Sen. Edward M. Kennedy chose to undergo yesterday's brain surgery at Duke University after some of the country's top medical experts disagreed with specialists at the Boston hospital where he was initially treated.
Dr. Allan H. Friedman, co-director of Duke's brain tumor center, was among those who favored an aggressive attack on the tumor that triggered a seizure last month, alerting doctors to his condition, according to a Johns Hopkins physician who consulted in the case.
Friedman, an internationally known neurosurgeon, announced yesterday that the 3 1/2 -hour operation went well and that his patient was talking and in good spirits afterward.
"I am pleased to report that Senator Kennedy's surgery was successful and accomplished our goals," said Friedman. "Senator Kennedy was awake during the resection and should therefore experience no permanent neurological effects from the surgery."
Brain surgery while a patient is awake is becoming increasingly common, said Dr. Henry Brem, director of neurosurgery at Johns Hopkins Hospital and a consultant in Kennedy's case.
To determine whether removing additional tissue will hinder their patient's ability to function, surgeons electrically stimulate the area and observe the effects. The current temporarily blocks signals produced by the tissue, mimicking what would happen if the tissue were removed.
A neuropsychologist standing by engages the patient in conversation and judges whether removing the tissue would be harmful.
The operation is aimed at extending Kennedy's life but does not cure the condition, experts say. Average survival for similar patients receiving a combination of surgery, chemotherapy and radiation is two years, double what it was not long ago.
On Friday, experts from some of the nation's elite neurosurgical centers met at Massachusetts General Hospital to discuss the 76-year-old senator's treatment options.
Surgeons there, who had removed a sample of the tumor for diagnostic purposes, apparently recommended a combination of chemotherapy and radiation without further surgery.
But Dr. Henry Brem, who consulted in the case but was unable to attend the session, said several experts argued that surgery and follow-up treatment offered the best survival chances. Attending the meeting were Friedman; Dr. Stuart A. Grossman, a Hopkins neurosurgeon; and specialists from Massachusetts General and the University of California San Francisco.
"We recommended surgery, the Duke group recommended surgery, and I believe the UCSF group recommended surgery," said Brem. "There are always differences in opinion as to what the best treatment is.
"The question was what removing more tumor would accomplish. Our data shows that people do best if they have the maximum amount of tumor removed safely."
Brem said patients in similar cases often seek opinions from two or three medical centers before deciding whether to undergo brain surgery.
"Kennedy worked the other way around," said Brem. "Everybody came to him."
The Hopkins neurosurgeon said the arrangement was appropriate because Kennedy "has devoted his whole life to improving health care for this country."
Kennedy is expected to remain at Duke for about a week before returning to Boston, where he will receive further treatment at Massachusetts General.
Friedman, 59, is a professor of surgery and chief of the neurosurgery division at Duke, whose Web site says he is responsible for about 90 percent of tumor resections there.
"He's very highly regarded and is one of the thought leaders in the field," said Dr. Richard North, a neurosurgeon at Sinai Hospital in Baltimore. North was a Duke intern when Friedman was a resident there in the late 1970s, and the two have maintained a friendship over the years.
Kennedy's brain tumor is in the left parietal region of the brain, in the top, rear portion of the skull. The region plays a role in sensation, speech and other faculties, so surgeons must balance the need to remove as much tumor as possible with the need to preserve functions critical to a patient's quality of life.
No matter how much tissue they remove, they cannot eradicate the entire mass because it sends microscopic tentacles into surrounding tissue, North said.
"It has spread beyond what one would see with one's eyes in the operating room," said North, who also worked at Hopkins for many years. "It's spread beyond what one can see on a scan."
The tumor has a high propensity to spread - even to the other side of the brain - because it is so deeply rooted, North said.
Surgeons also have the option of implanting chemotherapy wafers that attack the remaining cancer from within. The wafers were developed at Hopkins, and Duke has used the wafers and published research on their benefits. The hospital has not indicated whether its doctors opted for this.
"It's an intraoperative decision," said Brem.