Brain Tumor Surgery in Washington, DC: Meningioma, Glioma and Brain Metastases

What a brain tumor is

A tumor is a growth of cells that should not be there. In the head, that one word covers very different things: a slow growth on the lining of the brain that may never cause trouble, a tumor that arises within the brain itself, and a cancer that has spread to the brain from another part of the body.

“Tumor” does not mean “cancer.” Each year about 26 of every 100,000 Americans are found to have a tumor that started in the brain or its coverings, and about 19 of those 26 are non-malignant, meaning they are not cancer.¹ Five years after a non-malignant tumor is found, survival is 91.7% of what would be expected for people of the same age without one.¹

Benign does not always mean harmless. The skull is a closed box, and a growth that presses on the brain or on a nerve can cause real problems even if it will never spread. And malignant does not mean that nothing can be done. What matters is the exact kind of tumor, where it sits and how it behaves over time.

This page is about adults. I see patients 18 and older.

Meningiomaon the lining

Gliomawithin the brain

Metastasesspread from elsewhere

A slice of the brain as it appears on an MRI scan, simplified. Tumors are shown in dark red. A meningioma grows from the lining and presses on the brain from outside. A glioma grows within the brain, and its edges blend into normal tissue. Metastases are often more than one, and each tends to be round and well defined.

The three kinds I see most

Together, meningiomas, gliomas and metastases account for most brain tumors in adults.

MeningiomaThe most common tumor that starts in the head

A meningioma grows from the meninges, the lining between the brain and the skull, not from the brain itself. Meningiomas make up 42.6% of all tumors that start in the brain or its coverings,¹ and most are benign and slow growing.

Many are found by chance and only need to be watched. Those that are large, growing or causing symptoms are removed with surgery, which is often curative when the whole tumor and its attachment can be taken out.⁴ Radiosurgery is an option for some.

GliomaStarts in the brain’s own supporting cells

Gliomas include astrocytoma, oligodendroglioma and glioblastoma, and make up 22.2% of tumors that start in the brain.¹ They range from slow-growing tumors that people live with for many years to glioblastoma, the most common malignant brain tumor in adults, at 13.7% of the total.¹

Because a glioma blends into the brain around it, surgery aims to remove as much as can be removed safely and to obtain tissue. The tissue is tested for genetic markers, such as IDH and 1p/19q, that now define the diagnosis and guide whether radiation, chemotherapy or a targeted drug comes next.

Brain metastasesCancer that has spread from elsewhere

A metastasis is a deposit of a cancer that began in another organ, most often the lung, the breast, the skin (melanoma) or the kidney. Between 10 and 40 of every 100 people with a solid cancer develop one or more, which makes metastases about ten times as common as malignant tumors that start in the brain.⁵

Treatment has changed a great deal. Focused radiation, called radiosurgery, now treats most small metastases without an incision. Surgery is used for large ones, or when the diagnosis is uncertain. Some newer cancer drugs also reach the brain.⁶

How the three most common brain tumors in adults typically differ
Feature	Meningioma	Glioma	Metastasis
Where it starts	The lining of the brain	Within the brain itself	Another organ; it reaches the brain through the blood
Benign or malignant	Usually benign	Ranges from slow-growing to highly malignant	Malignant
How many	Usually one	Usually one	Often more than one
How it is found	Often by chance; otherwise a seizure, headaches or slow changes	A seizure, or changes in speech, strength or thinking	A scan during cancer care, or new symptoms
On MRI	Attached to the lining, with a smooth edge	Within the brain, with edges that blend in	Round and well defined, often with swelling around it
First decision	Watch or treat	Remove or biopsy, to learn exactly what it is	Radiosurgery, surgery or both, planned with the cancer team
Main treatments	Watching, surgery, radiosurgery	Surgery, radiation, chemotherapy, targeted drugs	Radiosurgery, surgery, cancer drugs

These are patterns, not rules. Other conditions can look like a tumor on a scan, including infection, inflammation, a stroke and abnormal blood vessels. Sometimes the only way to be certain is to examine a piece of the tissue under the microscope.

Other kinds of tumor

Tumors of the pituitary gland, tumors of the hearing and balance nerve (vestibular schwannoma, also called acoustic neuroma) and tumors deep in the base of the skull are treated by surgeons who concentrate on those areas. If that is what your scan shows, you can still call. I will tell you so and help you reach the right surgeon.

