GLIOBLASTOMA MULTIFORME (GBM)
is the most invasive type of brain cancer, arising from glial cells such as either astrocytes or oligodendrocytes. It occurs most frequently in adults 55 and older. This aggressive brain tumor can spread to other parts of the brain but seldom metastasizes outside of the nervous system. Glioblastoma Multiform represent the highest grade (Grade IV) tumors arising from glial cells which are in the brain and spinal cord.
Modern advancements successfully used CNSO neurosurgeons and neurooncologists may combine minimally invasive brain surgery, chemotherapy, proton therapy, and radiation therapy to significantly improve quality of life, minimize side effects, and increase the length of survival. The team at Centers for Neurosurgery, Spine & Orthopedics includes world-renowned neurosurgeons, pain management doctors, and physical therapists who work with top-notch oncologists and radiation doctors to create a comprehensive treatment and care plan for each patient.
Causes and Risk Factors
Glioblastomas that are cancerous arise from normal glial cells in the brain or spine that have undergone certain types of changes to their DNA. The result of damage to the normal DNA structure can be unregulated growth. The cells then begin to multiply in a disordered fashion, pushing against and invading into normal surrounding structures. Some cancerous cell may enter the blood stream and travel or metastasize to other areas of the nervous system.
While all the specifics are not understood regarding how this damage occurs in brain cells, certain risk factors have been identified:
- Age: Aggressively growing brain tumors are more common in adults over 35 years old.
- Radiation exposure: Previous exposure to ionizing radiation, including X-rays, radiation treatments, and nuclear waste is a significant factor in the development of Glioblastoma. There is no evidence that electromagnetic radiation from electrical power lines, microwaves, or cell phones is connected to certain types of brain cancer. These types of radiation are considered to be relatively new and no long-term studies are available yet to confirm or rule out harmful effects on brain tissue.
- Family history/genetic factors: A history of familial brain cancer or genetic conditions, such as a NF1 gene abnormality or deletion, can increase the risk for glioblastoma occurrence.
Symptoms caused by glioblastoma, also known as a glioblastoma multiforme, may be from the mass effect of the tumor itself, from swelling (edema) around the tumor, or by tumor cells infiltrating and damaging nearby brain cells. Symptoms can vary depending on the location of the tumor and include:
- Headaches, especially in the morning and progressively worsening headaches
- Persistent back pain
- Personality changes
- Altered mental status
- Nausea and vomiting
- Vision changes
- Speech difficulties
- Muscle weakness/spasms on one or both sides of the body
- Loss of bladder and/or bowel control
- Loss of balance and gait instability (ataxia)
- New onset of seizures or unexplained worsening of existing epilepsy
These symptoms are often vague and overlap with many other medical conditions. Evaluation by a neurosurgeon is required to make a proper diagnosis.
Because symptoms of a glioma or glioblastoma can be vague and nonspecific, a detailed history needs to be taken regarding the nature and duration of symptoms, factors that make symptoms better or worse, and associated symptoms such as weakness, numbness, or seizures. This will be followed by a comprehensive physical exam that looks for neurological deficits that may be stemming from the brain, spine, or peripheral nerves. If present, the signs may be subtle or extreme. A CNSO neurosurgeon will also be able to decipher if the symptoms are related to nervous system disorder, a tumor, or a musculoskeletal condition.
The preferred imaging for any neurological view, including a Glioblastoma, is an MRI. This test provides the best radiographic visualize details of the brain and nerve structures. If an MRI cannot be performed, a CAT Scan (computer tomography scan) with contrast or PET (position emission tomography) scan should be utilized instead.
Glioblastomas have a characteristic appearance on MRI or CAT scans, and the initial decision for surgery can be made based on symptoms and imaging alone. In some cases, however, there may be uncertainty as to the type of tumor seen on imaging. To develop an exact treatment plan, a firm diagnosis must first be made because different types of brain tumors respond better to certain types of chemotherapy or radiation being given prior to or instead of a surgical extraction of the tumor. A firm diagnosis can be accomplished via a minimally invasive stereotaxic biopsy. This neurosurgical procedure uses computer neuronavigation synched to the patient’s Cat Scan image via electrodes place on the patient’s head at the time of the Cat Scan that remain on throughout the procedure, to secure a biopsy needle size sample of the tumor for histologic analysis.
Tissue collected during a biopsy is sent to the laboratory for evaluation under a microscope after the specimen has been properly prepared for by the pathologist for microscopic analysis. The pathologist will determine the type of cells in the tumor which will then determine the type of brain tumor. The pathologist will also determine whether the tumor is benign (non-cancerous) or malignant (cancerous), and will grade of the tumor specimen. The grading of a brain tumor follows strict criteria for determining how advanced or aggressive the tumor already is at the time of the specimen. If the tumor has spread to other parts of the brain, nervous system or body, this will also affect the grade of the tumor. Further genetic testing for IDH-mutant, IDH-wildtype, and mutations of the tumor suppressor gene, TP53, which is associated with Li-Fraumeni syndrome, will help determine appropriate treatment.
The type of tumor, such as gliosarcoma or gliomatosis cerebri, its malignancy status, genetic markers, and grade will allow the medical team to formulate a treatment plan based on the latest proven techniques to control or cure a brain tumor.
