Expert: Claes-Gustaf Nordquist, M.D. - 8/21/2008

Question
QUESTION: My father was just diagnosed with a brain tumor that is melanoma. This is his third case of melanoma. His first spot was on his back(stage 3) and he had a lymph node removed that was the size of a golf ball. He then had a melanoma on his bottom. He was told to have his groin lymph nodes removed but he choose not to do that. He recently presented to the ER with stroke like symptoms, loss of feeling in his right hand, leg and a drooping face. He had a cat scan in the ER and was told he had one large tumor that is 1 1/2" and 3 smaller tumors. We were told that the tumor is in the back left side of the brain and that the swelling was invading the motor area of his brain. They told us that the large tumor is too big to use the gamma knife so it will be removed tomorrow with surgery. The other 3 tumors are going to get gamma knife treatment. My question is what should we expect for his after surgery care and recovery? My dad is a diabetic who in December had a left leg amputation, so right now the loss of his right leg and arm is a true burden for him. Will he get the use of his right side back after the surgery? He is in and out of consciousness and a lot of the time is acting out with anger and can't tell us what he wants. He talks backwards and is hard to understand. Will this change at all in your opinion? Also we can't get any real answers about the recent finding of blood in the tumor. What does blood changes in the tumor mean? I may not be saying this correctly but I guess the oncologist and radiologist sees blood in the Cat Scan in the tumor area.
Thanks

ANSWER: I'm sorry to read about his & your problems! Yes his big brain tumor is too big for the GammaKnife unfortunately. It is 3.81 cm in size. The GammaKnife has an absolute upper target size limit of 4 cm but that is for benign (non cancerous) lesions. Here we are dealing with a malignant (cancerous) lesion so a wider margin of treatment is necessary for getting it all. That leaves surgery as the only treatment option (maybe radio frequency ablation too but probably too risky in the brain). Unfortunately malignant melanoma is usually not very sensitive to conventional radiation therapy or chemo therapy so those options are more or less out. Some interesting and promising experiments in immuno therapy of melanomas are going on but they are still very experimental. The planned treatment MAY give him back his mental facilities and control & feeling of his right side or at least some of it but I can not PROMISE that. His diabetes does not make it easier. Have they seen bleeding(s) in his tumor areas? If so any results are even more uncertain. That is definitely a complication! Also, unfortunately his long time prognosis is bad too since the risk is big that his melanoma will come back in his brain - especially from the lesion that has to be treated with surgery. And extensive treatments with the GammaKnife are at present not possible. I'm sorry I have nothing better to tell you!


---------- FOLLOW-UP ----------

QUESTION: Thank you for your quick response.
My dad's surgery went very well yesterday. They got all of the tumor out. The surgeon told us that the tumor was full of blood. What does this mean? He said the tumor was very large but that they sent off two frozen samples to see what exactly they took out. My father also got some movement back in his arm and leg. He is moving them better now than before surgery. The bad news is that he is very very angry and thrashes around the bed demanding to go home. He is swearing and yelling at everyone. The neurologist said this is a side effect of the steriods he is on for the swelling. In your opinion could his behavior be a side effect of the medicine? Also they did another CatScan this morning and didn't see any bleeding but there is still swelling. Finally is the GammaKnife an outpatient procedure or will he have yet another hospital stay to have this done? When is the likely time frame for having this done?
Thanks so much

Answer
No one can promise that a cancerous tumor has been completely removed since there is always a risk that malignant cells remain behind unfortunately! There has probably been a bleeding in his tumor which is not very uncommon. It may be a side effect of his steroids or of the surgery or a combination of both. But the steroids are necessary to bring down his brain swelling. It can probably - if his condition permits it - be done on an outpatient basis. I'm a Swede, living in Sweden so I have no knowledge of your local hospital procedures. But it should be done as quickly as possible!