What brings people in

Symptoms depend more on where a tumor sits than on what kind it is.

A seizureOften the first sign

A first seizure in an adult always calls for a brain scan. It may be a full convulsion, or only a spell of twitching, tingling, a strange smell or a few lost seconds.

Seizures are especially common with slow-growing gliomas. In one series of 1,028 people with tumors that started in the brain, 85% of those with a low-grade glioma had seizures, compared with 49% of those with glioblastoma.¹¹

Strength, speech and vision

Weakness, clumsiness or numbness on one side of the body. Trouble finding words or understanding them. Loss of part of the field of vision, or double vision.

With a tumor these usually build over days to weeks. When they appear within minutes, the cause is more often a stroke, and that needs 911.

Thinking and personality

Changes in memory, attention, mood or behavior that the family notices before the patient does. A tumor at the front of the brain can grow large while causing nothing but a slow change in personality.

HeadacheRarely the only sign

A headache caused by a tumor is usually new, gets steadily worse over weeks, is worse on waking or when lying down, and may come with nausea or vomiting.

A headache you have had for years, with a normal examination, is very unlikely to be a tumor.

Nothing at all

Many tumors, meningiomas especially, are found on a scan done for another reason: a fall, a sinus problem, a headache that turned out to be migraine.

When it cannot wait

Call 911 or go to the nearest emergency room for any of these:

A first seizure, or a seizure that lasts more than five minutes
Sudden weakness, trouble speaking or loss of vision
A severe headache with repeated vomiting or increasing drowsiness
Confusion that is getting worse by the hour

Found on a scan by chance

It happens more often than most people expect.

Brain scans are now so common, and so detailed, that tumors are regularly found in people who have no symptoms from them. A radiology report that says “meningioma” is not an emergency, and it is not by itself a reason for surgery.

1.6 in 100had a benign tumor and did not know

When 2,000 adults from the general population, average age 63, had a brain MRI for research, 1.6% had a benign tumor. Most of those were meningiomas.²

3 in 10meningiomas are found by chance

Discovery by chance accounts for about 30% of newly diagnosed meningiomas.³

8 in 100developed symptoms while watched

In a review of 20 studies and 2,130 people with a meningioma found by chance, about 8 in 100 of those who were watched went on to develop symptoms, and about 1 in 4 eventually had treatment. Most tumors that changed did so within five years.³

For a meningioma that is causing no symptoms, watching is the first option in the international guideline.⁴ Watching is a plan, not a delay: an MRI at set intervals, a clear list of what would change the plan, and one surgeon who compares each new scan with the last.

Treatment makes sense sooner when the tumor is large, is growing, is causing swelling in the brain next to it, or sits where even a little growth would do harm.

Not every finding can be watched. A scan that suggests a glioma or a metastasis calls for a prompt visit, because the diagnosis usually has to be made from tissue and treatment should not wait.

How a brain tumor is evaluated

The scan, the examination and the person all have to be considered together.

A conversation and an examination

I ask what you have noticed and when, and what your family has noticed. I examine strength, sensation, speech, vision and coordination. I also ask about your general health and any history of cancer, because both change the plan.
A close look at the images

I review the MRI myself and show you what I see. The standard study is an MRI with and without contrast dye. If you have already had one, bring the images; you may not need another.

Some tumors call for more: a CT of the chest, abdomen and pelvis when a metastasis is suspected, or special MRI sequences that map the areas for speech and movement and the pathways that connect them.
Deciding whether tissue is needed

Some diagnoses can be made from the scan with confidence. Others cannot, and the only way to know what a tumor is, and which treatment it will respond to, is to remove it or to take a small sample with a needle, called a biopsy. The tissue is examined under the microscope and tested for genetic markers.
A plan made with the right team

Brain tumor care is rarely one doctor’s work. Depending on the diagnosis, I plan treatment together with radiation oncologists and with the medical oncologists who manage cancer drugs. If you already have an oncologist, I work with them.
A decision made together

You will hear what I recommend and why: watching, surgery, radiosurgery or a combination. You will also hear what I would expect if we did nothing. If another surgeon or another kind of treatment would serve you better, I will say so plainly.

