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Glioblastoma Multiforme

The most common primary brain tumor is called glioblastoma multiforme. It is also known as a Grade IV astrocytoma. A vast amount of research has focused on treatment strategies to eradicate this tumor, but, sadly, it remains incurable.

Glioblastoma usually is diagnosed after a brief history of headaches, often severe and associated with nausea and vomiting. Often there may be a new onset of seizures. Sometimes there may be a new neurological deficit such as weakness on one side. Often symptoms have been present for only a week prior to coming to medical attention usually through a visit to the emergency room.

While there has been great deal of research devoted to improving survival, the most effective treatments to date that can prolong survival and preserve quality of life are aggressive surgical resection followed by chemotherapy and radiotherapy. In some cases surgery must be repeated several times. It has been established that the real benefits in survival with surgery occur when the surgeon is able to remove at least 90% of the tumor volume. These patients survive longer than patients who have a biopsy alone. Many neurosurgeons do not operate on a significant number of brain tumors in the scope of their practice. It is the skill and judgment of a neurosurgeon with a subspecialty practice area of expertise in brain tumors who is most likely to be able to balance the intraoperative risks of injury to surrounding functional brain tissues with the courage to push the limits of resection to allow a near gross total resection that can sometimes mean a survival measured in several years versus months. With an incurable brain tumor, being able to provide a patient with as long a time as possible with his or her family, and with preservation of as much brain function as possible, is a gift that is treasured by that family.

The following images show an example of a glioblastoma multiforme that came to medical attention by causing headaches and changes in behavior.

glioblastoma multiforme that caused headaches and behavior changes

These tumors have multiple consistencies that cause the variation in appearance of different areas of the tumor (arrow points to the lesion in the picture on the right.) While these tumors cannot be cured, very aggressive surgery followed by chemotherapy and radiotherapy are the proven methods that, when optimized, deliver the longest survival after diagnosis.

Example 1. The images below show the patient 1.5 years after his diagnosis and initial treatment with a scan that shows no identifiable tumor or progression (white arrow points to tumor resection cavity). This tumor is aggressive, and it will ultimately recur, but this is an excellent result with preservation of quality of life as well as prolonged survival. If untreated these tumors are associated with a 50 % mortality rate within 2 months of the time of diagnosis.

glioblastoma multiforme 2.5 years later

Example 2. This glioblastoma initially appeared to be a large spontaneous intracerebral hemorrhage. Judicious surgical practice generally dictates sending clot removed from brain for examination by the pathologist. In this case, glioblastoma cells were present, prompting reoperation for aggressive resection of tumor. This patient underwent aggressive microsurgical excision followed by chemotherapy with Temodar and radiation treatment. Here is the scan 2.5 years later showing no evidence of disease at this time.

glioblastoma multiforme that caused headaches and speech issues

Initial CT scan performed after 1 week history of headache and L sided weakness appears to show a 5 cm hemorrhage (white) but with some edema (gray area in front of white) in the brain tissue focally.

glioblastoma multiforme initial CT scan performed after 1 week history of headache

This is the MRI after removal of blood clot which contained glioblastoma cells. This was followed by surgical resection of the tumor that was present underlying the hemorrhage.

glioblastoma multiforme  removal of blood clot

This MRI is taken 2.5 years after GBM microsurgical resection, chemotherapy, and radiotherapy. The patient continues to function independently, with only some mild L sided weakness.

Example 3. The patient came to medical attention with headaches and difficulties with expressive speech.

glioblastoma multiforme that caused headaches and speech issues

This initial MRI demonstrates a dangerous location of this tumor in the medial temporal lobe of the dominant hemisphere. The patient underwent aggressive surgical resection of the lesion.

dangerous location of the glioblastoma multiforme

Immediate post-op enhanced CT images document the extent of resection with no obvious residual enhancing tumor visible. The patient improved slightly from his preoperative status, and he has retained his ability to understand and speak in fluent sentences. He has continued to live independently.

immediate post-op of the glioblastoma multiforme

There was no sign of progression until 22 months after original surgical resection at which time a small area adjacent to the original tumor site on MRI was suggestive of a small recurrence (arrow). This was treated by the neurosurgeon and radiation oncologist with fractionated stereotactic radiosurgery.

The above case examples show some exceptional results in terms of survival and quality of life with glioblastomas. However, while aggressive microsurgical resection is always the cornerstone of treatment associated with the longest survival, it is important to remember that this tumor is not considered curable even when optimum therapeutic strategies are utilized. I have personally observed only rare anecdotal exceptions during 30 years of practice. There may be some locations that are less favorable for a very aggressive (90%+) surgical resection, but in general, aggressive resection should always be considered the primary foundation of treatment of this disease unless precluded by location.

It is important that you feel confident with the surgeon you select for your care with this problem, and it is very important to be sure that brain tumors are an area of practice that your surgeon focuses on. Even if cure is not possible, it is important to strive for the treatments that are most likely to prolong your life and to protect and preserve the quality of life.

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