Case Report 'Glioblastoma

7/26/2019 Case Report 'Glioblastoma '

1/15

A CASE REPORT FROM WAHIDIN SUDIROHUSODO

Thursday, September 12 th 2013PRESENTED BY : APRIYANTI PURWANINGSIH

SUPERVISOR : Dr.Cahyono Kae an! Ph.D!S".PA#K$!S".S

I. REGISTRASION Name : Mr.J Admission date : 16 th July 2013Age : 45 years old Registration no. : 612514

II. ANAMNESIS

Chie !om"laint : #eada!he

$t o!!urred a%out one year ago& %ut it got 'orse in last t'o months& and the "ain elt

s"e!ially on the right side o the head area and it 'as s"reading to the %a!( o the head. )he

heada!he o ten elt in the morning and it %e!ame hea*y 'ith a!ti*ity& %ut it redu!ed i he

ta(ing analgeti( +"arame,-. #e also !om"lained that ha*e a dou%le *ision. #e elt 'ea(ness

on the le t side o the %ody "rogress sin!e 6 months ago. #e 'as treated in in/ai hos"ital

t'o days %e ore he 'as ta(en to ahidin udirohusodo #os"ital 'ith heada!he& *omiting

a%out three times& de!reased o !ons!iousness and sei ures. )he sei ures 'as e,"erien!edt'o times during t'o minutes and throughout the %ody. )here 'ere no history o head

trauma and e*er. )here 'ere no history o hy"ertension& !hest "ain and dia%etes mellitus.

#istory in the amily 'ith the same disease has denied.

PHYSICAL EXAMINATION

Vital Signs

: 130 0 mm#g RR : 20 , minute& thora!oa%dominal

#R : 60 , minute&regularly ) : 36&5 oC&a,illary

Internal Status

#ead : anemia + -& i!teri! + -& !yanoti! + -

)hora, : Cor and "ulmo 'ere 'ithin normal limit

Neurological Status

1


2/15

7C : 84M695

9A :

#igher !orti!al un!tion : 'ithin normal limit

Meningeal sign : No Ne!( sti ness& ;ernigire!t and $ndire!t light re le,es 'ere normal