What to bring to the first visit

Every brain MRI and CT you have had: the images on a disc, not only the written reports
Reports from any biopsy or cancer surgery, and the name of your oncologist if you have one
A list of medications, especially blood thinners, aspirin, steroids and seizure medicines
A family member or friend. A second set of ears helps.

Three ways forward

Many people need only one. Some need a combination.

Watching

MRI scans at set intervals, and treatment only if the tumor grows or begins to cause symptoms. The usual first step for a small meningioma found by chance.

Surgery

An operation to remove the tumor, or as much of it as is safe, and to learn exactly what it is. The usual choice for tumors that are large, causing symptoms or of uncertain type.

Radiosurgery

Focused radiation with no incision, in one to five outpatient sessions. The usual choice for small metastases and for some meningiomas.

The operation: a craniotomy

A craniotomy is an operation to remove a tumor through a window in the skull. It is done under general anesthesia. Before the incision, your MRI is loaded into a navigation system that works like GPS, so that the opening is placed directly over the tumor and is no larger than it needs to be.

The incision is placed behind the hairline when the tumor’s position allows, so that the scar is hidden once the hair grows back.
A window of bone is lifted out directly over the tumor. The navigation system shows exactly where to open.
The tumor is removed under an operating microscope, working between the folds of the brain where possible.
The bone is put back and held with small titanium plates, and the skin is closed over it.

When a tumor sits next to the areas that control speech or movement, additional tools help protect them. These include mapping those areas with a small electrical probe during the operation, monitoring the nerve pathways throughout, and for some tumors keeping the patient awake and comfortable for part of the procedure so that speech can be tested as the tumor comes out. In selected cases an MRI scan is done during the operation, before closing, to look for tumor that remains. I will explain which of these I recommend for you and why.

Radiosurgery: focused radiation, no incision

Despite the name, radiosurgery is not an operation. Many narrow beams of radiation are aimed from different directions so that they meet at the tumor. Each beam is too weak to harm the brain it passes through. Where they cross, the dose is high enough to stop the tumor from growing.

It works best for tumors that are small and clearly defined: most brain metastases, some meningiomas, and tumor that is left behind or returns after surgery. The tumor does not vanish overnight. Success means that it stops growing, and often that it shrinks slowly over months. I plan and deliver radiosurgery together with a radiation oncologist.

Laser ablation

For some tumors that are deep and hard to reach, and for areas of radiation injury that can follow earlier radiosurgery, a thin laser fiber can be guided to the target through an opening about the width of a pencil. The laser heats and destroys the tissue while an MRI scanner tracks the temperature.

Medication and radiation after surgery

For gliomas, and for cancers that have spread, surgery is usually one part of the treatment. Radiation, chemotherapy, immunotherapy and targeted drugs are chosen from the tissue diagnosis and managed by oncologists.

One example of how fast this is changing: for certain slow-growing gliomas that carry a mutation in a gene called IDH, a daily pill named vorasidenib, now approved by the FDA, more than doubled the time before the tumor grew, from 11.1 months to 27.7 months, in a trial of 331 patients.¹⁰

What treatment can and cannot do

Often curativemeningioma, fully removed

When a benign meningioma and its attachment to the lining can be removed completely, the operation is often curative.⁴ When part of it must be left because it is wrapped around a nerve or a blood vessel, what remains is watched or treated with radiosurgery.

72 vs 43in 100 free of regrowth at one year

After a metastasis is removed, focused radiation to the spot lowers the chance that it grows back. In a trial of 132 patients, 72% of those who had radiosurgery after surgery were free of regrowth at that spot one year later, compared with 43% of those who had surgery alone.⁸

Thinking protectedfocused vs whole-brain radiation

In 213 people with one to three metastases, radiosurgery alone was compared with radiosurgery plus radiation to the whole brain. Three months later, thinking had declined in 63.5% of those who had radiosurgery alone and in 91.7% of those who also had whole-brain radiation, and survival was no different.⁷ This is why focused treatment is now preferred whenever it is possible.⁶

Up to tenmetastases treated with radiosurgery alone

In a Japanese study of 1,194 patients treated with radiosurgery alone, people with five to ten metastases lived as long as people with two to four.⁹

More removedglioblastoma, when it is safe

Across 37 studies and 41,117 patients with glioblastoma, the risk of dying within a year was 38% lower when all of the visible tumor was removed than when part was left behind.¹² These were not randomized studies, and no part of the brain that you need is worth trading for a cleaner scan. The goal is the most that can be removed safely.

