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Tuesday, May 20th 2008

Ted Kennedy Has A High Grade Glioma

A Glioblastoma Multiforme

“Brain tumors” are pretty variable things.

True, it is never good to have something pathologically growing in your head, but if someone tells you they have a “brain tumor” that can mean many different things. Not all brain tumors are created equal and the outcome measures for various brain tumors can vary considerably. One of the cruel tricks of nature however is that the most prevalent types of adult brain tumors are the most aggressive ones.

Ted Kennedy had a seizure recently and has now been diagnosed with a ‘malignant’ (read: high grade) glioma following a biopsy. I should’ve featured that differential more prominently in my original post. Especially considering that in adults single seizure without other neurological deficits is apparently the most common presentation for these brain tumors.

The classification of gliomas is complex but we’ll keep it simple for this post. By the WHO classification, high grade means a tumor with a grade of 3 or 4 (on a 1 to 4 scale). The prognosis drops as the grade gets higher. Based on various characteristics, you can further classify these high grade gliomas. I’ll spare you the names. Let us just say that more than 75% of high grade gliomas are Grade 4 (aka glioblastoma multiforme).

Perhaps as no surprise advanced age typically means a worse prognosis and shorter life expectancy (versus the whole of HCG patients) with high grade gliomas. And that is on top of the fact that 5 year survival with grade 4 gliomas is probably less than 5% for all those suffering from them.

Senator Kennedy and his family have some tough decisions coming up which I cannot even imagine facing. I have no idea about his general health but consider his age and the fact that the treatment options can only marginally improve patient survival time and you can imagine it might actually be a challenge to risk the morbidity that comes with treatment versus merely taking only pallative care.

Many, many things will influence Senator Kennedy’s treatment course. Much more than we as the public know. Plus I’m just a medical student. In general however we can say that therapy, if undertaken, essentially always includes radiation therapy and often entails surgical debulking.

By definition high grade gliomas are impossible to cure by surgery as they are substantially, microscopically infiltrative to the white matter ‘under’ the outer layers of the brain. However gross debulking of certain high grade tumors does improve survival times, if just slightly. The risk however is for neurological deficit. You can imagine how poking and cutting around in someone’s brain could cause that.

Since most patients with brain tumors present as Senator Kennedy did (fully functional and with their ‘mind intact’ so to say) and since the gained survival is often relatively marginal, surgery can be a considerable risk. You do not want to cause a deficit that the tumor isn’t. In some cases the tumor is so close to “important” areas of the brain that the risk of neurologic morbidity is too high to even attempt significant radical resection.

There are other risks that come with brain surgery and many of them are increased due to the Senator’s advanced age.

Chemotherapy seems less likely, despite what Senator Specter threw out:

Sen. Arlen Specter (R-Pa.), who has struggled through Hodgkin’s disease, said he was optimistic.

“I know something about chemotherapy myself,” Specter said. “I’m in the middle of it right now for Hodgkin’s. But Sen. Kennedy is a real fighter, we all know that. And I’m betting on Sen. Kennedy.”

It is certainly a possibility and is used against high grade gliomas but it is less standard of care unless Senator Kennedy has one of a handful of specific, less common forms of tumor like a malignant oligodendroglioma with specific chromosomal mutations (1p deletion for instance). If Kennedy has, say a GBM, and gets the chemo it may just be a reflection of the “try anything”/keep fighting mentality that some seem to turn to when faced with these fatal diseases. The treatment efficacy is not likely to be very good.

I will keep praying for Senator Kennedy but if we judge the ‘success or failure’ of the rest of his life merely by its length I am afraid the odds are we will all be disappointed.