@undus!o"i => : "a"il edema

=ther Cranial ner*es : Right CN.9$ "arese +di"lo"ia-

Be t CN.$$$ "arese

Motor un!tion : Mo e!ent N Muscles strengt" 5 4

N 5 4

Tones N #PR N $PR N PR

N TPR N APR N % %

ensory un!tion : 'ithin normal limit

Autonomi! un!tion : Mi!turation : 'ithin normal limit

>e e!ation : 'ithin normal limit

III. &OR$ING 'IAGNOSIS

Clini!al : Chroni! #eada!he Be t #emi"aresis Multi"le !ranial ner*es "alsy

>i"lo"ia

)o"i!al : Right Cere%ral #emis"here

8thiologi!al : us"e!t =B $ntra!ranial

IV. TREATMENT

2


3/15

#ead u" 20 o 30o

$9@> RB 20 dro"s minute

Corti!osteroid : >e,amethason 10 mg i* and then ollo'ed 5 mg 6 hours i*

Neuro"rote!tor : ira!etam 3 gram 6 hours i*

Neurotro"i! : 1 6 12 1 am" 24 hours im

Analgesi! : ;etorola! 30 mg hours i*

#2 re!e"tor antagonist : Ranitidin 50 mg 12 hours i*

V. S(GGESTIONS

Com"lete %lood !ount

lood !hemistry e,amination

Chest D Ray A

#ead C) !an

8C7

VI. )OLLO& (P

*+t" ,ul- /*0 1 n2 2a- care3

Com"laint : #eada!he dou%le *ision 7C : 84M695

9A : 5 6

#igher !orti!al un!tion : 'ithin normal limit

Meningeal sign : No Ne!( sti ness& ;ernig


4/15

>ire!t and $ndire!t light re le,es 'ere normal

@undus(o"i => : "a"il edema

=ther !ranial ner*es : Right CN.9$ "arese +di"lo"ia- & Be t CN.9$ "arese

Motor un!tion : Mo e!ent N !uscles strengt" 5 4 Tones N

N 5 4 N

#PR N APR N PR

TPR N $PR N

ensory un!tion : ithin normal limit

Autonomi! un!tion : 'ithin normal limit

'iagnosis : Chroni! #eada!he Be t #emi"aresis Multi"le Cranial Ner*es

alsy >i"lo"ia e! us". Astro!ytoma

La4orator- )in2ing On *5 t" ,ul- /*0

C **670 8*/ 09!! 0 7lu!ose at random 120 mg dl +N E 140 mg dl-

#7 11&1 g dl R C Creatinin 0&30 mg dl +N E F1&3 mg dl-

R C 5&4 , 10 6 GB Greum 30 mg dB

#C) 33&4 H 7=) 25 u l +N E F 3 u B-

B) 243 , 10 3 mm3 7 ) 23 u l +N E F 41 u B-

MC9 1&3 l Total C"oles 0* !g92l +N E 200 mg dl-

MC# 2 &0 "g #>B Choles 45 mg dl +N E I 55 mg dl-

MC#C 33&2 g dl L'L C"oles :+ !g92l +N E F 130 mg dl-

Na 143 mmol l +NE136 145 mmol l- )rigliserida 125 mg dl +N E 200 mg dl-

; 4&2 mmol l +NE3&5 5&1 mmol l- Cl 103 mmol l +NE 111 mmol l-

$NR 1&03

Ra2iolog- ; Hea2 CT Scan


5/15

9isi%le heterogenous mass density 4 #G 'ith un!lear %oundary. 8dema "eri o!al si e 6. , 6.1 'hi!h !onstri!t the right lateral *entri!le and!ausing midline shi t to the le t as ar as 2 !m in the right ronto"arietalregion.=%literation o sul!i and gyri9isi%le "hysiologi!al !al!i i!ation in the "ineal %ody and !horoideus

"le,us.9entri!ular system and su%ara!hnoid s"a!e 'ithin normal limits.

ater !ell mastoids and sinuses "aranasalis 'ithin normal limits.ul%us o!uli and retro%ul%er s"a!e 'ithin normal limits.

)he %ones are inta!t.

IMPRESSION : $ntra!ranial mass sus".astro!ytoma

CHEST X=RAY AP Result on *5 t" ,ul- /*0

ECG ; &it"in nor!al li!it

5

ron!ho*as!uler "attern 'ithinnormal limit.)here is no s"e!i i! "ro!ess %oth thelungs.

oth sinuses and dia"hragms 'ithinnormal limitCor 'ithin normal limit.)he %ones are inta!t.

I!>ression ; ithin normal limit


6/15

Treat!ent

#ead u" 20 o 30o

$9@> RB 20 dro"s minute

Corti!osteroid : >e,sametason 5 mg 6 hours i*

Neuro"rote!tor : ira!etam 3 gr hours i*


Analgesi! : ara!etamol 3 , 500 mg

#2 re!e"tor antagonis : Ranitidin 50 mg 12 hours i*

Anti%ioti! : Ce tria,on 1 gr 12 hours i* +s(in test-

Antidisli"idemia : im*astatin 20 mg 0 0 1

uggestions : #ead C) !an 'ith !ontrast e,amination

Consultation to Neurosurgery a ter get the result o #ead C) !an 'ith

!ontrast e,amination.

/ t" ,ul- /*0 1? t" 2a- care3 Com"laint : #eada!he

7C : 84M695

9A : 4 5

#igher !orti!al un!tion : ithin normal limit

Meningeal ign : No Ne!( sti ness& ;ernigire!t and $ndire!t light re le,es 'ere normal

@undus!o"i => : "a"il edema

=ther !ranial ner*es : Be t CN.$$$ "arese

6


7/15

Right CN.9$ "arese +di"lo"ia-

Motor un!tion : Mo e!ent N !uscles strengt" 5 4 Tones N

N 5 4 N

TPR N $PR N PR

#PR N APR N

ensory un!tion : ithin normal limit

Autonomi! un!tion : Mi!turation : 'ithin normal limit

>e e!ation : 'ithin normal limit

'iagnosis ; Chroni! #eada!he Be t #emi"aresis Multi"le Cranial Ner*es alsy

di"lo"ia e! 7lio%lastoma Multi orme

Hea2 CT Scan &it" Contrast On *@ t" ,ul- /*0

7


8/15

9isi%le heterogenous mass density 4 #G 'ith un!lear %oundary. 8dema "eri o!alsi e 6. , 6.1 'hi!h !onstri!t the right lateral *entri!le and !ausing midline shi t to thele t as ar as 2 !m in the right ronto"arietal region. )he heterogenous enhan!ementmass in gi*ing !ontrast

