Expert: Claes-Gustaf Nordquist, M.D. - 7/21/2010

Question
My question is should I encourage my mother to consent to treatment for her multiple brain tumors? My mother is 80 years old and has just been diagnosed after having a CT scan of her brain with at least 7 identified brain tumors located all over her brain ranging in size from the smallest at 1.4 x 2cm to the largest at 3.4 x 6cm which indicated some hemorrhaging took place around some tumor sites. Prior to her diagnosis she was experiencing increasing difficulty with walking over a period of months, than developed a cold, sore throat, no appetite, falls, incontinence and confusion over a 2 week period. They did a CT scan of her body to look for a primary source and reported it was negative. There was a suspicious skin lesion on her left arm that was tested for melanoma with a punch biopsy which was reported as positive. My mother never went to a doctor except to have babies. She always insisted that she had that skin lesion for 10-15 years and it never changed shape. She has a team of doctors. All do not agree that melanoma is the cause for the brain tumors. Neurologically my mother has improved some with Dexamethasone therapy. The doctors discussed one of the treatment options, brain radiation if indicated. In order to have a more definitive diagnosis they want to do an MRI and brain biopsy. However my mother is refusing to have any brain radiation and biopsy to be done. She had an illegitimate son that died after aggressive treatment for brain mets that's primary site was the lung 3 months after being diagmosed. The doctor told me there is no point to do the MRI if she is going to refuse radiation treatment, if recommended, and the brain biopsy. Should I insist they do the MRI to get a more definitive diagnosis that will enable the doctors to give us a prognosis? Will the MRI give us more answers to our questions or at least direct us to other options that offer a better quality of life for the time she has left?

Answer
At the moment the only KNOWN possible primary tumor is her malignant melanoma. Malignant melanomas are usually not very sensitive to radiation therapy or chemotherapy. So if it indeed is her melanoma that has spread (and that is definitely a possibility) then her prognosis is unfortunately very bad and the possibilities of treating her condition in any meaningful way are unfortunately small if existing at all. There are interesting and even promising experiments of immunotherapy going on with melanomas but they are still very experimental. It is of course possible that she has some other primary tumor somewhere even though it in that case is so far yet undetected. Such a tumor MAY be more sensitive to radiation therapy (the only practical treatment method with so many tumors involved) but it can not cure her since her cancer must in this case be regarded as a stage 4 cancer (it obviously has spread to her brain - another organ - from somewhere else, primary brain tumors do not behave in this way) and such cancers are at present incurable. With brain metastases it is also eventually fatal even with such treatment. And her survival time even with treatment can probably at most be measured in months. So such treatment can only at best to some extent decrease her symptoms temporarily and also to some extent prolong her survival time. MRI brain scans MAY give more information with regards to her tumors but if enough for a more sure diagnosis is an open question. But it IS a non invasive method. To be SURE what this is a brain biopsy is most probably necessary and if she refuses that it is probably impossible to come much further. On the other hand that does not change the situation much unfortunately. Unfortunately apart from hospice care I'm not aware of any treatment that can improve her quality of life to any large extent in this situation either. I'm sorry I have nothing better to tell you!



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