What it will not do

Surgery does not cure a glioma on its own, because tumor cells extend beyond what any scan or microscope can show. It does not treat cancer elsewhere in the body. And an operation cannot always restore function that a tumor has already taken, though relieving pressure often helps. I am direct about this before surgery, not after.

The risks

This is brain surgery, and I will not minimize that. In a national registry of 7,376 operations for malignant brain tumors, 12.9% of patients had a major complication within 30 days. The most common were a return to the operating room (5.1%) and a blood clot in the legs or lungs (3.5%), and 2.6% died within 30 days.¹³

Those figures are for malignant tumors, which include some of the most difficult operations. Your own risk depends on the kind of tumor, where it sits and your general health, and I will tell you where it falls.

Bleeding in or around the brain, which sometimes requires a second operation.
New weakness, numbness, or difficulty with speech or vision. This can be temporary, from swelling, or less often permanent.
Seizures.
Infection, or a leak of spinal fluid from the incision.
Blood clots in the legs or lungs.
Stroke.

Radiosurgery has risks of its own: fatigue, swelling around the treated tumor in the following weeks, and in some patients an area of radiation injury months later. In the Japanese study above, 8% of patients had a side effect of treatment.⁹

Recovery

Most people spend a few days in the hospital after a craniotomy and are walking the day after surgery. Tiredness is the main complaint in the first weeks. When you may drive, return to work and fly depends on the operation and on whether you have had seizures, and I go over each of these with every patient.

Second opinions

You still leave with a plan.

A brain tumor diagnosis is a reasonable time to ask a second surgeon to look. I welcome it in both directions: I am glad to review a plan made elsewhere, and I encourage my own patients to seek another opinion whenever they want one.

If you have been told to have surgery

Bring the scans. I will tell you whether I would recommend the same operation, a different treatment, or watching.

If you have been told nothing can be done

Sometimes that is right. Sometimes there is an option that was not offered, such as radiosurgery, laser ablation or a different surgical approach. It is worth one more look.

If you have cancer elsewhere

I work with your oncologist, not around them. The brain is treated as part of your overall cancer plan, and the timing of surgery or radiosurgery is set so that it does not hold up your other treatment.

If I am not the right surgeon

I will say so at the start and help you reach the one who is. You do not need to know what kind of tumor you have before you call.

Who you will be seeing

I am Carlos Esmond Sanchez, a board-certified neurosurgeon in Washington, DC, with fellowship training in pediatric neurosurgery. My practice is for adults, and brain tumors and disorders of the brain’s fluid system are at the center of it.

I trained in neurosurgery and neurocritical care at the University of New Mexico, then completed a fellowship in pediatric neurosurgery at Rady Children’s Hospital and the University of California, San Diego. I spent the next five years as a pediatric neurosurgeon at Children’s National Hospital in Washington.

Brain tumors are among the most common reasons a child needs a neurosurgeon, and removing them, often from small spaces next to critical structures, was a regular part of that work. I bring that experience to adults.

I speak Spanish, and I see Spanish-speaking patients in Spanish.

I have been named to Washingtonian magazine’s Top Doctors list every year since 2023, and I serve on the Board of Advisors of Columbia University’s Mailman School of Public Health.

When you call, ask to be scheduled with me. I do the evaluation, I do the operation, and I follow you afterward, including the scans in the years that follow.

I plan radiosurgery together with a radiation oncologist, and when a tumor is part of a cancer elsewhere in the body I work with your oncologist.

Carlos Esmond Sanchez, MD

Certification Board-certified neurosurgeon
Fellowships Pediatric neurosurgery, Rady Children’s Hospital and UC San Diego; neurocritical care, University of New Mexico
Residency Neurological surgery, University of New Mexico
Languages English and Spanish
Recognition Washingtonian Top Doctors, every year since 2023
Service Board of Advisors, Columbia University Mailman School of Public Health

For patients in the District, Maryland and Virginia

I see patients and operate in Washington, DC, within about an hour’s drive of most of the region. If travel is difficult, say so when you call so that visits can be planned around it.