=%literation o sul!i and gyri 9isi%le "hysiologi!al !al!i i!ation in the "ineal %ody and !horoideus "le,us. 9entri!ular system and su%ara!hnoid s"a!e 'ithin normal limits. ater !ell mastoids and sinuses "aranasalis 'ithin normal limits. ul%us o!uli and retro%ul%er s"a!e 'ithin normal limits. )he %ones are inta!t.

$M R8 $=N : @eaturing o 7lio%lastoma Multi orme

TREATMENT #ead u" 20 o 30o

$9@> RB 20 dro"s menit

Corti!osteroid : >e,amethason 5 mg 24 hours i*

Neuro"rote!tor : ira!etam 3 gr hours i*


Analgesi! : ara!etamol 3,500 mg

#2 re!e"tor antagonist : Ranitidin 50 mg 12 hours i*

Antidisli"idemia : im*astatin 20 mg 0 0 1

)he ans'er !onsult rom neurosurgery : got any ad*i!e or !raniotomy to "artial

remo*al tumor that !an hel"s relie*e sym"toms %y redu!ing "ressure on the %rain %ut the amily

and himsel re used to do the o"eration.

+t" ,ul- /*0 1* t" 2a- care3 ; T"e >atient orce2 to go "o!e 4- "i!sel .8


9/15

VII. )INAL 'IAGNOSIS

Clini!al : Chroni! #eada!he Be t #emi"aresis Multi"le !ranial ner*es "alsy

di"lo"ia

)o"i!al : Right Cere%ral #emis"here& right ronto"arietal region

8thiologi!al : 7lio%lastoma Multi orme

VIII. PROGNOSIS

Kuo ad *itam : "oorlyKuo ad sanationam : "oorly

IX. 'ISC(SSION

A male 45 years old !ame to the hos"ital 'ith heada!he. $t o!!urred a%out one year ago&

%ut it got 'orse in last t'o months& the "ain elt s"e!ially on the right side o the head area

and it 'as s"reading to the %a!( o the head. )he heada!he 'as more o ten elt in the

morning and it %e!ame hea*y 'ith a!ti*ity& %ut it redu!ed i he ta(ing analgeti! +"arame,-.

#e also ha*e a dou%le *ision. #e elt 'ea(ness on the le t side o the %ody "rogress sin!e 6

months ago. #e 'as treated in in/ai hos"ital t'o days %e ore he 'as ta(en to ahidin

udirohusodo #os"ital 'ith heada!he& *omiting a%out three times& de!reased o

!ons!iousness and sei ures. )he sei ures 'as e,"erien!ed t'o times during t'o minutes

and throughout the %ody.. @rom the "hysi!al e,aminations 'e ound 7C 84M695& there

'ere le t hemi"aresis e,tremity 'ith de!reasead o tonus and "hysiologi!al re le,es& "arese

o le t third ner*e and right si,th ner*e. )here 'as %a%ins(i %ilateral. )he su""orting

e,aminations 'ere la%oratory tests& 8C7& Chest D Ray A & #ead C) !an 'ithout and 'ith

!ontrast. )he result o #ead C) !an 'ithout !ontrast 'as astro!ytoma sus"e!ted

intra!ranial mass& and #ead C) !an 'ith !ontrast 'as !ommensurate 'ith 7lio%lastoma

Multi orme. )he Chest D Ray 'as 'ithin normal limits. ased on history& "hysi!al

e,amination and su""orting e,amination it 'as diagnosed !hroni! heada!he Be t

#emi"aresis Multi"le !ranial ner*es "alsy di"lo"ia e! 7lio%lastoma Multi orme.

9


10/15

7lio%lastoma multi orme +7 M& malignant glioma- is a malignant "rimary %rain tumor

is the most !ommon and most aggressi*e in humans +in adults-& in*ol*ing glial !ells.

