November 2002 rediagnosed with a recurring tumor I am going to bring you through the whole fun thing
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This is where you stick random tidbits of information about yourself.
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Brain Tumor History And Other Rants
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Tuesday, September 23, 2003
OK here is the skinny from my neuro-oncologist (head cancer doctor) about where I am at with my condition, I tried to through in a couple comments to explain some stuff you will see them in parenthesis. If you have any questions email me at b_blasser@yahoo.com. But most of this has some attached stories explaining more of these events in detail earlier in my blog. This covers some of my history with this hell in a compact version.
Enjoy! It cost my insurance companies a lot of money to bring you this story.
August 28th, 2003
RE: Robert Blasser
Dx: Oligo-astrocytoma, Low/Intermediate Grade Recurrent
DOB: April 12th 1973 (Current Age, 30 yr old)
I met today with Robert to review his recent MRI of August 26th, and to discuss plans for his future management, in view of my imminent departure for California. (for those of you who aren’t aware on neuro-oncologist at NYU has moved to UCLA)
I am pleased to report that his brain MRI remains entirely stable, without evidence of any new gadolinium enhancement. More importantly, MR multi-voxel spectroscopy and perfusion imaging are entirely without FLAIR/T2 residual abnormality being gliosis rather than residual tumor. (He is thinking that there is nothing new in my head, a lot of people knew that already and have been big supporters of the fact that my head is empty. But I have seen pictures of a brain in there I swear.)
Robert himself, as you well know, has not recovered his blood counts following his last cycle of carboplatin/ temzolomide (the 2 chemo drugs I was on), and required a platelet transfusion yesterday, and is also re-starting Neupogen (shots in my belly to help my low white count) due to his ANC dropping again to 400/mm3.
History of Present Condition:
Robert initially presented on October 10th 1999 when he experienced a partial complex seizure: he was in the middle of a conversation with his girlfriend when he became aware of his eyes then his head deviating to the left; he was well aware of the event, was able to describe what was happening to him, jumped up and “snapped out of it”; the event lasted no longer than 20 seconds. The following day, while walking down a corridor at work, he experienced a second episode, his eyes move to the left, followed by his head. He walked to the mens room with a friend, asked for assistance, became incoherent, and dropped to the floor. He was apparently “out of it” for about 3 minutes. He was transported by EMS to St. Claire’s Hospital, where a brain CT scan revealed a right frontal lobe lesion. (Stay away from St. Clairs in the city if you can). Dilantin (Anti-seizure medication) was given and he was transferred to NYU on October 13th following consultation with Dr. Devinsky. A Brain MRI on October 15th revealed a minimally enhancing 3 cm x 3 cm lesion in the right posterior frontal lobe.
On October 18th 1999, extra-operative functional brain mapping was performed, with placements of subdural and depth electrodes. (I went in for surgery to put a “brain mapping device into my head to help located the important parts of my brain for surgery. Basically they opened me up, put a piece of some material with electrodes on it, closed me up and left a bunch of wires coming out of my head. And oh yeah a piece of my skull was put on ice until my next surgery). No seizures were recorded. (They really wanted me to have a seizure while this map was in my head to locate the bad area, but I didn’t have one for them). On October 25th, a right craniotomy was performed by Dr. Werner Doyle. (Picture the coolest brain surgeon who loves the stones and zeppelin, only I would find this guy, he’s good!!) The post-op brain MRI performed on October 26th confirmed a near total resection of the tumor. (Dr. Doyle said I couldn’t have planted it better for him to remove). The pathology was called a difuse low-grade ganglioglioeurocytoma by Dr. Douglas Miller at NYU. Review by Dr. Marc Rosenblum at MSKCC yielded a diagnosis of low-grade oligoastrocytoma. (Don’t ask me I look up the names, but it seems all the doctors have their own nomenclatures for tumors).
Robert was switched from Dilatnin to Tegretol, (again my current anti-seizure medication, I have been on it for almost 4 years). and subsequently followed with serial follow-up MRI’s, (first every 3 months for a year, then every 4 months then every 6 months which led me up to my 3 year anniversary of my tumor where I was caught recurring) which were entirely stable until the study of October 15th 2002. This study demonstrated some extension of the T2/FLAIR signal abnormality inferiorly to the operative cavity, without any obvious gadolinium enhancement. (Basically I had a recurrence on my motor controls side of my tumor cavity hole in my head, the wrong side to have the recurrence on) Accordingly, I referred Robert to Dr. Werner Doyle, who re-operated on him on January 17th 2003, with resection of the recurrent tumor. (He pulled out what he could).
The pathology at NYU, reviewed by Dr. George Kleinman, was called a recurrent ganglioglioneurocytoma, but far more densely cellular than the initial tumor in 1999, with fewer oligo-like cells. The MIB-1 index (how they rate tumors) was also increased focally to up to 15%, compared with the initial tumor, raising the concern that this tumor was developing anaplasia (malignancy, this tumor was worse, they always are when they come back, they are more aggressive). Review by Dr. Marc Rosenblum, however, still held that the tumor was a low-grade oligo-astrocytoma.
Accordingly, after much discussion with my colleagues as well as with Robert and his father, I elected to treat him first with as aggressive chemotherapy regimen on an NYU IRB-approved protocol, including temozolomide (150mg/m2/day x 5 days) and Carboplatin (AUC = 8 per day x 2 days), cycles to be repeated every 4 weeks for a total of 4 cycles.
Robert has now completed his four cycles of chemotherapy, but has experienced, not unexpectedly, significant myelosuppression with delayed recovery, necessitating use of platlet and red cell transfusions, as well as Neupogen, and Neumega (and Procrit – they are all injections to help with my blood counts being suppressed because of the chemo-therapy). He has I believe required one or two hospitalizations (one and it quite possibly was the worst friggin week of my life) for febrile neutropenia (basically you have a bug or a cold and no white cells to defend yourself). Of note, concomitant with each 5-day cycle of chemotherapy, he experienced break through seizures, likely due to chemotherapy causing increased hepatic catabolism of Tegretol, resulting in sub-therapeutic levels.
Impression and Recommendations:
Clearly, any further therapy must await complete resolution of his pancytopenias. (getting my blood counts back) However, after his next brain MRI in 2 months’ (the end of October) time I would recommend his starting up the following “maintenance” chemotherapy regimen, which should be extremely well tolerated: (a) Temozolomide at 75mg / m2 / day x 42 consecutive days at bedtime followed by a 14 day break. (b) calcitriol 0.5ugm daily continuously.
I would check his LFT’s every 2 months, and, at least initially, his CBC every two weeks. He must hold the temzolomide for at least one week if he develops any infection, cold or fever, etc.
In review of his relatively low/ intermediate tumor status, his young age, the mixed (oligo-astro) nature of the tumor – all of which portend a much more slowly transforming tumor – I have not recommended either irradiation or myeloablative chemotherapy with autologous stem cell rescue to obviate the irradiation. Certainly, one more recurrence, and the latter approach is absolutely that which I would recommend. (great one more recurrence – hey now that I know what I am in for, I will chose wisely before anymore treatment dammit!)
It has been a pleasure being involved in his care, and I do so much appreciate your own heavy involvement and commitment to his day-by-day management.
Jonathan Finlay, M.D., Director,
Neuro-Oncology Program
The NYU Cancer Institute
2:56 PM
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