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- Wed Aug 11, 2010 10:23 pm
Please advise us on the possible pontine brain tumor treatment for this patient who has been detected for tumor in year 2000.
The patient is a female aged 35 years with 2 children. First baby(girl) born in june 2000. Six months after the baby is born the symptoms came out (eye, mouth deviation).
December, 2000: Stereotactic biopsy was done. Findings: 3 fragments of Greyish white soft tissue measuring 0.5 cms – 3 all was taken. The report reads – Multiple sections show brain tissue with occasional granular bodies. There is no evidence of a neoplasm nor is there evidence of any other specific lesion. It was non-diagnostic.
Dec’00 – Feb’01 : The patient was under ATT treatment.
Sept, 2002-MRI report: The brain stem lesion measures 4.3 x 3.4 x 3.8 cms. In comparison with previous MRIs the lesion is minimally decreased in size by absolute size and extended superiorly to involve left half of superior pons and right inferior colliculus region of midbrain. No change in morphology of lesion appreciated. No contrast enhancement noted.
November 2003: Second baby was born. Symptoms of deviation of mouth, inability to close right eye, inability to walk without support, diminished hearing have increased. MRI Report: 5.2 X 4.5 X 5.2cm lesion in pons.
July to August 2004: Radiation treatment was given.
There were no significant issues till 2009.
Subsequently in 2009 symptoms were visible again. Patient was on steroids for a couple weeks, about 8 months ago i.e during nov/dec 2009 and no visible improvement noticed. Further a review of MRIs of brain stem (with focus on pons) of the patient – one taken during oct 2009 and another during june 2010 revealed that there is no significant growth visible. Inability to walk has increased a lot. Symptoms of difficulty in gulping food, diminished hearing and speech issues appeared.
What is the possible treatment for the patient at this time as the patient was already given radiation. Are there any new technologies or medicines?
| Dr.M.Aroon kamath
- Sun Aug 15, 2010 3:24 am
You indicate that the first biopsy report(December, 2000) reads as follows "Multiple sections show brain tissue with occasional 'granular' bodies". Are you certain it was 'granular', or perhaps, 'granulomas'?
Pontine tumors are the most common variety of brainstem tumor and unfortunately they also carry the worst prognosis. Pontine gliomas may be,
Focal-- perhaps < 5% iof all brainstem tumors and 20% or more of brain stem gliomas. These tumors are more circumscribed (contained within the pons) and occupy < 50% of the cross sectional surface area of the pons.These tumors may have cysts or tend to grow out from the brain stem(i.e., exophytic) or
diffuse intrinsic type(tend to spread in all directions).
The majority of pontine tumors are diffuse intrinsic gliomas, which are most often high grade, locally infiltrative, and have a uniformly poor prognosis. A tendency for brainstem gliomas to follow a more indolent course in adults than in children has been noted. In adults, these tumors are more likely to be low grade and remain localized for unknown reasons.
Surgery may be possible in focal pontine gliomas. Radiotherapy has been the cornerstone in the management of brainstem gliomas. In adults, this may be followed by adjuvant chemotherapy.
Newer approaches: Currently temozolomide following radiotherapy is being investigated (in adults with diffuse high grade gliomas). A small subgroup of patients can be successfully treated with high dose chemotherapy followed by autologous stem cell rescue. [Oligodendroglioma with specific molecular changes (allelic loss on chromosomes 1p and 19q) have been recognized fairly recently to be a distinct subgroup with a better prognosis and a particular sensitivity to chemotherapy].Other modalities such as, angiogenesis inhibitors, radiosensitizers and other biological modifiers are being currently investigated in phase I/II trials.
Generally, focal masses and ring-enhancing (on a contrast-enhanced MRI) masses have the highest proportion of benign lesions (60% and 36.8%, respectively). Histological verification of all enhancing (especially ring-enhancing) and focal brainstem masses is recommended to identify patients with benign nonneoplastic lesions. The main advantage of stereotactic biopsy lies in the diagnosis of benign masses in a significant proportion of patients with intrinsic brainstem masses and in providing a rapid and safe means for evacuation of the contents of cystic masses.
In your patient, the initial biopsy had most probably shown some 'granulomas' and perhaps Acid-fast bacilli (AFBs) were not demonstrated or grown in culture.So, she was probably started on anti tubercular therapy(ATT) empirically.The second MRI(september 2002) following the ATT had shown small reduction in size and a "non-enhancing" lesion.
Apart from tuberculosis, the other granulomatous disease that can affect the brain is sarcoidosis.Neurosarcoidosis occurs in less than 5% of patients with sarcoidosis. Cases of neurosarcoidosis involving the brain stem have been reported in the literature. Leptomeningeal enhancement on MRI is the finding that generally suggests a diagnosis of neurosarcoidosis. A biopsy is usually sufficient for a diagnosis and they show a good response to high-dose steroid therapy.
Although some patients show a rapid response to corticosteroids, many require prolonged steroid treatment or alternative therapies. The available alternative therapeutic agents include cyclosporine, methotrexate, azathioprine, chlorambucil, cyclophosphamide, hydroxychloroquine, and radiation therapy.
As your patient already had received radiotherapy, and the suspicion of a granulomatous etiology (especially neurosarcoidosis)still remains.Every effort must be made to exclude this possibility.
Only her neurosurgeon will be best placed to decide on the further course of action.