Diagnosis, treatment, and prognosis of glioma: 5 new things

5 new ideas that are changing the management of brain tumor patients:

1. Prognosis and glioma subtypes. The cell of origin of the glioblastoma has never been defined. In his pioneering work “Death Foretold,” Dr. Christakis says “prognosis gives diagnosis its affective component, striking fear in patients and physicians alike.” There has been a lot of therapeutic nihilism about the treatment of glioblastoma, but that is now changing. Image source: Sen. Ted Kennedy who died of glioma in 2009.

2. Diagnosis and imaging mimics. Acute stroke in the luxury perfusion stage is probably the most common mimic of a brain tumor. Diffusion MRI sequences and perfusion CT scan are helpful in differentiating stroke from tumor by showing hypoperfusion as would be expected, rather than hyperperfusion seen in tumors.

3. Treatment and pseudoprogression. Temozolomide is an oral drug, which is changed into MTIC (methyltriazeno-imidazole-carboxamide), a DNA-methylating drug. The concomitant use of radiation therapy and adjuvant temozolomide in glioblastoma patients showed a median survival of 14.6 months.

Increase in contrast enhancement and mass effect can mimic tumor progression. The term “pseudoprogression” describes the inflammatory reaction to effective treatment. Increasing steroid doses can control the edema.

4. Antiepileptic drugs. Prophylactic use of antiepileptic drugs (AEDs) is not recommended in patients with brain tumor due to lack of efficacy. The interactions between AEDs and chemotherapy can also be problematic.

5. Quality of life issues. The incidence of common symptoms reported was fatigue (90%–94%), sleep disturbance (32%–52%), headache (50%), and cognitive impairment (50%). Ritalin, modafinil, and Aricept have all been shown to have a positive effect on mood and cognition. Cause of death was presumed brain herniation 73% of the time.

References:

Diagnosis, treatment, and prognosis of glioma. Five new things. Lynne P. Taylor, MD. Neurology November 2, 2010 vol. 75 no. 18 Supplement 1 S28-S32.

Image source: Sen. Kennedy who died of glioma in 2009, Wikipedia, GNU Free Documentation license.