Life and Times; L.A. Medical. Dr. Keith Black

<v Dr. Keith Black>This is a 50 year old lady who was in good health until approximately three months ago when she had the sensation of unusual taste in the mouth. <v Nurse>You want the- your whole head shaved or do you want just part of your hair? <v Beverly Nishimura>I'd Like to keep my hair, I brought a wig just in case. <v Beverly Nishimura>I really didn't know too much about brain tumors and if anything scared me, it was to have somebody open my head and take it out. <v Narrator>Next on Life and Times, a profile of neurosurgeon Keith Black and his fight against brain tumors. <v Host>Major funding for Life and Times is provided by the James Irvine Foundation, which is dedicated to the development of an informed California citizenry with additional support from GTE- a company committed to telecommunications excellence and an open dialog among all people. This episode of Life and Times offers a profile of a surgeon, it contains timely and important information about the medical battle against brain tumors. The program includes scenes of actual brain surgery that some viewers may find disturbing. Viewer discretion is advised.

<v Nurse>Ok, first thing that I am going to do is to check your name. <v Beverly Nishimura>Oh yes. That's a good idea. See if I am the right person. <v Nurse>OK, you have another one here? <v Beverly Nishimura>Yes. <v Narrator>Keith Black is head of neurosurgical oncology at UCLA. His patient, Beverly Nishimura, is about to undergo surgery to remove what doctors think is a tumor in her brain.

<v Beverly Nishimura>Well, I began to get dizzy spells occasionally, not frequently, but occasionally. And I would have to hold on to walls or the furniture or something. And I guess the first one was quite dramatic. I woke up in the middle of the night and it was strong and I was very dizzy and sick to my- felt sick to my stomach and held on to the wall and the bed. And I didn't feel well. That was the first indication that something was not quite right. And I went to the doctor and I thought it was an inner ear infection because it was going around. Different friends had it and he thought so. And then it became more frequent until I got a very strong sensation of taste and smell. It was very strong, reminded me of banana oil, and that's when I thought something is not quite right. And my doctor had me take an MRI and that's when I saw the tumor, and the photograph. <v Dr. Keith Black>This is the MRI scan of Mrs. Nishumara's brain, uh, you can see the eyes, uh, this is the nose and this gray area here is the actual brain tissue itself. Uh, this white area that we see is all abnormal tissue. Um, this area is probably, uh, uh, about four inches in maximum diameter. It's on the right side. And it's primarily located in the temporal lobe, um, in a very deep area of the temporal lobe.

<v Narrator>Until now, aside from injuries suffered in an auto accident, Mrs. Nishimura has not had to face serious medical problems. Her life has gone well for her. She is married to an attorney and her daughter, Jenny, is 11. She grew up in Massachusetts. <v Beverly Nishimura>I went into the Peace Corps after graduating from University of Massachusetts and stayed three years in Tunisia, North Africa, and then traveled all around the Middle East. Eastern Europe, up to Moscow, lived in Paris for a year, taught at the Berlitz School of Languages, and then returned home in 1968 and wanted to see the rest of this country, came out here and got a job with L.A. City schools and worked with them for a number of years. And then when I had my daughter, I decided that I would resign and stay home and be with her. I was fortunate enough to be able to do so. <v Dr. Keith Black>Kill the music. You can just turn it completely off.

<v Narrator>This morning, Keith Black has been in and out of the operating room. His patient, Mrs. Nishimura, has already been here for two hours undergoing preparations for a craniotomy to remove her brain tumor. <v Dr. Keith Black>Thank you [inaudible] Thank you very much. Alright we're ready for blue towels. <v Dr. Keith Black>There are forty thousand new cases of brain tumors diagnosed every year in the United States. Brain tumors is the second leading cause of death from cancer among children. So it's a major health issue. <v Dr. Keith Black>At least we have it visualized so-. <v Dr. Keith Black>The incidence of brain tumors is increasing in contrast to other forms of cancer, where the incidence is actually decreasing because we're changing our behavior. For example, fewer people smoke. So there's a lower incidence of lung cancer. We can't change our behavior that we know of at this point and change our risk of developing a brain tumor. And for whatever reason, whether it's environmental or whatever, we know that the incidence is on the rise. Unlike any other cancers. It is a tumor that essentially takes away your very soul. Uh, your rest of the body is healthy. You feel physically fit, your heart is fine, your lungs are fine. Your muscles are in good shape. But you basically lose your character. You lose your intellectual ability. Uh, so in that sense, I think it's one of the most devastating forms of disease in this country, and it affects people like no other disease can. <v Narrator>To enter. Mrs. Nishamura's brain, a window has been cut in the right side of her skull in the temporal area. Dr. Black and his assistants have been using ultrasound to help them navigate. And now they have reached the tumor