Treatment of a glioblastoma Multiforme depends on the location, size, grade of the tumor, overall health, and past medical history. High-grade gliomas need to be treated immediately in order to improve survival rate. Other malignant glioma tumors, such as an anaplastic astrocytoma should be treated within a short period of time from diagnosis because malignant gliomas have a lower survival rate associated with a delay in treatment. For example, secondary glioblastoma, which is a low-grade astrocytoma that can evolve into a higher-grade glioma, has a longer overall survival rate if there is no delayed in its removal.
The initial treatment of a GBM may include steroid medications to reduce swelling around the tumor and to decrease pressure on nearby structures. Anti-seizure medications might also be prescribed.
Evidenced based clinical trial medicine currently recommends, the initial treatment for a glioblastoma is a surgical resection or the tumor. CNSO neurosurgeons, using minimally invasive techniques whenever possible will utilize computer modeling as necessary to plan surgical trajectories and minimize irritation to important brain and vascular structures nearby. Other tools routinely used to maximize safety include lasers, intraoperative MRI, and even awake surgery.
If part of the Glioblastoma invades an important location of the brain, it may not be possible to safely remove all parts of the tumor. In that case, GBM patients may have some tumor material left rather than risk further brain damage. The smaller volume of the remaining tumor can then be treated in other ways by Neuro-Oncology. Ideally the tumor will not continue to grow but cancer cells may escape and cause a recurrent glioblastoma.
Additional treatment modalities for glioblastoma patients commonly used in combination with surgical resection are:
Radiation Therapy (RT) usually follows the resection of the tumor, but sometimes could be used to shrink the tumor before the surgery. Radiation therapy is provided by radiation oncology specialists with the use of a special machine that directs a beam of high-energy particles (X-Rays or protons) to the location of the tumor to kill remaining cells and/or shrink the tumor.
- Image-guided and Intensity-Modulated techniques use 3D brain CT images, CT scans, or x-rays taken before or during the treatment session to deliver beams of radiation of different intensities and angles to the brain tumor location.
- Proton therapy, or proton beam therapy, is used for brain tumors located near sensitive areas. Protons release most of their energy within the GBM tumor, leaving surrounding tissue relatively undamaged.
The machines that are used as treatment options for delivering RT have different names, such as GammaKnife, CyberKnife, and LinAc (Linear Accelerator).
Radiation therapy can contribute to some side effects of treatment options for glioblastoma patients such as hair loss, nausea, headaches, tiredness, loss of appetite, red, sore, inflamed skin, and other effects that are more specific to brain tumor location.
Chemotherapy is another adjuvant treatment for GBMs, as well as astrocytomas, oligoastrocytoma, and oligodendrogliomas. Chemotherapy is directed by a neuro-oncologist or oncologist and is commonly used together with radiation therapy to achieve better results. Chemotherapy involves taking a medication, by mouth or IV, that targets cancerous tumor cells.
Temozolomide (Temodar) is the most commonly used oral medication for astrocytoma.
Side effects of chemotherapy can include nausea/vomiting/decreased appetite, fever, weakness, and hair loss. The severity of effects usually depends on the dose and type of drug administered.
Tumor Treating Fields (TTF) Therapy is used either together with chemotherapy or after radiation therapy and utilizes the electrical field to disrupt the growth of cancerous cells. During this treatment, adhesive pads are applied on the shaved area of the scalp, corresponding to tumor location and the electrical field will be distributed from a wearable device called Optune.
Prognosis, Follow-up, and Rehabilitation
Important prognostic factors affecting glioblastoma prognosis are the location of the tumor, the overall health of the patient, and functional deficit caused by the tumor or treatments. At CNSO, GBM patients will have prognosis included as part of their pre-treatment and post-treatment discussions.
During the treatment course, the CNSO team keeps its GBM patients under close observation. Regular check-up appointments are necessary to monitor progression of the brain tumor symptoms, side effects of treatment plus routine scans to check for a continuous shrinking response to treatment. Scans will also be used to detect any recurrent glioblastoma.
Depending on the postoperative course and the surrounding area of the brain tumor, some neurological deficits, such as vision, balance, and motor changes may be experienced. Occupational therapists and physical therapy specialists can significantly restore these functions and will be involved to increase the rate of recovery and function.
Centers for Neurosurgery, Spine, & Orthopedics Can Help
The dedicated team at Centers for Neurosurgery, Spine, and Orthopedics (CNSO) understands how much the diagnosis and treatment of glioblastoma multiforme can impact the lives of patients and their loved ones. The CNSO team approach includes recognized board-certified neurosurgeons, non-surgical physicians, physiatrists, rehabilitation specialists, and certified physical therapists to provide patients with a comprehensive and coordinated treatment plan. CNSO offers multiple convenient locations spanning from Hudson County to Morris County, Bergen County to Essex County and nearby towns including Jersey City, Clifton, Paramus, and Parsippany, NJ. Northern NJ patients can learn more about minimally invasive brain surgery for glioblastomas and other brain tumors by contacting the doctors and neurosurgeons at CNSO today.