McGraw_Connell_Group 3_Glioblastoma Multiforme Handout

Glioblastoma Multiforme
A glioblastoma multiforme is a malignant, primary brain tumor. It is the most common adult brain neoplasm, that has a rapid growth rate and complete surgical incision is impossible. It occurs most frequently in the 5th and 6th decades of life and life expectancy is 1218 months. The five year survival rate of the disease has remained unchanged over the past 30 years, and stands at less than three percent. 3,4 Pathophysiology of an Astrocytoma 6 Astrocytomas are primary intracranial tumors derived from astrocytes cells of the brain. They may arise in the cerebral hemispheres, in the posterior fossa, in the optic nerve, and rarely, the spinal cord. The World Health Organization (WHO) has given a four point scale depending on the histologic grade of the tumor. Astrocytomas have great variation in their presentation. The WHO acknowledges the following grading system for astrocytomas: Grade 1 pilocytic astrocytoma- primarily pediatric tumor, with median age of diagnosis at 12 Grade 2 diffuse astrocytoma Grade 3 anaplastic (malignant) astrocytoma Grade 4 glioblastoma multiforme (most common) Pathophysiology of a Glioblastoma Multiforme 1,2,3,4,5 A glioblastoma multiformes classification is a Grade IV astrocytoma. It is most commonly in the cerebral hemisphere and often spreads to the contralateral side via corpus callosum. The clinical history of patients with glioblastoma multiformes (GBMs) usually is short, spanning less than 3 months in more than 50% of patients, unless the neoplasm developed from a lower-grade astrocytoma. These fast growing astrocytomas contain areas of dead (necrotic) tumor cells.5 Aside from the rare occurrence of familial brain tumors, which constitute less than 1% of all the patients with gliomas, the etiology of gliomas remains unknown. Incidence and S/S 17,000 new cases of primary brain tumors are treated each year in the United States5 and occur at only 2-3 cases per 100,000 people in Europe and North America6 Neurologic symptoms and signs can be general or focal.1,2 General symptoms include: headaches, nausea and vomiting, personality changes, and slowing of cognitive function. Headaches vary in intensity and quality, and they frequently are more severe in the early morning or upon first awakening. Changes in personality, mood, mental capacity, and concentration can be early indicators or may be the only abnormalities observed. Focal signs include: hemiparesis, sensory loss, visual loss, aphasia, and others. Seizures are a presenting symptom in approximately 20% of patients with supratentorial brain tumors. Differential Diagnosis9 : Other brain-related conditions: Grade 3 Astrocytomas do not have necrotic tissue6 Brain abscess is typically identifiable as a thin, regular rim of enhancement around a central cavity10 Metastatic foci are smaller, more peripherally located & associated with relatively edema than would be expected for their size11 Lymphomas tend to enhance homogeneously s necrosis11
Brain Tumors [symptoms depend on location; refer to Karens notes for specificity] -headache -nausea -vomiting -visual changes -difficulty concentrating -memory loss -personality change -irritability -increased sleeping -Seizures (without previous history) -Sensory changes -Mm weakness/ hemiparesis -Bladder dysfunction -Increased LE reflexes compared with UE reflexes -Decreased coordination/ataxia -Positive Babinski reflex -Clonus (ankle or wrist) DIFFERENTIALS&S forCARDINAL ONPRESENTATIGENERAL Glioblastoma Multiforme Depends on area affected~Rapid Stroke Parkinsons Dementia

Depends on type & area affected~Acute/sudden

CNS disorder: affects motor skills & speech ~Degenerative

Sypmtoms depend on etiology~Progressive

Deficits of: -Memory -Personality -Neurological -Seizure -Nausea -Vomiting -Headache -Hemiplegia

-Acute facial paresis -Arm drift -Abnormal speech

-Shuffling/Freezing gait -Lack of arm swing -Stooped/fwd posture -Fastination: motor & speech - reaction time -Executive dysfunction -Drooling

Impaired: -Memory -Language -Attention -Problem-solving -Disoriented in time -* Decline in cognitive function beyond what is characteristic of aging