<v Dr. Keith Black>Right down on the tumor at this point. And now what we're going to do is going into the microscope to get better magnification into the deeper structures. <v Narrator>The surgical microscope will magnify by three times the area where Dr. Black is working and help him to minimize the risks. In almost all brain surgeries, there are many potential dangers. <v Dr. Keith Black>[inaudible] Yes. OK, let's have the [unclear] <v Dr. Keith Black>The brain is organized in what we call a topographical arrangement, which means that not all regions of the brain are equal. There are areas that are high real estate areas that are very low. Real estate, for example. Most of your language ability is concentrated in two very particular areas within the brain so that we know that if we go into these two small areas, we can cause a very dramatic speech deficit. And it's an area that neurosurgeons need to avoid at all cost. So we have a tumor, for example, that's located close to the language area. We have to decide No. one, is this tumor invading the language area and then it's truly inoperable or is it pushing the language area aside? And if it is pushing the language area aside, can we find a corridor to enter the brain that doesn't enter the language area and to dissect the tumor away from language and spare a language function within that patient? <v Narrator>In working in the area of Mrs. Nishimura's temporal lobe, Dr. Black must avoid impairing her ability to move, to see and to process information. He must also be mindful of the blood vessels in her brain so that she does not suffer a stroke. Despite the risks inherent in the operation, Mrs. Nishimura approached the day of surgery with at least an outward air of calm.

<v Beverly Nishimura>I knew that if I left it there would just keep growing and I didn't want it to be there and I just thought, why wait? We'll just do it as soon as Dr. Black could do it because I don't want to dwell on it. I mean, it has to be done. So that's how we have to accept it. <v Dr. Keith Black>We're coming down on the tumor. The tumor is very discrete from the rest of the brain, it looks gray, you know, with a more defined capsule. <v Dr. Keith Black>There's a lot of concern before surgery. Uh, there is a lot of thought given to the fact that you want to make absolutely, positively sure that you're doing the right thing for your patient, uh, not only in electing to do the surgery, but that you've picked the best approach to do the surgery. Uh, and then once you go into surgery, at least for me, is, uh, is is something that's difficult to describe. But, uh, you begin to focus only on the surgery so that everything else sort of blurs out, um, at least in my mind, sort of. I'm not aware of a lot of other things that are going on around me in the surgical room, but I'm concentrating entirely on trying to get the tumor out or dealing with with the dissection and trying to get the best plane careful dissection around the tumor. <v Dr. Keith Black>Even though that we've got a nice, clear plane of the section in the ventricle and this area here is beginning to blend more into the brain tissue.

<v Dr. Keith Black>Yes. <v Pathologist>That pathology on Beverly Nishimura that frozen section shows an astrocytoma. <v Dr. Keith Black>What grade? <v Pathologist>It's at least grade two to three. <v Dr. Keith Black>OK, thank you. <v Narrator>Earlier, Dr. Black sent to the pathology lab a small piece of tissue from the tumor. Now, with a diagnosis of an intermediate grade, very likely malignant brain tumor confirmed, the task is to remove the tumor. For Beverly Nishimura, the immediate situation is far less grim than it used to be for patients with her diagnosis. <v Dr. Keith Black>Neurosurgery is a very young feild. It started approximately 50, 60 years ago. If you look back at some of their original data, there was a 70 to 80 percent mortality associated with the neurosurgical operation, which meant that if you went in for a neurosurgical operation, you had a 70 percent chance of dying from that operation. The things that have made a tremendous difference is the use of drugs to reduce brain swelling and the surgical microscope. <v Narrator>Dr. Black expects that he and the residents he is teaching today will themselves see enormous changes.

<v Dr. Keith Black>The interesting thing to keep in mind about the teaching is that the operations that the residents are being taught now will be obsolete five years from now. I've been out of my residency for six years and the way that I operate now is completely different than the way I operated when I finished my residency. So the most important thing for them to learn is not necessarily a technical sequence of how to do a particular operation, but to learn the principles of surgery so that as the field of neurosurgery evolves and it will evolve, I think, quite dramatically over the next five to 10 years that they're able to evolve with it. <v Narrator>Keith Black's interest in the human body goes back to his boyhood, he haunted medical research labs while he was in junior high and he was not yet out of high school when he published his first scientific paper. <v Dr. Keith Black>My parents never pushed me, but they always provided me with opportunity. I remember as a young boy, I think around six or seven, you know, cleaning chickens with my mother and taking heart out of the chicken before she cooked it and being fascinated with that. So to fallout with that, my father went and got a cow heart for me to look at and dissect and just sort of cultivated the interest that I showed a natural tendency towards. But there was never any pressure to just sort of achieve or do anything special. <v Dr. Keith Black>Anteriorly we're certainly safe, right. All of this stuff here is just tumor.

