GLIOBLASTOMA
MULTIFORME
Jackson Baumgartner
Patient Profile
66 years old
Caucasian male
Treated at The James Cancer Center (Vault 7)
Patient presents with a Glioblastoma Multiforme
(GBM) – What stage is this?
Patient Presentation
Was in his usual state of health until May 2017
Startedhaving progressive balance difficulties and
some dizziness
Originallythis was only noticeable whenever he was
working (cutting trees)
He was started on medications for dizziness, however,
symptoms became more pronounced
Developed neurological deficits including facial droop
and slurred speech
Experienced fatigue to the point where he could not
perform any activities
Medical/Social History
Past Surgeries
Release carpel tunnel surgery (2014)
Married
Never smoker
Never used smokeless tobacco
Does not drink alcohol
No recreational drug use
No outpatient prescriptions prior to visit
No facility administered medications prior to visit
Brain Anatomy
Brain Anatomy
Brain Anatomy
Brain Anatomy
Brain Anatomy
Brain Anatomy
Brain Anatomy
Brain Anatomy
Epidemiology – CNS
CNS Tumors represent 1.5-2% of newly diagnosed
cancer in the US per year
80% of these diagnoses are in the brain
Other 20% affect the Brainstem or Spinal Cord
Approximately 23,800 new CNS tumors are diagnosed
annually on the US (13,450 males and 10,350 females)
and result in ~16,700 deaths
Overall chance of developing in a person’s lifetime =
1/140 (males) and 1/180 (females)
Peak ages are 3-12 and 40-80 years of age
Epidemiology - Gliomas
Adults
50% of all primary brain tumors
Most commonly in cerebrum
Children
45% of all primary brain tumors
Most commonly in the cerebellum and brain stem
GBM – most common adult CNS malignant tumor
and has the worst prognosis
Etiology – Risk Factors
Mostly unknown
A genetic link is thought to exist but no definitive
proof:
For example: Neurofibromatosis type 1 and 2 (NF1/2)
- also known as von Recklinghausen disease, is the most
common syndrome linked to brain or spinal cord tumors.
People with this condition have higher risks of
schwannomas, meningiomas, and certain types of
gliomas, as well as neurofibromas (benign tumors of
peripheral nerves)
Etiology – Risk Factors Cont.
Possible link to exposure to rubber compounds,
polyvinyl chloride (used to make PVC pipes), and
polycyclic hydrocarbons (particles that exist in
nature – thought to be formed from the Big Bang)
Possible link to previous radiation exposure
Possible link to immune disorders
Common Presentation
Common signs and symptoms
Headache
Nausea
Vomiting
Blurred vision
Seizures
Unilateral weakness
Balance issues
Mental changes (personality/behavioral)
Fatigue
Screening
Usually found/suspected by observing signs and
symptoms. If a tumor is suspected then further
testing is required
Complete medical history (focusing on symptoms and
when they began)
Neurological exam (checking brain/spinal cord
function – test reflexes, muscle strength, coordination,
etc.)
Imaging (CT/MRI/PET scan)
Chest X-rays also likely performed. Why?
Biopsy
Images
Check out IHIS for full picture
Lymphatics
What nodes drain the brain?
Lymphatics
None!
Staging
Staging follows the WHO Scale
Grade I – lesions with low proliferative potention;
possibility of cure following surgical resection
Grade II – lesions are generally infiltrating and low
in mitotic activity but recur
Grade III – lesions with evidence of malignancy and
anaplasia
Grade IV – lesions which are mitotically active,
necroting, and rapid evolution
Tx for GBMs
Complete resection of tumor
Post OP Radiation
Tx borders and Dose
Borders:2-3 cm beyond the edema on the CT
Most commonly use 3D conformal, IMRT or VMAT
TD: approximately 50 - 60 Gy using 1.8 - 2 Gy/Fx
Tx Plan for Patient
Surgery
Craniotomy
EBRT
Prescribed 6,000 cGy in 30 Fx’s (200cGy/Fx)
Machine energy – 6MV Photons
VMAT (3 Arcs) – 6 DOF used
IMRT to spare Brainstem, Optic Nerves/Chiasm, and Cochlea
Setup
Patient supine, Aquaplast mask, Q2+Custom headrest, hands at side grasping
handles, legs in knee sponge
Chemotherapy
Dexamethasone
Temozolomide
Tx Plan
Possible Side Effects
Fatigue
Skin reaction (Erythema usually first side effect
observed)
Alopecia
Mental changes
Nausea, vomiting, and/or headaches
Possible brain swelling
Hormone changes
Paralysis/debilitation
Loss of strength to extremities
TD 5/5’s
Whole Brain –
Spinal Cord –
Optic Chiasm –
Optic Nerve –
Lens of eye –
TD 5/5’s
Whole Brain – 4500 cGy
Spinal Cord – 4700 cGy
Optic Chiasm – 5000 cGy
Optic Nerve – 5000 cGy
Lens of eye – 1000 cGy
Prognosis and Survival
Not good
5-year relative survival (based on age)
20 – 44 (17%)
45 – 54 (6%)
55 – 64 (4%)
My discussion with the patient…
Sources
Washington CM, Leaver DT. Principles and Practice of Radiation
Therapy. St. Louis, MO: Elsevier, Mosby; 2016
What Are the Key Statistics About Brain and Spinal Cord
Tumors? American Cancer Society.
https://www.cancer.org/cancer/brain-spinal-cord-tumors-
adults/about/key-statistics.html. Accessed September 14,
2017.
What Are the Risk Factors for Brain and Spinal Cord Tumors?
American Cancer Society.
https://www.cancer.org/cancer/brain-spinal-cord-tumors-
adults/causes-risks-prevention/risk-factors.html. Accessed
September 14, 2017.