Washington, DC

All eight wards of the city.

Maryland

Bethesda, Chevy Chase, Potomac, Rockville, Silver Spring, Columbia, Bowie and Annapolis.

Virginia

Arlington, Alexandria, McLean, Falls Church, Fairfax, Reston and Leesburg.

Questions patients ask

Is a brain tumor always cancer?

No. Of the tumors that start in the brain or its coverings, about 19 of every 26 are non-malignant. The most common kind, meningioma, is usually benign. A benign tumor can still need treatment if it presses on the brain or on a nerve.

What is the difference between a brain tumor and brain cancer?

“Brain tumor” is the broad term for any abnormal growth inside the head. “Brain cancer” means a malignant tumor, one that grows faster and invades the tissue around it. Cancer that has spread to the brain from another organ is called a metastasis and is named for where it began, such as lung cancer that has spread to the brain.

Does every brain tumor need surgery?

No. Many meningiomas found by chance are watched with MRI scans, and in published follow-up only about 1 in 4 went on to have treatment. Many metastases are treated with focused radiation and no incision. Surgery is for tumors that are large, growing or causing symptoms, or when tissue is needed to make the diagnosis.

How quickly do I need to be seen?

It depends on the scan and on the symptoms. A small meningioma found by chance can wait for a scheduled visit. A tumor that is causing swelling, weakness, seizures or worsening headaches should be seen within days. Say what the scan report says when you call. A first seizure, sudden weakness or increasing drowsiness needs an emergency room.

What is radiosurgery?

Radiosurgery is focused radiation, not an operation. Many narrow beams are aimed so that they meet at the tumor, which receives a high dose while the brain around it receives very little. It is given in one to five outpatient sessions, with no incision.

Will my head be shaved for surgery?

Usually not. In most operations only a narrow strip of hair along the incision is clipped, and the incision is placed behind the hairline when the tumor’s position allows.

How long is the hospital stay after a craniotomy?

Most people spend a few days in the hospital and are walking the day after surgery. The exact stay depends on the tumor, where it sits and your general health.

Will I need radiation or chemotherapy after surgery?

That depends on what the tissue shows. A benign meningioma that is completely removed usually needs neither. Gliomas and metastases usually need further treatment, which is planned with radiation oncologists and medical oncologists once the final diagnosis is back.

Can a brain tumor come back?

Some do, which is why MRI scans continue for years after treatment. A benign meningioma that is completely removed often does not return. Gliomas tend to return over time, and metastases can appear in new places. Regrowth found on a scheduled scan is easier to treat than regrowth found because of symptoms.

When can I drive again after a seizure?

Each state sets its own rule, and the District, Maryland and Virginia differ. All of them require a period without seizures before you drive again. I go over the rule that applies to you at your visit.

Is it reasonable to get a second opinion?

Yes. Bring the scans. I will tell you whether I would recommend the same plan, a different treatment or watching. I also encourage my own patients to seek another opinion whenever they want one.

Do you treat children with brain tumors?

I see adults 18 and older. A child with a brain tumor should be seen by a pediatric neurosurgeon.

Do I need a referral?

You do not need a referral to call. Some insurance plans require one before a specialist visit, so check with your plan or ask when you call.

Does insurance cover the evaluation and treatment?

Evaluation and treatment of a brain tumor are established medical care and are generally covered by Medicare and commercial insurance when medically necessary. Details differ from plan to plan, so ask about yours when you call.

Arrange an evaluation

(202) 741-2750

Ask to be scheduled with Dr. Sanchez and say you are calling about a brain tumor. If the scan report mentions swelling, or you have had a seizure or new weakness, say so, so that the visit can be set quickly. Have the name of the place where the scan was done.

For physicians

I welcome direct calls from oncologists, emergency physicians, neurologists and primary care doctors about adults with a newly found brain mass or brain metastases, including those in whom it is not yet clear whether surgery, radiosurgery or observation is best. It helps to send the MRI, the pathology of any known cancer, current steroid and anticoagulant doses, and a note on how the patient is functioning day to day.

This site is not for emergencies. A first seizure, sudden weakness, trouble speaking, a sudden severe headache or increasing drowsiness needs 911 or the nearest emergency room.