "For two years I was alright, but it recurred again," she noted, without any sense of alarm. "This time, my doctor suggested we give it radiation after removing it," she said. "Even though it is benign, he told me, it seems locally aggressive," she repeated his exact words. "So, after my third operation, I underwent radiation in 2009," laying out all the reports in front of me.

She mentioned that she got married and had two beautiful children in the decade that followed, when, in 2019, she noticed that something was wrong again. The MRI showed a new large tumour on the other side of the brain. "I had no option, but to have my fourth surgery," she said, parting her hair and showing me the maze of scars on her scalp. "Then COVID happened and I couldn't get an MRI for two years," she confessed. "I didn't have any problems until a month ago, so I didn't bother, but now, my right hand and leg have slowed down considerably," she acknowledged, pulling out her latest MRI with some difficulty. Her previous surgeon had retired, which is why she had come to me, she said.

I examined her scans. Her ghoulish tumours had returned. This time, it wasn't one, but five of them in varying locations over the entire left hemisphere of the brain, with the largest one pressing against the motor strip, causing the weakness in her limbs. It was 6 cm in size. The others were 2-3 cm each. I peered deeply at the images. "We'll have to remove all five," I decreed, never having done that before. "But repeated surgery is not the solution to this," I paused. "We'll have to do some genetic studies on the tumour and then give you immunotherapy or chemotherapy," I announced, knowing that it was important to find out why these kept coming back. She smiled peacefully, as though resigned to her fate.

A few days later, we made a large opening in the entire left side of the head. I removed the big tumour first, meticulously separating it from the brain scarred by previous surgeries. It was firm and multilobulated. We were excavating boulders from a pink mountain; luckily, there was no landslide. It didn't bleed much either. I went around circumferentially, methodically removing the rest of them until we were convinced we had gotten them all out. We scrupulously reconstructed the covering of the brain called the dura (some of which had to be removed with the tumour). When she awoke from surgery, she was able to lift her right hand way higher than she had ever been able to in the past month, indicating her strength was back. She beamed with delight, her smile broader and brighter than I had seen before. "We'll do a CT scan tomorrow morning to make sure everything is clear and then shift you out of the ICU," I told her, with her family by her bedside. I was amazed at myself for have pulled this one off.

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The next morning when I came to see her in the ICU, she was sitting up and eating breakfast on her own. Nothing gives a surgeon more joy than to see a radiant patient the morning after surgery. The nurse handed me the CT scan to review, which I held up against the morning light beaming though the ICU window. And my heart sank. I literally felt it slump two inches lower. Nothing gives a surgeon more despair than to find tumour on a scan that he thought he had removed completely. I seemed to have left behind one of the five tumours, which, on studying the image carefully, was a separate tumour and not a lobule of the main tumour. It had probably been hidden by a sliver of brain. This wretchedness is what ages me many years in a few hours.

"If this was anyone else, I would leave this tumour alone because they almost never grow," I told her family, "But in her, I'm requesting you to allow me to go back and remove it. Because if we don't, all our efforts would be wasted." I was gutted; just yesterday, I had told her that this would be her last surgery, and today, I was going back on my word. But in my experience, if you tell patients the truth, they more often than not understand what you're saying and tend to see things from your perspective. "Go ahead doctor, do what you think is best," Preeti told me, amidst silent sobs as she tried to hold on to her dampened smile.

The next morning we opened her head up again, undoing our labour of love. Like I had predicted, the tumour was hidden beneath a sliver of normal brain, but it had indented and lifted the motor cortex from below. The previous tumour had pushed it down from above. I worried that while the first operation had redeemed her function, this one would destroy it, given its precarious location. I remembered a famous surgeon once tell me, "There may be a few patients whom we may not be able to heal, but there are none we cannot harm."

Unfortunately, he was right. She woke up paralysed on the right side. I should have just let it be, I told myself, but also comforted myself knowing that this weakness is often transient, and as the swelling in the brain subsides, it gets better. By day three, she was walking independently, and one week later, when she was ready to be discharged, her hand grip was as firm as mine. I was able to absolve myself.

Just when I thought I'd never see anything like this again, a few days later, I saw another lady in my office. She was in her 50s. All she had had was a headache that had persisted for a week. Her MRI showed five round balls of varying sizes close to each other. "This could be TB or this could be tumour," I told the husband and wife, who were petrified that the seeming insignificance of her symptoms had yielded something so dramatic inside the brain. The PET scan did not reveal any source of a possible metastasis. We'll be lucky if this is TB; she'll have a cure, I hoped.

I removed them all. This time I was doubly cautious, and the postoperative scan confirmed a total excision. She went home in pristine condition, relieved of her headache, which had occurred owing to raised intracranial pressure. Unfortunately, this set of five tumours weren't harmless; it turned out to be a Grade 4 cancer.

The writer is practicing neurosurgeon at Wockhardt Hospitals and Honorary Assistant Professor of Neurosurgery at Grant Medical College and Sir JJ Group of Hospitals.