CF

LEARN MORE ONLINE Visit our Therapy Update

Paul Smith AusDoc editor

A look at the evidence given by an expert neurosurgeon .

NIC BEZZINA

The two patients diagnosed with brain cancer were desperate to live , Dr Teo became their last hope but the surgical procedures he offered were futile given the risk of severe permanent disability and death .

There has been a vigorous debate among doctors about the cases and whether Dr Teo is a victim of the system he has long claimed was out to crush him .

This article attempts to document how deep the futility of what Dr Teo was offering went — whether it sat in the complex medical grey area or beyond it — by taking you through the expert clinical testimony given to the Medical Professional Standards Committee in regard to Patient A .

It tracks the basis on which Dr Teo decided to operate , the information he had about her tumour for other doctors , what he did during the surgery and why it did not work as he had hoped .

The original diagnosis

Patient A was 41 years old , married and the mother of three children , the youngest of whom was aged six .

She was diagnosed with a brainstem glioma ( BSG ) in October 2018 following CT scans and an MRI at St John of God Subiaco Hospital in Perth .

The imaging showed a 19mm x 18mm x 22mm dorsal midbrain mass involving the tectum and cerebral peduncle , most likely a tectal plate glioma .

A needle biopsy confirmed the mass as a tectal midbrain tumour H3K27M-mutant diffuse glioma , WHO grade IV .

According to the notes of Professor Christopher Lind — the neurosurgeon who made the diagnosis — surgical resection was pointless .

Patient A was referred to a radiation oncologist and a medical oncologist . She sought a second opinion , but the committee said she was again advised against surgery .

On 23 October , both Patient A and her husband travelled from WA to Sydney to meet with Dr Teo .

The following day , she underwent surgery at Prince of Wales Private Hospital , where Dr Teo was director of the Centre for Minimally Invasive Neurosurgery .

The committee was told the aim was to achieve resection of the tumour , to debulk the mass to aid further improvement with radiotherapy .

The expert witness for the NSW Health Care Complaints Commission ( HCCC ) was neurosurgeon Associate Professor Andrew Morokoff from the University of Melbourne .

His view of Dr Teo ’ s conduct was straightforward .

“ In general , the risks with operating on the brainstem are very high , which is why it is rarely done ,” he said , listing the possible outcomes as prolonged coma , vegetative state or death .

I made an error , a surgical error . I went too far and damaged this lady .

— Dr Charlie Teo

Was the tumour focal ?

The key discussion in the inquiry was whether the tumour was focal or diffuse , and whether it had crossed the midline .

Professor Morokoff said the MRI taken before the operation showed it was not focal because the T2 signal changes extended well beyond the midbrain tectum into the cerebral peduncles and thalamus on both sides .

On the focal versus diffuse question , the expert witness used by Dr Teo ’ s own lawyers was in agreement .

WA neurosurgeon Professor Bryant Stokes , the founding head of the neurosurgery department at Sir Charles Gairdner Hospital , acknowledged that the tumour did not meet the definition of a focal BSG , even as defined in a published paper authored by Dr Teo himself .

Both experts agreed that the tumour as a whole was diffuse , adding that describing it to a patient as focal would be misleading because it was factually wrong .

For Professor Morokoff , this meant any attempt to resect more than 95 % of the tumour , as Dr Teo planned , carried significant risks of profound neurological sequelae .

During the inquiry , he was asked about the extent of the clinical uncertainties before the operation .

Did the literature support the view that radiological characteristics based on CT or MRI imaging were unreliable markers of malignancy ?

Professor Morokoff said the question was “ slightly vague ” but broadly agreed , saying a surgical biopsy and histopathological examination of tissue were needed for a definitive diagnosis .

However , he rejected a second suggestion that imaging was often insufficient to enable definitive classification of a tumour as focal or diffuse .

Given this , he went on to stress that there was little robust evidence in the published literature

‘ The risks with operating on the brainstem are very high , which is why it is rarely done .’

supporting Dr Teo ’ s decision to attempt surgical resection of the BSG .

No randomised controlled study had been done , he said .

Yes , there was evidence that complete surgical resection for supratentorial glioblastoma in adults was beneficial in terms of survival .

But BSG resection proposed operating on an area where the patient was likely to sustain major neurological deficits or complications , even if the tumour itself was treated successfully .

Dr Teo ’ s research

Professor Morokoff was asked about two papers co-authored by Dr Teo .

The first was published in 2008 in a journal called Child ’ s Nervous System — a review of 34 paediatric cases of focal BSG where radical resection was attempted and associated with patient survival .

It involved the analysis of 33 BSG patients , Professor Morokoff said , and showed that the extent of resection did not influence survival and that 20 % of the 10 high-grade BSG patients had worse outcomes postoperatively .

The second paper , published in 2021 in World Neurosurgery , was a review of 77 BSG cases operated on by Dr Teo , covering survival and complication outcomes .

It was presented as a single- PAGE 6