Expert: Claes-Gustaf Nordquist, M.D. - 1/10/2012

Question
Thank you for your excellent narrowing down of my long multifaceted question on husbands recent diagnosis. The backstop is, he presented with a grand mal seizure in July , had many follow up mris with supposedly no tumor, then after presenting major decline in  right side motor function was corded another in November and they saw a rapidly expanding lesion whereas before it had not been expanding. It went from about cm to 5 in one month I believe. They were alarmed enough to order a biopsy next day. Pathological diagnosis of Frozen section for brain leftfrontoparietal mass came back anaplastic astrocytoma who111 with a comment that the 3 conditions of cellular atypia,,mitotic rate, and neovascularization and cellularity of the tumor make it "suspicious" of gliobastoma.But since necrosis is not present, this diagnosis#I'm assuming they mean the Gliobastoma# is not render aed. The pathology report then says that the absence of necrosis  may be due to sampling, so radiographic and clinical correlation is recommended.  Please tell me exactly what that means. I think the clinical part is where the neurosurgeon brought us in and said quite arrogantly #but maybe hes right # to ignore that report and I can darn tell you its a Gliobastoma and then on and on about the mortality stats and the surgery options that sound quite involved but don't help much. Anyway. we are having major beurocratic glitches and slowdowns on getting at minimum one second opinion on the diagnosis and concurrent treatment options. Although time is pressing, it seems the logical thing to due since the surgeries are so invasive and we are dealing with family, trying to get him as healthy as possible going into surgery #the steroids are causing major problems with sleep which is then affecting his ability to be healthy going into surgery. We are working with them on that and as soon as we make a decision regarding partial or full resection, and get a concurrent diagnosis/treatment option from a 2nd opinion, were good to go.  I feel that waiting and doing research on what to expect from the brain surgery and the recovery period and possible complications and problems with this GLioma situation as I call it now, will help us deal with this very stressful situation. My husbands health is overall very good, and though I get the total seriousness of both Astrocymas and Gliobastoma,our daily quality of life and p hysical health can be improved and maybe extended(yes maybe Se only for a while#by keeping the stress levels down, getting information, and thinking things through unless some symptoms are changing. I feel he will come out the surgery better. Bottom line, diagnosis was pn 12/13, major roadblocks to 2nd opi nion and even getting surgery specifics from the neurosurgeon. Finally got more answers by faxing rather than calling. It sounded like full resection would cause more permanent damage to the left side he said mostly the arm, possibly the leg. Thats pretty major thing to purposely sign up for in surgery, though you say it probably extends life span. To clarify, I'm still confused as to why. Is it because your saying they WILL GIBE more radiation afterward because there is more tumor left to kill. Or are you saying they probably live longer with full resection because there is less tumor causing tambour related problems. OR BOTH. Its confusing because he doesn't want to die of excess radiation treatment for remaining tumor either. I know theres no good choice but just want to clarify the radiation part of the equation. Again, the size was 5.2cm to exact location on prebiopsy mri wasmposterior of left frontal lobe (with chronic microhemmorage. Clinically, he told us post biopsy it was not only growing but infiltratin :all over". So. probably partial or full is a personal decision with some informed input from the neuro? He also gave us a choic of not treatment, get hospice and you'll live 7 weeks. Again, I smell avoidance of malpractice if he didn't recommend we jump right onto the operating table{ He actually had tried to preschedul the surgery for the day after consult with not pre surgery consult or preparation or anything.. I said whoa cowpony. He also laughed at getting a 2nd opnion, he should have referred us immediately so we couldget it done faster through him instead of hubbys primary. We are on week 4 and hubby is fine except for having ahuge tumour and steroid sleep problems. His motor skills have actually improved dramatically since the biopsy, because hes been working at it and maybe the steroids im not sure. Please concur or not that another week for a 2nd op. on at least diagnosis is a good idea, especially for the two difficult surgical options. I didn't like the looks of clinical trials wither, but don't know enough about them. Thanks.

Answer
Well, the description of his tumor unfortunately does sound like a glioblastoma multiforme even if no necrosis was present. But since it was just a biopsy it may have missed any necrotic areas. So that makes it necessary to correlate these findings with the MRI scan picture of the tumor to try to reach a valid diagnosis. There is a difference between a grade 4 tumor (glioblastoma) and a grade 3 one but it is not big. Both grade 3 and grade 4 are bad, grade 4 only more so. There is an upper limit to how much radiation you can give a patient like this. So what I meant was that if as much of the tumor as possible has been removed surgically there is less tumor left to be irradiated and that will give the radiation therapy better effect (but a permanent cure is unfortunately most probably impossible). His steroids ARE probably helping him even if they have some side effects. So they are probably the cause he is that much better. Radiation levels in these cases are NEVER big enough to kill the patient! I still recommend that a complete tumor removal - if possible - should be the goal but again the choice is yours. That is all I can tell you. I'm usually saying that a second opinion is never wrong but I must also add here that this matter is somewhat urgent. Not much time is available.



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