<v Dr. Keith Black>[inaudible] this way. Ok let's what we've got now. <v Surgeon>Forceps. <v Dr. Keith Black>Ok and you got- <v Surgeon>The graspers? <v Dr. Keith Black>Bipolars. <v Dr. Keith Black>Specimen.

<v Dr. Keith Black>So now we have a pretty deep hole. I think we have a plane posteriorly <v Dr. Keith Black>this is really sort of as far as we go. <v Dr. Keith Black>Probably the most critical decision that we have to make is it's the balance between when to stop, when have we taken out as much tumor as we can safely take out, and when are we increasing the risk that we're going to leave a patient with a permanent deficit? So, you know, we're constantly reevaluating that at the time of surgery to try to achieve the best surgical resection as possible. <v Narrator>Five hours have now passed since Beverley Nishimura arrived in the operating room. Dr. Black has finished removing as much of the tumor as he can see. Tomorrow, an MRI will show whether any fragments remain. Surgery is often not a complete cure for brain tumors and other approaches, such as radiation or drugs, may be needed to eliminate all cancer cells. In addition to his work as a brain surgeon, Dr. Black is active in brain tumor research. <v Dr. Keith Black>This is your new data, right? Right. And it's all randomized.

<v Researcher>Yes. <v Dr. Keith Black>OK. And this data corresponds to that. What happened with this right here? <v Narrator>Dr. Black and his associates are seeking a way to deliver medicines across the barrier that normally isolates brain tissue from chemicals in the blood. They have recently made a major breakthrough. <v Dr. Keith Black>We now have the ability, at least in our lab laboratory model, to open up the barrier within brain tumors, one thousand two hundred percent twelvefold selectively within the tumor to very large molecules without opening the normal blood brain barrier at all. And that's a very, I think, important observation. <v Narrator>Dr. Black's research will soon be moving into human trials. If successful, it will allow doctors to deliver antitumor compounds to a brain tumor alone, leaving healthy tissues unaffected. <v Dr. Keith Black>Are we going to have pathology today too?

<v Brain Tumor board member>No. Harry has a heavy brain cutting day. <v Brain Tumor board member>Okay, guys, let's let's get this off the rug. The first patient that we're going to present is Mr.- <v Narrator>Every week, UCLA's brain tumor board meets to review cases, to sort out the best strategies for treating each patient. Usually in attendance are specialists with backgrounds in a variety of disciplines radiation therapy, surgery, pathology and oncology. <v Dr. Keith Black>So the next patient is Beverly Nishamura, um, she's a 50 year old lady patient of actually, uh, Dr. Gruber. Uh, it's right hand and enjoying good health until December of nineteen ninety two when she began having some strange sensations of, uh, unusual smells or factory odors and I quote, sensation of lightheadedness. <v Narrator>Dr. Black is presenting the outcome of Beverly Nishimura surgery and subsequent tests since the final pathology report confirmed that her tumor was malignant. She'll be undergoing chemotherapy under the care of neuro oncologist Michael Gruder. UCLA started developing a major brain tumor treatment program in 1987, the year Dr. Black arrived. <v Dr. Keith Black>Brain tumors are treated in a very haphazard way. Uh, I think there was a total of 50 brain tumors treated at UCLA Medical Center, uh, in nineteen eighty seven, um, versus three hundred brain tumors being treated here surgically, uh, per year, currently over three hundred. If she had agreed to a more aggressive protocol, Mike, which you think would have been the best protocol for her.

<v Mike>I think I would have entered her into the in interarterial, super selective [inaudible] <v Narrator>The world ofrain tumor experts seems to consist primarily of white men surgery. Dr. Black says that more women are entering the field of neurosurgery now, but he finds it unfortunate that the number of African-Americans attending medical schools is actually decreasing. For himself. He thinks he's been able to change some perceptions. <v Dr. Keith Black>When I was a resident at Michigan, I operated on a patient with a with a brain tumor who happened to be Caucasian, uh, and, uh, went through the surgery and did very well. And after surgery, came back to clinic a few weeks later and he said, well, you know, Doc, I like to thank you for two things. Uh, one, for saving my life and two, for allowing me not to be a racist anymore. So because before you took my brain tumor out, I didn't like black people. And, uh, you, uh, you changed my perspective on that. And maybe it was a message from God, you know, that I wasn't to be a racist anymore. Um, and I think that we have to change, um, the perception of society and continue to move in a very positive direction. <v Narrator>Every year, Dr. Black performs about 150 brain tumor operations, he usually sees his patients once or twice before surgery, and then follows their cases periodically depending on their diagnosis. Two weeks have passed since the surgery to remove Beverly Nishamura's brain tumor. She had to stay in the hospital only four days. Dr. Black is now seeing her for the first time since she left the hospital.

