Expert: Claes-Gustaf Nordquist, M.D. - 1/14/2011

Question
QUESTION: My husband recently found out he has a grade 2 astrocytoma.  He is 46 years old, the surgeon was able to achieve a gross total resection and recommended no further treatment except for follow up MRIs every three months.  My first question, does this sound reasonable to you?  Also, is there any predictors on the pathology report that will tell the surgeon what to except from this tumor in terms of prognosis.  We have not be given any prognosis.  We have three children and are not sure what to tell them.  Thank you for your input.

ANSWER: All malignant astrocytomas are malignant so long time prognosis is always doubtful. But grade 1 and grade 2 tumors grow slowly over many years while grade 3 and worst grade 4 tumors grow quickly. I think his doctor is reserving radiation therapy and chemotherapy to a time when regrowth of his tumor has made new surgery necessary. How long it will take until then is however impossible to predict with any accuracy. For the time being just tell your children that surgery has been done and that you will have to wait to see the outcome which also happens to be the truth. Good luck!




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

QUESTION: Thank you so much for your quick response.  I am trying to make sense of my husband's pathology report.  The report mentions monosomy 7 and 10, loss of pten, GFAP strongly positive, MIB-1, 2% or lower, P53 seen in less than 3%,and negative for amplification of EGFR sequences.  From everything I am trying to put together, it seems that this maybe a GBM.  My husband has almost fully recovered and doing well.  Do you think I should just let this go until I see his surgeon next month for the six month MRI?  Thank you so very much for your time.

ANSWER: Let me read the full report so I can make sense out of it for you. You can copy it here. When I have read it I can answer your questions.





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

QUESTION: ADDENDUM REPORT 08/11/10
THIS ADDENDUM REPORT SUPERSESES THE ORIGINAL REPORT ISSUED 08/02/10.  THIS REPORT INCLUDES RESULTS OF CYTOGENETIC STUDIES PERFORMED BY       GENETICS LABORATORY IN THE DIAGNOSIS AND COMMENT BELOW.  THE ADDITIONAL TEXT IS IN BOLD CAPITALIZED TYPE.  THE DIAGNOSIS REMAINS UNCHANGED.  

ADDENDUM MICROSCOPIC DIAGNOSIS 08/11/10
Brain mass, left temporal lobe, resection (A,B)
-Diffuse fibrillary astrocytoma, WHO II (see comment)
-NEGATIVE FOR DELETION OF 1P36 SEQUENCES (RATIO 1P36:1Q25=1.01)
-NEGATIVE FOR DELETION OF 10Q13SEQUENCES (RATIO 19Q13;19P13=1.03)
-NEGATIVE FOR AMPLIFICATION OF EGFR SEQUENCES
-PTEN ABNORMAL; LOSS OF CHROMOSOME 10 SEQUENCES (MONOSOMY)
*SIGNIFICANCE OF PTEN LOSS DISCUSSED

ORIGINAL Microscopic Diagnosis 08/02/10
Brain mass, left temporal lobe, resection (A, B)
-Diffuse fibrillary astrocytoma, WHO II

ADDENDUM COMMENTS 08/02/10
FOUR DUAL-COLOR CHROMOSOME ENUMERATION ASSAYS FOR INTERPHASE CELLS WERE PERFORMED ON FORMALIN-FIXED, PARAFFIN-EMBEDDED TISSUE THAT WAS PRETREATED WITH PROTEINASE K, AND HYBRIDIZED WITH VYSIS PROBES:A
1P36/1Q25 PROBE SET TO ASSESS DELETION OF 1P36 RELATIVE TO A CONTROL PROBE FOR 1Q25; A 19P13/19Q13 PROBE SET TO ASSESS DELETION OF 19Q13 RELATIVE TO A CONTROL PROBE FOR 19P13; A CHROMOSOME 7P12(EGFR) SPECIFIC DNA PROBE WITH AN ALPHA SATELITE PROBE FOR CHROMOSOME 7 CENTROMERE; AND PTEN (10Q23)SPECIFIC DNA PROBE WITH CHROMOSOME 10 CENTROMERE PROBE.

THE RATIOS FOR THE 1PAND 19Q PROBE SETS ARE LISTED ABOVE, A NORMAL RATIO IS APPROXIMATELY 1.0 ANY RATIO <0.80 IS CONSISTENT WITH DELETION OF THE REGION OF INTEREST.  THERE IS NO EVIDENCE OF DELETION OF EITHER SEQUENCE WITH THIS METHOD.

THERE IS NO EVIDENCE FOR AMPLIFICATION OF EGFR SEQUENCES WITH THIS TECHNIQUE.  LOSS OF 7 CENTROMERE AND EGFR SEQUENCES, A PATTERN CONSISTENT WITH MONOSOMY 7, WAS OBSERVED.  SIMILARLY, LOSS OF BOTH 10 CENTROMERE AND PTEN SEQUENCES, CONSISTENT WITH MONOSOMY 10, WAS OBSERVED.

ORGIINAL comments 08/02/10
FISH studies are in progress for possible LOH 1p, 19q, PTEN loss, and/or EGFR amplification; an addendum will be issued upon completion of results.  Only very minimal oligodendroglial component is seen by light microscopy by LOH 1p,19q is undertaken to identify any such component better.
No definitive high-grade features corresponding to the "punctate enhancement" were seen after in toto submission of the lesion.

Clinical History:
MR scan showed very large hypointense lesion involving the mesial temporal lobe extending into the deep white matterand periventricular area with significant compression of the left temporal horn.  Tumor appeared to compress the optic radiations.  There were several foci of punctate enhancement.  There was no significant surronding edema.  Resection was undertaken.
Macroscopic summary;
Speciman type: Resection
Speciman size 5.5 cm in maximum dimension
Laterality; left
Tumor site: Temporal lobe
Microscopic Summary:
Histologic grade; WHO grade II
Additional studies: FISH studies for LOH 1p, 10q, PTEN loss, and EGFR amplification
Microscopic Description
Sections (A1) (A2) and (B1-B4) demonstrate a low-grade glioma, confirming frozen section diagnosis.  Collectively, the frozen section diagnosis is low-grade glioma.  These demonstrate an infiltrating tumor involving both cortex and white matter that shows widespread microcyst formation, but no calcification, necrosis, or microvascular proliferation.  Careful search for mitoses is negative.  GFAP is strongly postive, MIB-1 is 2% or less.  P53 is seen in less than 3%.  A minimal (1/4) oligodendroglial component is recognized with minimal rounded nuclei and ill-developed perinuclear haloes and perineuronal satellitosis.
p53+
MIB-1/Ki-67 DAB  
GFAP +

Thank you for any inputs you may have.

Answer
Thanks! As far as I know and understand this will not in any significant way change my previous estimate.




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