When Madisonville resident Calvin Kaul fainted and collapsed one day a few months ago, it began an odyssey that would peel back the layers of medical care in the state of Louisiana — specifically the diagnosis and treatment of brain tumors.
And that was the diagnosis handed to Kaul after his initial CAT scan.
“From the day I got the diagnosis, I began to get medical opinion after medical opinion," said Kaul, who is 40 and works in human resources. "Was it benign or malignant? Did it need to be removed, and was that even possible? A needle biopsy was done by one of the institutions I went to for an opinion. It revealed the tumor was probably benign, but everyone I spoke with said it was inoperable.”
“Calvin had been told that the tumor was in his speech area, making it too dangerous to operate,” said Dr. Frank Culicchia, chairman of the LSU Health New Orleans Department of Neurosurgery, “but I thought surgery was possible, since Calvin had no speech problems.”
“A few days before my surgery, Dr. Culicchia called me,” the patient said. “He told me he wanted to do my surgery at University Medical Center New Orleans because a brand-new piece of equipment which had first become available in August would give him the ability to see precisely what he was doing right in the middle of the surgery.”
“The only way to really know if the tumor was resectable," or removable, Culicchia said, “was to do brain mapping in an operating room setting, and determine if the tumor was in what’s called an eloquent part of the brain, affecting speech, vision, motor abilities or memory, for example.”
A close look at the brain
Brain mapping is a procedure in which the brain is exposed in the operating room while the patient is under light sedation, so he’s relaxed but still able to speak. A probe is put on a specific part of the brain, and, using an electrical current, a specific area of the brain can be stimulated. Since Calvin’s neurosurgeon was looking for his speech center, he stimulated that part of the brain.
“As different target centers are stimulated and we ask questions of the patient, he will either have a speech arrest (where he can no longer speak), or the patient will be unable to find a word, or words will be jumbled,” said Culicchia. “Now, we say, where is this tumor in relation to that area we’ve just mapped out? Brain mapping has been used across the country for years, but this instantaneous imaging, using this new intraoperative magnetic resonance imager (i-MRI) gives us a higher level of care and allows us to keep going with tumor removal, as we know exactly where we are, using real-time imaging.”
“With this image guidance, mapping the cortex around the tumor, I can actually determine if his speech area is too close. And, I could see on the image before me that it was one gyrus (a brain ridge) away. And that was enough to allow me to excise it. Having an i-MRI allows me to check on my work, and adjust, while we’re still in the OR, and I’m cutting,” Culicchia said.
Ordinarily, MRI scans take hours to read, with radiologists in a different part of the hospital. But with a conveyor belt transporting the patient quickly between the operating table and the i-MRI, it’s a seamless procedure.
“We’ve never had access in this state to this sort of sophisticated imaging tool in the OR,” said Culicchia. “Louisiana and Mississippi often lost patients to Texas, as many patients felt like getting state-of-the-art care meant leaving the state. Not only does UMC now have the best equipment, but additionally, LSU has added a neuro-oncologist to its staff. This is the first time in a decade that this subspecialty, which treats patients during initial diagnosis and post-operatively, is available in our state.”
Treating illness close to home
James Favrot, of New Orleans, whose wife Kelsey succumbed to a malignant brain tumor in 2009, knows all too well the misery involved in traveling with a terminally ill patient to another state.
“During the course of Kelsey’s treatment, we really felt that we needed to take her to M.D. Anderson in Houston to get the latest in equipment and specialists,” Favrot said. “But we have four children, and it was unbelievably traumatic to be going back and forth in such a trying time.
"Kelsey said to me, as she was enduring treatment, that whether she made it or not, Louisiana needed state-of-the-art care for those with brain tumors. When she passed, my family and I began to fund the Kelsey Favrot chair for neuro-oncology at LSU, as part of a larger and future Brain Tumor Center.”
“Everything that’s happened here recently is a great kick-start to bringing the entire Gulf South region into the forefront as a center for brain tumors,” said Culicchia. “We now have the machinery in the OR, and we have a funded chair for neuro-oncology, which is a prestigious appointment in academic circles.
"And, we’re looking to expand. We’re going to want a radiation oncologist specifically trained in brain tumors, a fellowship trained neuropathologist, and a myriad of other specialists which will put us on the map as the place to come for treatment of brain tumors. Eventually, I’d like a comprehensive center which will include dietary, spiritual and all of the holistic approaches which are important in treatment.”
Because patient Calvin Kaul was kept awake during his brain surgery, he was able to assist his neurosurgeon in determining exactly how he was functioning during the operation. His memory of the surgery is blurred, but the neurosurgeon says patient participation is critical in helping him make sure of the brain’s functions as the operation proceeds.
Risks and rewards
“To further determine where we are exactly in the brain, we ask specific questions of the patient, and determine how long it takes him to respond and what the quality of the response is. So, let’s say we hold up a picture of a telephone, and he calls it an earring — then we know we could be near a memory or visual center,” Culicchia said.
“This is why the intra-operative MRI is so critical, as I can determine as I remove the tumor whether I’m entering a vital area of the brain, in which continuing on with the resection might leave the patient with a neurological deficit. And it’s as easy as a conveyor belt that transports the patient off of the operating room table into the adjacent MRI for imaging, while just a glass wall away we receive computer images.”
The surgery took seven hours. Any surgery can be traumatic to the body, and Calvin Kaul was aware of the risks and rewards. Because his tumor was benign, there is no need for chemotherapy or radiation.
“The first week post-op I felt sort of strange, because I couldn’t remember how to say certain words. I could write them, but couldn’t actually say them,” Kaul said. “But within a week, and literally overnight, it all came back.
"I left the hospital after two days, and was back at work in two weeks. It’s been over a month now since the surgery, and I feel great. After all, who can complain when everyone tells you that your tumor is inoperable, and now you’re tumor-free? I’ll go back in three months for a brain scan follow-up, but I feel incredibly fortunate. My tumor has been removed, and I’m back to my life.”
RACE TO SUPPORT BRAIN CANCER TREATMENT
WHAT: The Kelsey Bradley Favrot Memorial 5K Run/Walk
WHERE: Audubon Park Shelter #10 — New Orleans
WHEN: Oct. 8
TO REGISTER: Kelseygoal.com
All proceeds benefit the LSU Neurosurgery Brain Tumor Center.