Expert: Claes-Gustaf Nordquist, M.D. - 6/26/2011

Question
QUESTION: Hello.  My husband had a seizure one month ago and has since been diagnosed with a brain tumor in the left occipital lobe.  Two biopsies were performed (first did not get a good sample) and the neurosurgeon tells us that the first pathologist called it a grade 4 GBM and the second pathologist called it a grade 3 anaplastic astrocytoma but "almost a grade 4".  So the neurosurgeon called it a grade "3 1/2".  

My question is - what is the difference?  Should we consider this a grade 4 tumor?  Also, since the tumor is in the left occipital lobe, surgery to remove it will cause significant vision loss - the right field in both eyes.  The neurosurgeon suggests waiting until after he has radiation to consider surgery.  Should we wait?

ANSWER: Grading brain tumors is difficult! Normally it is done by concensus by a team of expert neuropathologist. So they must be in agreement.  Both grade 3 and grade 4 are bad, grade 4 is worst, in fact the worst there is. So the prognosis here is not good unfortunately. The only thing I can say is that the prognosis MAY be somewhere in between grade 3 and grade 4 but in this situation I do suggest that you regard it as a grade 4. Well if the neurosurgeon suggests waiting until after radiation therapy I'm hardly in a position to argue. I'm not a neurosurgeon. I'm a medical oncologist & radiation therapist. I see no reason why radiation therapy can not be given now. So if the neurosurgeon wants to wait that is the proper matter for the surgeon to decide. Not for the radiation therapist. So I do suggest that you follow the advice of his surgeon. How big is the tumor? Its size may influence treatment.


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

QUESTION: The tumor is 2 cm, and did not change in size at all during the two weeks between the first and second biopsies.

Answer
Aha, thanks! Interesting! Then, since the neurosurgeon is hesitating with regards to surgical treatment I do suggest that you discuss "stereotactic radiation therapy" either with the so called "GammaKnife" or the so called "CyberKnife" or with proton beams with his neurosurgeon and his radiological oncologist (my colleague). His tumor has the right size for such treatment - it is anyway not too big for it. But as always when a grade 4 (or as here a probable grade 4) tumor is discussed I can not promise a cure. Nor can I promise that his eye sight will not be affected but that risk is probably smaller than with surgery at least with regards to how much it will be affected.
Please do keep me posted!



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