Diagnostic Procedures: 1st: through CT, MRI, or angiography to reveal location, size, and characteristics of the mass3. [GBM: irregular, dark center, lighter outer ring, surrounded by edema] Then, a biopsy or craniotomy for analysis of tumor cells may be performed. Frequently, the surgeon will go ahead and remove a part of the tumor at this point. [GBM Histologically: small areas of necrosis surrounded by anaplastic (primitive) cells] *It is thought that changes in cellular metabolism occur before anatomic changes. These are called functional changes. Tests that can reveal functional changes at the cell level include: fMRI, PET, and MRS (Magnetic Resonance Spectroscopy).3 Diagnostics of Brain Tumors (general): CT: Can distinguish between many soft tissues and can indicate the location, density, and borders of the tumor, as well as the presence of edema.3 [fast & pretty good accuracy] MRI: Method of choice due to finer resolution; gives more information about the characteristics of the tumor than CT scans and can better diagnose metastatic tumors.3 Angiography: Used to diagnose and map vascularized tumors (information on the blood supply to the tumor and the location of the brain tumor in relation to the blood supply of the brain).3 Psychosocial Manifestations 7,8 -The main issue with these patients is coping with their illness: often they are symptom free until the late stages of the cancer: given a matter of weeks, months, or years to live; Few patients with glioblastoma multiforme survive longer than 3 years -Disease manifestations: decreased attention, behavior changes, decreased problem solving skills, altered judgment, altered emotions, altered coordination, or altered personality. -Dramatic and sudden change in family roles: unable to drive, unable to care for young children, not independent anymore, cannot provide for family. -Loss of self worth and drive to live: patient will have a loss of control and fear of the unknown. -education on the course and prognosis of the cancer/tumor will help the patient and family to cope- may give a small source of control -Emotional and psychological support can be gained via support groups, psychiatrists, and organizations; frequent contact with others that have had similar experiences will help patients validate their feelings, prevent isolation, and offer emotional release. -COPE program: Connection Of Personal Experiences: offered through the brain tumor society- matches volunteers to cancer patients going through the same experiences -Hope versus letting go/preparing for death: Theres no way to make this easier for the patient other than to be understanding and give them as much control as possible of their condition and treatment. Commonly Used Treatment 1,2,3,5,6 No significant advancements in the treatment of glioblastoma have occurred in the past 25 years. Although current therapies remain palliative, they have been shown to prolong quality survival. Mean survival is inversely correlated with age, which may reflect exclusion of older patients from clinical trials. Without therapy, patients with GBMs uniformly die within 3 months. Patients treated with optimal therapy, including surgical resection, radiation therapy, and chemotherapy, have a median survival of approximately 12 months, with fewer than 25% of patients surviving up to 2 years and fewer than 10% of patients surviving up to 5 years. Whether the prognosis of patients with secondary glioblastoma is better than or similar to those patients with primary glioblastoma remains controversial. Glioblastomas are difficult to treat but are usually treated with: surgery, radiation therapy, steroids, and chemotherapy have shown the ability to prolong survival but these are usually palative measures.5,6 Supportive treatment focuses on relieving symptoms and improving the patients neurologic function. The primary supportive agents are anticonvulsant and corticosteroids.6Anticonvulsants are administered to the ~25% of patients who have had a seizure.6 Corticosteroids, usually dexamethosone, can reduce peritumoral edema, diminishing mass effect and lowering intracranial pressure, with a decrease in headache or drowsiness.6 A resection with maximal tumor-free margins ("debulking") is usually performed along with external beam radiation and chemotherapy. Most oncologists prefer a combination chemotherapy consisting of procarbazine, lomustine, and vincristine (PCV regimen). 6 The extent of surgery (biopsy vs resection) has been shown in a number of studies to affect length of survival. In a study by Ammirati and colleagues (1987), patients with high-grade gliomas who had a gross total resection had a 2-year survival rate of 19%, while those with a subtotal resection had a 2-year survival rate of 0%.

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There are no universal restrictions on activity are necessary for patients with glioblastomas. The patient's activity depends on his or her overall neurologic status. The presence of seizures may prevent the patient from driving. In many circumstances, physical therapy and/or rehabilitation are extremely beneficial. Activity is encouraged to reduce the risk of deep venous thrombosis. PT Interventions- Hospice Care PT interventions can includes: husband education including: transfers, body mechanics, nutritional needs, and bed mobility, ROM exercises: neck, walking safety: use of cane, railings, removal of throw rugs and cats, house modifications: move furniture to allow w/c through, trapeze for bed, shower chair and handle, pressure relief and bed mobility, fitting for arm sling and education to don and doff, arm positioning while sleeping to prevent subluxation, pain relief techniques: relaxation, physical agents (heat or cold**), Tibetan Yoga: shows improved sleeping, time managment to work around fatigue, document when most tired and plan nap at this time and document nutritional intake), and body mechanics for pt. energy conservation.