Tiresias: The Goldilocks solution

"Not too little, not too much: there safety lies."

Euripides

My friends,

Last week Tiresias talked of many things, perhaps too many for one digest. Today Tiresias will address a single subject, his favourite subject, and will try to be brief. Today Tiresias will discuss his favourite subject, the one that originally piqued his interest in Optiscan confocal real-time in-vivo digital pathology, to wit, malignant brain tumour: glioblastoma multiforme. As Tiresias has said many times and keeps saying, in the last 60 years, despite all the advances in neuroimaging, neuro-oncology, neuro-immunology and technical neurosurgery, there has not been any improvement in prognosis or survival of patients with malignant brain tumour. The reason is really very simple. You see my friends, at operation, the surgeon cannot tell, what is normal brain and what has cancer. This means that if the surgeon attempts to “cure” the tumour he is at risk of taking out significant normal brain and leaving a patient with a significant deficit and still no guarantee that the tumour cells have been removed. If however he follows Hippocrates prime directive, “primum non nocere”, (first do no harm) and removes minimum tissue, with no idea where the margin of the tumour lies, the malignant cells will be left behind, they grow they will multiply, and the patient will die. This tension is at every operation for this malignant brain tumour. It is this tension that has led to a modern medical Greek tragedy. It is the tragedy of the current suspension of Dr Charlie Teo.

The tension in the operating room, of balancing removal of tumour cells verses preserving normal brain cells, has spilled out of the operating rooms into medical regulatory authorities, the legal system, and the media, and resulted in the ongoing drama in our media. It is the tension of why so many desperate patients and families and lay media are clamouring to have Charlie Teo reinstated to give them and their families some hope, some chance, of surviving malignant brain tumour. They know the current treatment for all its drama and expense gives no hope. You see this dispute is over balancing of perhaps attempting removal of tumour cells too hard and as a result perhaps removal of normal tissue. In Tiresias’s opinion, they are all working in the dark, in ignorance. Of course, the conservative surgeon and the aggressive surgeon; the most conservative surgeon and Charlie Teo, none of them know. They don’t have a clue what is the right operation. They do not know how far to go. They do not know if they have removed the malignant cells and they do not know if they're removing normal brain. They use the now ancient and flawed technique of frozen section, with all the problems, fraught delays, sampling issues, technical difficulties, inaccuracies, and limited number of times it can be done. Understood this way, it is not at all surprising that survival in patients with malignant brain tumour has not improved in the last 60 years. Now, with Optiscan real-time digital in-vivo digital pathology and with the advent of specific fluorescent labelling of tumour cells, all is changed. Finally, neurosurgery for malignant brain tumour will be put on a rational footing. The surgeon will and can now see malignant cells. All current malignant brain tumour surgery is now obsolete. Tiresias cannot believe how long it's taken Carl Zeiss to get this up and running. Tiresias cannot understand why medical regulatory authorities, why neurosurgical societies, why cancer associations, the media, do nothing about this. It is scandalous. Tiresias dreams that perhaps in using his enforced sabbatical, Dr Charlie Teo have looked at the CONVIVO and will return, with a justifiable claim that now, his surgery makes his antagonists’ claims unreasonable. That traditional surgery is now obsolete. Tiresias also dreams that some inspired young neurosurgeon, inspired to do something meaningful, is talking to Carl Zeiss now. Tiresias dreams but knowing the medical system, as he does, Tiresias sometimes also despairs. You see my friends, there are many perverse incentives in Australian medicine and Australian surgery. But Tiresias is also patient and looks to the fulfillment of his dreams, and soon.