Glioblastoma of the right temporal occipital region
A 61 year old male who presented with an epileptic episode was evaluated. A temporo-parietal-occipito mass was detected on MRI and PET CT. A follow-up MRI one year later showed progression of the lesion. One month later he had a craniotomy and what seems to be a partial removel of the mass. The pathology revealed glioblastoma. He was scheduled for radiotherapy two months later. The post operative MRI showed post operative changes including blood at the surgical cavity. However, there is a significant residual tumor present which is enhancing following administration of contrast.
1) Do you agree with the treatment adopted until now?
2) Which treatment do you indicate for the future?
3) Can you indicate centers of excellence in Europe?
61 years old, male.
Following the onset of epileptic seizures, medical tests were performed, resulting in an expansive cerebral lesion in the right temporal occipital region.
The first test was a cerebral PET, that was carried out one month after seizures onset, to assess an expansive cerebral lesion. Its conclusions were: “negative investigation for images of pathological accumulation of significant tracer due to presence of neo productive elevated carbohydrate metabolism lesions. On the brain level, the lesion reported close to the right temporal occipital region appears to be clearly hypocaptating”.
A brain NMR with contrast medium that was performed one month later determined: “right cortical subcortical temporal-parietal-occipital, whose imaging and spectrum characteristics at first would refer to a glial lesion with low degree of malignancy”. The lesion was monitored during over time by additional brain NMRs after 2-3 months, with evidence on of a slight increase in size of this lesion 5 months later, and of the mass effect exercised by it on the trigone and on the occipital horn of the right lateral ventricle”.
Another NMR ,year after the onset of symptoms, showed progression of right temporal disease classifiable as “intrinsic lesion of the glial series with elevated grading”.
After blood tests and chest X-rays were run, with results that were within normal limits, the patient was hospitalized to undergo an operation to remove the known expansive lesion. When admitted, the patient was alert, cooperative, with right eye visual decline and without focal neurological dysfunctions. Surgery was performed, and the result of the histological examination of the neoplasm specified that it was a glioblastoma (IV degree according to O.M.S.); the relevant diagnosis particularly states glial neoplasm of high degree with evidence of mostly gliotic tissue in one of the strips sent –possible presence of isolated neoplastic elements.
A CT study of the brain displayed correct surgical results, with surgical wound that was already healing upon discharge, two weeks after the operation. The radiation therapist prescribed a course of radiation therapy to commence month later.
The following home therapy was prescribed: Lansox 1 tablet in the morning; Keppra 1000 twice a day; Keppra 500 at noon; Cotareg 1 tablet twice a day; Dintoina 100 1 tablet a day; Viscom 1 sc injection at 4 p.m. on odd days; Clexane 4000 UI sc in the evening; Soldesam 4 mg i.m. in the morning; Soldesam 4 mg im in the morning; Adjuvant 2 injection at 4 p.m. even days.
At the end of this report the conclusions of the brain NMR with contrast medium performed one month after surgery, are provided: “further progression of the right temporal occipital profound residual lesion component with current involvement of also the parahippocampal region and initial involvement of the splenium of the corpus callosum. Certain increased spread of ventricular ependymal disease”.
A 61 year old male who presented with an epileptic episode. Following a work up that included PET and a MRI study a temporo-parietal-occipito mass was detected. A follow-up MRI one year later showed progression of the lesion. One month later he had a craniotomy and what seems to be a partial removel of the mass. The pathology revealed glioblastoma. He was scheduled for radiotherapy two months later. The post operative MRI is available for review. This MRI showed post operative changes including blood at the surgical cavity. However, there is a significant residual tumor present which is enhancing following administration of contrast. The tumor extends into the right ventricle and ependymal seeding is evident with an intraventricular mass present is the contralateral left trigon area.
The summary indicates that the plan is to treat with radiotherapy but does not mention any intention to give chemotherapy. The standard treatment for glioblastoma includes combination of chemo-radiation with concurrent treatment with temozolomide (75mg/m2/d) and radiation therapy followed by adjuvant cycles of temozolomide (150-200 mg/m2/d x5 days, q28 days). This treatment should be given. If the tumor would progress on this therapy, the second line approach is to treat with bevacizumab (Avastin). MRI imaging should be performed every 2-3 months to monitor the response to treatment.
Regarding centers of excellence for treatment of his condition there are several academic centers in Italy, which are well known. I recommend approaching Prof. Soffietti from the University of San Giovanni Battista Hospital, Torino.
The overall prognosis is poor but chemotherapy as indicated above may prolong the lifespan of the patient.