Rationale
Michael*, a married 68-year old male, was chosen for this case study because of the instant rapport I struck with him and how his case caused me to reflect on the psychosocial strain of a de-novo GBM case, for which there exists no definitive risk factors. I was also intrigued by his 2-phase sequential technique employing a true vertex-field, which from previous discussions with my colleagues, have caused me to develop inherited negative opinions regarding its use.
Patient History & Diagnosis
As per WHO classification, Glioblastoma Multiforme (GBM) (Grade IV astrocytoma) is the most prevalent malignant brain tumour in adults accounting for 54% of all gliomas.(1, 2) It’s associated with poor-prognosis with approximately one-third of …show more content…
This scale was a modification of less commonly used 3 and 14 and is best known as the Modified GCS. Michael scored 15/15. GCS ≥13 is classified as minor brain injury which seemed applicable for Michael. The GCS has come under controversy amongst researchers regarding its poor inter-rater reliability and lack of prognostic-utility.(14) Newer scores such as simplified motor-scale and FOUR Score have been developed as improvements to the GCS.(15) Following admission and neurologic examination, he subsequently underwent an urgent T1-weighted gadolinium enhanced MRI, the imaging-modality of choice for evaluation of Central Nervous System (CNS) tumours. This confirmed this mass of at least 4cm with mass-effect, a probable primary brain tumour as his history was of no pertinence. T2-weighted MRI fluid attenuation inversion recovery (FLAIR) was also acquired to detect possible oedema and infiltration of the brain parenchyma. Pre-operative imaging is crucial for determining surgical respectability in addition to the patient’s Performance Status (PS). The enhancement and diffusion patterns of Michael’s T1 weighted MRI were consistent with High-Grade (HG) disease, accounting for 80% of cases, as gadolinium …show more content…
As per NCCN Guidelines, Gross Total Resection (GTR) has been shown to be most effective in those with good PS, however, in light of the infiltrative characteristics of his HG disease and the proximity of the mass to the speech-areas, only 50% of the lesion could be safely removed at the posterioferior-margin to maintain his already limited speech. Biopsy would also be applicable but Laws et al have shown that resection versus biopsy alone has a significant prognostic impact in such HG cases.(17) This was a key prognosticator in determining adjuvant treatment. Patients receiving GTR versus STR/biopsy like Michael will have better prognoses. For all surgical candidates, the role of surgery is to alleviate symptoms caused by tumour mass-effects, raised intracranial-pressure, allow for histopathological diagnosis, prolong survival and decrease steroid
Michael*, a married 68-year old male, was chosen for this case study because of the instant rapport I struck with him and how his case caused me to reflect on the psychosocial strain of a de-novo GBM case, for which there exists no definitive risk factors. I was also intrigued by his 2-phase sequential technique employing a true vertex-field, which from previous discussions with my colleagues, have caused me to develop inherited negative opinions regarding its use.
Patient History & Diagnosis
As per WHO classification, Glioblastoma Multiforme (GBM) (Grade IV astrocytoma) is the most prevalent malignant brain tumour in adults accounting for 54% of all gliomas.(1, 2) It’s associated with poor-prognosis with approximately one-third of …show more content…
This scale was a modification of less commonly used 3 and 14 and is best known as the Modified GCS. Michael scored 15/15. GCS ≥13 is classified as minor brain injury which seemed applicable for Michael. The GCS has come under controversy amongst researchers regarding its poor inter-rater reliability and lack of prognostic-utility.(14) Newer scores such as simplified motor-scale and FOUR Score have been developed as improvements to the GCS.(15) Following admission and neurologic examination, he subsequently underwent an urgent T1-weighted gadolinium enhanced MRI, the imaging-modality of choice for evaluation of Central Nervous System (CNS) tumours. This confirmed this mass of at least 4cm with mass-effect, a probable primary brain tumour as his history was of no pertinence. T2-weighted MRI fluid attenuation inversion recovery (FLAIR) was also acquired to detect possible oedema and infiltration of the brain parenchyma. Pre-operative imaging is crucial for determining surgical respectability in addition to the patient’s Performance Status (PS). The enhancement and diffusion patterns of Michael’s T1 weighted MRI were consistent with High-Grade (HG) disease, accounting for 80% of cases, as gadolinium …show more content…
As per NCCN Guidelines, Gross Total Resection (GTR) has been shown to be most effective in those with good PS, however, in light of the infiltrative characteristics of his HG disease and the proximity of the mass to the speech-areas, only 50% of the lesion could be safely removed at the posterioferior-margin to maintain his already limited speech. Biopsy would also be applicable but Laws et al have shown that resection versus biopsy alone has a significant prognostic impact in such HG cases.(17) This was a key prognosticator in determining adjuvant treatment. Patients receiving GTR versus STR/biopsy like Michael will have better prognoses. For all surgical candidates, the role of surgery is to alleviate symptoms caused by tumour mass-effects, raised intracranial-pressure, allow for histopathological diagnosis, prolong survival and decrease steroid