What is Glioblastoma?
Glioblastoma
or glioblastoma multiforme is one of the most common brain tumors accounting
for approximately 12 to 15 percent of all brain tumors. The name of
the tumor is commonly abbreviated to GBM. While GBM is the most common
malignant brain cancer, it is a
relatively rare occurrence compared to other cancers such as colon or lung
cancer. The cells in glioblastoma resemble astrocytes- cells that
normally nourish and support neurons as well as respond to injury of brain
tissue. It is thought that a stem cell or immature astrocyte is the cell of
origin that acquires a genetic abnormality and ultimately grows into an entire
population of cancerous glioblastoma cells. This population can grow
quickly and also spread through the brain while mingling with and overrunning
normal brain cells.
How is GBM classified according
to the WHO Grading System?
According
to the WHO grading system, grade I
tumors are low grade- the least malignant- while grade IV tumors are the most
malignant, with potential to grow
quickly and behave aggressively. The World Health Organization classifies GBM
as a grade IV astrocytoma.
What risk factors pertain
to GBM?
Risk
factors for glioblastoma are largely unknown.
However, research has shown
that men are more frequently diagnosed with glioblastoma than women. The occurrence of GBM in a male to female
ratio is around 1.6 to 1. Incident rates
peak between the ages of 50 and 84 years,
with less than 10 percent of cases occurring in children. GBM rates are highest in non-Hispanic whites
followed by Hispanics. Non-Hispanic
blacks and Asian/Pacific Islanders tend to have the lowest rates of this brain
cancer. Constant exposure to ionizing
radiation, chemicals, and polyvinyl chloride may increase the chance of
developing GBM. Diet, smoking,
and the use of cell phones have not been definitively linked to GBM. The vast majority of GBM patients have
sporadic tumors- that is, they
probably did not inherit a gene that significantly predisposed them to the
cancer. Furthermore, these patients’ children are not more likely to
get GBM. However,
there are rare cases of familial GBM where the risk for GBM can be transmitted
to descendants.
What are some signs and symptoms of
GBM?
The signs
and symptoms of GBM vary depending on the tumor’s size,
location, and rate of growth. Some common signs of glioblastoma include headaches, vomiting,
confusion, weakness, numbness,
dizziness, seizures, and loss of balance. If you are experiencing any
of these symptoms, please contact a
physician as soon as possible to evaluate the cause. While brain tumors may cause such symptoms, there are many other possible neurologic causes as
well.
What is
an angiogram? What is an EEG?
Other forms
of diagnosis include angiogram, a
type of study that shows the brain’s blood vessels. It can be helpful for helping surgeons
understand how close a brain tumor is crucial blood vessels in the brain. An electroencephalogram (EEG) is a test
that records the brain’s activity by measuring electrical currents and impulses.
It can be useful for detecting seizures
and other electrical abnormalities of the brain.
The test and imaging studies (e.g.
MRI) suggest a brain tumor. What type of
doctor should I see?
We suggest
seeing a doctor who treats a lot of brain cancers. Such a doctor may be a neuro-oncologist, oncologist,
or neurosurgeon. Your personal physician can likely help you find a good brain
cancer specialist. Often at brain tumor centers,
the neurosurgeons, neuro-oncologists, neuroradiologists,
and neuropathologists work closely together as a team to provide a diagnosis
and care.
What is the purpose of surgery?
If possible, surgeons attempt to remove all cancerous tissue to
relieve pressure on the surrounding brain without damaging neurological
functions. In most GBM cases, surgery is quite feasible and effective in
combating the tumor. Craniotomy is the
most common surgical procedure in which the cranium,
or skull, is opened. The neurosurgeon
makes an incision in a small section of the scalp,
removing a part of skull in order to reach the brain. As much as possible tumor is removed. After the surgical procedure, the scalp is closed with either staples or
stitches. Patients are then taken to the
intensive care unit (ICU) for recovery.
During surgery,
a biopsy and/or resection may be performed. What is a biopsy? What is a resection?
A biopsy is
a surgical procedure in which a neurosurgeon takes a small sample of tissue
from the tumor and gives it to a pathologist who specializes in examining
tissues under a microscope or with genetic tests. The pathologist gives a diagnosis that can
help the neurosurgeon and oncologist decide what the next best steps are. Depending on the diagnosis, a resection may be performed. A resection is a surgery where as much as
possible of the tumor is cut out.
What happens to the tumor tissue
once it has been removed from my brain?
The
standard process is to process and store sufficient tumor tissue in blocks of
wax that can then be used for a variety of studies to establish with certainty
what the diagnosis is. At the time of
surgery, if there is tissue left over after enough tissue is given to the
pathologist for diagnosis, some tissue can be frozen at very cold temperatures
in liquid nitrogen or special freezers.
Experimental therapy trials or clinical trials sometimes require 200-400
mg of frozen tissue (0.5 cm3 or pea-sized fragment) for entry. If you are interested in a particular
clinical trial, get information from the doctors in charge of the clinical
trial well before surgery and convey that to your neurosurgeon so that they can
coordinate with the clinical trial staff.
What kinds of treatments
are available for GBM?