<v Dr. Keith Black>Hi. <v Beverly Nishimura>Hello Dr. Black. <v Dr. Keith Black>How are you feeling? <v Beverly Nishimura>Fine, how are you? <v Dr. Keith Black>Good. Have a seat. <v Beverly Nishimura>OK. <v Dr. Keith Black>Any problems since surgery? <v Beverly Nishimura>No. I've been doing quite a few things. <v Dr. Keith Black>What are you doing? <v Beverly Nishimura>Well, I went to my daughter's softball game and then we went out to the country fair at LMU and went out to dinner at Houston's. <v Dr. Keith Black>And so you feel better or worse or about the same since your surgery. <v Beverly Nishimura>Since the surgery. So much better. Oh, yes. I'm not dizzy at all.Such a blessing. <v Dr. Keith Black>And it's 10 days. <v Beverly Nishimura>Let's see the surgery with. Well, I don't know exactly how I'm counting the days-

<v Dr. Keith Black>Alright, Let's just take a look agt your incision here. <v Beverly Nishimura>It is sort to hide but- <v Beverly Nishimura>I don't know how to wash too well over there yet so- <v Dr. Keith Black>OK. all your sutures are out? <v Beverly Nishimura>Yes. <v Dr. Keith Black>That's looking very good. There is one staple left here. <v Beverly Nishimura>Oh, dear, really? <v Dr. Keith Black>Yeah. <v Beverly Nishimura>Oh dear. <v Dr. Keith Black>We can get that and you can start washing your hair tonight. OK. <v Beverly Nishimura>I was surprised there was so much hair but I said do whatever you have to do. <v Dr. Keith Black>I know you remember what the tumor looked like before and you might want to come up and take a look you can see [better in the center one.] You can see from the MRI that you had after surgery, there is no tumor left that we can see on an MRI scan, so that's very good. Alright. <v Beverly Nishimura>Yes terrific.

<v Dr. Keith Black>And that's exactly where we like to be at this point. We know that one of the things that will ultimately determine how well we do is this first step in making sure that on the MRI scan that we've got all of the tumor out that we could see the final pathology show that this was a malignant tumor. We tend to grade these on a scale of one to four, as you know, one being the best, four being the worst. This is probably somewhere around a grade three. <v Beverly Nishimura>OK. <v Dr. Keith Black>Uh, but, uh, you know, we can be aggressive and try to keep it under control and try to keep you looking perfect. Do you have any other questions for me? <v Beverly Nishimura>I don't think so. I think you explained everything well and did a great job. <v Dr. Keith Black>Thank you. Um, you know, we all work as a very close team here and with Dr. Gruber and Dr. Clauci and myself and Dr. Saltz in radiation. So, you know, we'll all be following you together from this point. Um, but I'd like to see you back again in about six weeks. <v Beverly Nishimura>Thank you very much.

<v Dr. Keith Black>You're welcome. See you later. <v Beverly Nishimura>Bye. <v Dr. Keith Black>Bye bye. <v Narrator>In addition to chemotherapy, Mrs. Nishimura will have radiation in an effort to wipe out any remaining malignant cells. She has put her faith in her doctors. <v Beverly Nishimura>I have not gone to the library. I have not found books on cancer or have delved into research at all. I have just listened to the doctors. <v Dr. Keith Black>Her life will not be normal. I mean, there's- she definitely has a risk of having, uh, tumor recurrence. The likelihood is that at some point in the future, the tumor will recur. Uh, we need to keep a very high surveillance, uh, on her with frequent MRI scans to look for any evidence of the tumor growing back. <v Beverly Nishimura>I think I approach life from a very positive point of view. I don't dwell on negatives. There's not enough time in life to dwell on the negative. And I don't think that helps anyway. And it certainly bores people to hear about negative things. So I just don't. <v Dr. Keith Black>You know, there is no safety, there's only relative safety and there's no absolute, um, uh, and no matter how safe we think we are, we're never really safe. And we could only do the best that we can do and, uh, to try to make sure that we have our soul and spirit in order, because that's really all that we can hope for in the end.

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