Andy Starnes, Post-Gazette Stephen Dubovich undergoes an awake craniotomy at UPMC Presbyterian Hospital on June 29. The surgery was performed by Dr. Arlan Mintz, director of neurological oncology at UPMC and Dr. Jonathan Engh, above, chief resident in the department of neurological surgery. Mr. Dubovich was asked to respond to instructions, such as "Smile for me" and "Squeeze my hand," during surgery so doctors could gauge how close they were getting to cutting into deeper areas that could affect motor function on his left side. Click photo for larger image. Related coverage Watch a video about an awake craniotomy

It's not the usual operating room conversation: "Smile for me again, Steve. Move your foot for me. Good job. Smile again, Steve. Squeeze my hand."

Stephen Dubovich, a 61-year-old from McClellandtown, Fayette County, was having surgery as he followed the instructions issued by a neurophysiology technician crouching by him at the operating table.

Behind a plastic drape, Dr. Arlan Mintz, director of neurosurgical oncology at the University of Pittsburgh Medical Center, carefully probed the exposed surface of the right side of the patient's brain, near his temple.

"I'm just listening to what's going on around me," Mr. Dubovich said. "They told me I'd be awake and talking. I'm awake and talking."

Hearing him say he'd be glad when it was over, Dr. Mintz got him to chuckle by responding, "If you find this boring, it's very good. It means you're not in pain and everything is going fine."

The operation is called an awake craniotomy, and Mr. Dubovich had it done so that the surgeon could carefully resect -- the medical term for cut out -- a tumor that threatened to invade the brain's motor strip, which lets him use his left side.

"If he's awake and I keep taking tumor out and he keeps moving and he's fine, I can keep pushing the resection," Dr. Mintz explained before the surgery. The goal: excise more than 90 percent of Mr. Dubovich's cancer, called a glioblastoma, because studies indicate that can lengthen survival time.

"We know we can't remove the entire tumor," the surgeon said. "At some point, we have to stop because the tumor is intermingled with normal brain matter."

Imagine the brain is the white paint in a bucket, and the tumor is a glob of red paint dropped into it, Dr. Mintz said. There are very red areas that could be scooped out, but then some pinky-white parts, whitey-pink parts and then white.

"As you get into that whitey-pink area, you're taking more brain than tumor," he said, and that could unacceptably impair the patient's function.

To find the right balance, Dr. Mintz and his team used sophisticated GPS-like technology to map out the region around the tumor before attempting to remove any of it.

After identifying brain tissue that is "eloquent," or functional, then "we'll bring in the microscope and start taking out the tumor," Dr. Mintz said.

In Mr. Dubovich's case, he said, "during the operation, we continue to have him move to assess if we're getting closer to any deeper areas that affect motor function."

Not every brain cancer surgery needs to be done with the patient awake. Conventional operations with the patient under general anesthesia may be the better choice when the tumor is located in a spot where the risk of removing normal tissue is low.

Dr. Mintz recently did an awake procedure on a woman whose speech center should have been exclusively in the left brain, according to textbook anatomy. But while mapping the right side of her brain for the operation, he found that she reliably stopped talking whenever a certain location was stimulated, warning the surgeon that he should leave it intact.

"We could have injured her speech if we [hadn't done] it awake," he said. "A lot of times I know I would have given a patient a deficit because I would have gone in that area," which mapping would have designated off-limits.

Stephen Dubovich

Most large medical centers have surgeons who do brain surgery on awake patients, Dr. Mintz said. Recently, UPMC's neuro-oncology program has been developing it into a strength that is beginning to draw surgical candidates from around the country. He performs about four awake craniotomies monthly.

In the procedure, the patient is lightly sedated during the first part of the operation, during which the scalp is numbed, the head is clamped to a frame so it remains still, a piece of skull is removed and an incision is made through the covering layers to expose the brain.

At that point, the sedation is lightened to allow the patient to awaken.

"He'll have no pain," Dr. Mintz said. "There's no pain in the brain."

Many patients are initially uncertain, but get over their qualms after learning more about the awake craniotomy. Still, there are some risks to consider.

Because the patient is expected to be aware and talking, a breathing tube is not inserted. If the patient has a seizure, or a respiratory or cardiac problem during the surgery, precious time could be lost until the exposed brain is recovered and ventilatory support can be provided.

Mr. Dubovich had a seizure shortly before his surgery was to begin, and the team decided to postpone until his medications could be adjusted.

Generally, awake craniotomy patients are comfortable and pain-free during surgery. Some are curious enough to watch the surgeon's-eye-view on operating room monitors. One man noticed the anesthesiologist checking e-mail, so he asked to have his own account checked, Dr. Mintz said.

Patients recover more quickly than they would from general anesthetic, so a large majority go home the next day or the day after, he added.

That was the case for Mr. Dubovich, who has since joined a clinical trial at UPMC Hillman Cancer Center for further treatment of his brain tumor.

In November 2005, he was at a grocery store bank when he felt his face twitching and his tongue thicken. He walked to the parking lot and leaned against his truck until he regained his composure, as he put it.

He drove home and, thinking he'd had a stroke, called his brother to help.

A brain scan showed a suspicious shadow, and a biopsy confirmed it was a tumor. Since then he has had multiple rounds of chemotherapy and 30-some radiation treatments. Until recently, daily medication kept the cancer at bay. Then the symptoms began returning, leading him to seek Dr. Mintz's help.

Survival rates for glioblastoma are low, the surgeon noted. Most patients who have it die within 12 months, even with surgery, radiation and chemotherapy.

But Mr. Dubovich already passed that milestone, and "that's why we're pushing ahead with the aggressive therapy, because he's done so well," Dr. Mintz said.

The awake craniotomy didn't intimidate Mr. Dubovich.

"I'm not a squeamish person," he said. "I prefer to go the route that gives me the best chance."

Dr. Mintz took out all the tumor he could find during the surgery, and a postoperative brain scan shows empty space where the cancer used to be. He figured more than 95 percent of it was removed.

Mr. Dubovich, who turned 20 while serving in Vietnam, was chosen for the honor guard that escorted President Eisenhower's funeral cortege and worked in coal mines as a laborer and later as a federal safety and health inspector, understands that the cancer will likely grow back.

He wants to mow his lawn in the summer, shovel his driveway in the winter, go out to eat and maybe even play some golf for as long as possible.

"The research is better every day," Mr. Dubovich pointed out. "As long as it gets you back on your feet, you go. That's my way of looking at it. I just can't see being a quitter."

For more information on the awake craniotomy and UPMC's Minimally Invasive Endoneurosurgery Center, see www.upmc.com and www.minc.upmc.com