With
today’s technological advances, new
treatments are offering hope to many individuals fighting the battle against glioblastoma, the most aggressive brain tumor. Typical therapy for glioblastoma patients
includes surgery, followed by
radiation and chemotherapy. However, sometimes radiation or chemotherapy may be omitted
as not everyone can tolerate all the therapies.
In addition to standard treatment,
vaccinations and molecular targeted therapies are being tested in clinical
trials across the country. A
neuro-oncologist can provide you on information regarding such trials. The website www.ClinicalTrials.gov has a tool to search for glioblastoma trials throughout the
country and in your specific city.
What is Important to know about radiation?
After tumor
has been removed using craniotomy, the surrounding area of the brain is usually
treated with radiation. Radiation
therapy uses high-energy x-rays (ionizing radiation) to stop cancer cells from
dividing. It can slow or stop the growth
of the remaining tumor, as ionizing radiation damages a cell’s DNA.
What are the different types of radiation
therapy?
Conventional radiation therapy delivers an external beam of
radiation to the region of the brain containing the tumor. Typically patients receive around 30
radiation treatments, over the course of six weeks. A typical dose of therapy is 1.8-2.0 Gy
(Gray), with the total treatment amounting to 50-60 Gy. The actual radiation doses may depend on the
proximity of the tumor in the brain to vulnerable brain structures and also the
patient’s . For example, very elderly
patients may not be able to tolerate some radiation regimens. Stereotactic
Radiosurgery (SRS) may also be available in some cases. During SRS, a single dose of radiation is
targeted at the tumor, attempting to kill all cancerous cells in that area.
What are the effects of radiation?
Common
short-term side effects of radiation therapy are loss of appetite, fatigue, and
nausea. Short-term memory loss, skin
reactions, and hair loss may also occur.
Long-term side effects may include problems with coordination,
reasoning, and thinking. Because
constant ionizing radiation exposure is linked to the formation of GBM tumor,
later recurrences of tumor may arise.
What is chemotherapy?
After
surgery and radiation, chemotherapy may be administered by a
neuro-oncologist. Chemotherapy is a type
of treatment that uses drugs to inhibit or destroy cancerous cells. Chemo is given in cycles, which vary
depending on the drugs used. It is
often given orally or through injection in veins. The most common chemotherapy drugs are
temozolomide (Temodar), lomustine (CCNU), and carmustine (BCNU).
Should I
enter a clinical trial?
It is
important to know that standard therapies have established efficacy for a
period of time. Many if not most GBM
patients do enter clinical trials eventually but please understand that the
experimental therapies in these trials may or may not work. In any case, the clinical trials often
provide very valuable information that may help others in the future. Also, one can enter some clinical trials
once the standard therapies aren’t working.
The decision to enter or not to enter a trial can be discussed with your
doctor and your family. Your physician,
oncologist, and friends in support groups may be able to help you understand
what a clinical trial is and whether to participate.
What happens after treatment?
Once
treatment is over, patients are checked by physicians (neurological
examinations) and receive MRI or CT scans to check for tumor recurrence.
I’ve found a doctor but where can I
get more information and support?
The National Brain Tumor Society provides a
wide range of information and other resources.
Their website is www.braintumor.org/.
Their link for brain tumor support groups is at www.braintumor.org/patients-family-friends/find-support/.
Support groups are composed of brain tumor patients and their families, friends,
and sometimes health care providers.
They typically meet regularly and appreciate what you may be going
through. They can share with you what they’ve been through- providing moral and
practical support. Brain tumor programs
at major medical centers may also have their own support groups. The Brain
Tumor Society also has an excellent free booklet called “The Essential Guide to
Brain Tumors” that you can download at www.braintumor.org/patients-family-friends/about-brain-tumors/publications/essentialguide.pdf.
The Musella Foundation for Brain
Tumor Research and Information Inc. provides a downloadable PDF booklet called
“Brain Tumor Guide for the Newly Diagnosed” at http://www.virtualtrials.com/faq/PatientGuide2010.pdf.
The Pediatric Brain Tumor
Foundation provides information for families with children suffering from
brain cancers at http://www.pbtfus.org/about/.
I am a general practitioner or other
health care provider and want more information- Where can I go?
An oncologist at your medical center is a good place to start. For additional information, neuro-oncologists
at a nearby or distant major medical center are often happy to talk with you
and provide advice. The
neuro-oncologists are often listed under Brain Tumor Program or Neuro-oncology
on the medical center websites. The
brain tumor guides above also are helpful.
The Central Brain Tumor Registry of the Untied States provides detailed
statistics on brain tumors including survival of different tumor types
stratifying by age and ethnicity.
As a health care provider, I would
like to get educational materials for my underserved or minority patients -
where can I go?
Intercultural Cancer Council (ICC): The ICC provides cancer fact sheets
to health care providers regarding minorities including for African-Americans, Latinos,
Hawaiians/Pacific Islanders, Native
Americans. Please visit www.iccnetwork.org
Redes En Acción: The National Latino Cancer Research
Network is a National Cancer Institute-funded initiative to combat cancer among
Latino patients. They provide training
and resources to providers. Please visit
www.redesenaccion.org
IMPORTANT:
The information provided in this
blog is intended to educate. Please see
a licensed physician in the state where you are seeking care for specific
guidance on your medical situation.
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