7lio%lastoma multi orme is the highest grade astro!ytoma& 'hi!h o!!urred a%out t'o thirds

o all !ases o astro!ytoma. Astro!ytoma is a %rain "rimary tumors deri*ed rom %rain glial

!ells. Astro!ytoma a!!ounted or 5H o all gliomas. Astro!ytoma !lassi ied %y #= into 4

grades %ased histologi(nya "i!ture& grade $ + pilocytic astrocytoma - to grade $9

+ glioblastoma multiforme -. +1&2&3&-

7lio%lastoma multi orme +7 M- is the most malignant %rain tumor and is most

!ommon in adults& 'hi!h is a%out 33 45H o all "rimary %rain tumors& more !ommon in

men than 'omen +3: 2-& and usually o!!urs in "atients aged more than 50 years. hereas

lo' grade astro!ytoma usually o!!ur in young "eo"le& the a*erage age 'as 35 years.Although this tumour !an o!!ur in all age grou"s& in!luding !hildren& the a*erage age at

'hi!h it is diagnosed is 55 years. +1&4& -

@or un(no'n reasons& 7 M o!!urs more !ommonly in males. Most glio%lastoma

tumors a""ear to %e s"oradi!& 'ithout any geneti! "redis"osition . Consum"tion o the

arti i!ial s'eetener as"artame !auses %rain tumors in rats and its in!reasing "re*alen!e in

diet sodas "arallels the in!reasing "re*alen!e o glio%lastoma in 'estern !ultures. No lin(s

ha*e %een ound %et'een glio%lastoma and smo(ing &!onsum"tion o !ured meat & or

ele!tromagneti! ields . Al!ohol !onsum"tion may %e a "ossi%le ris( a!tor.

Clini!al sym"toms and signs that !an %e ound in "atients 'ith astrocytoma (including

GBM) & among others: +1.2.5-

1. igns o in!reased intra!ranial "ressure 'ith !lini!al sym"toms and signs in!lude

heada!he& nausea and *omiting& loss o !ons!iousness& edema and "a"illedema.

$n!reased intra!ranial "ressure due to a tumor and edema "eri o!al +mass e e!t-may result in herniation o the %rain that !an lead to death. Mass e e!t !an also

result in hydro!e"halus.2. @o!al neurologi! de i!its su!h as sei ures& "aralysis o !ranial ner*es& motor and

sensory disorders& !ogniti*e disorders& %eha*ioral disorders& ata,ia& a"hasia&

im"aired *ision loss e*en 'hen the lesion o!!urs in the o"ti! "ath'ay& and

di"lo"ia. +1&2&5-

@or this "atient almost to ha*e all the sym"toms and signs a%o*e. )he signs and

sym"tom"s are dire!tly de"endent on the lo!ali ation o the tumor in the !ere%ral tissue. + -

10
http://en.wikipedia.org/wiki/Genetic_predispositionhttp://en.wikipedia.org/wiki/Aspartamehttp://en.wikipedia.org/wiki/Smokinghttp://en.wikipedia.org/wiki/Curing_(food_preservation)http://en.wikipedia.org/wiki/Electromagnetic_fieldshttp://en.wikipedia.org/wiki/Electromagnetic_fieldshttp://en.wikipedia.org/wiki/Aspartamehttp://en.wikipedia.org/wiki/Smokinghttp://en.wikipedia.org/wiki/Curing_(food_preservation)http://en.wikipedia.org/wiki/Electromagnetic_fieldshttp://en.wikipedia.org/wiki/Genetic_predisposition


11/15

7 M is usually lo!ated in the !ere%ral hemis"heres& 'ith a "redile!tion or the 'hite

matter on the !entrum semio*ale and !or"us !allosum. )here is relati*e s"aring o the

%asal ganglia and grey matter. osterior ossa and %rain stem gliomas are seen in a

younger age grou". Bo!ation o the tumor or this "atient in the right ronto"arietal region.

>iagnosis !an %e esta%lished %y su""orting e,amination are #ead C) !an and MR$. )he

#ead C) !an and MR$ sho'ed all o intra!ranial tumor and %e a irst in*estigation

"ro!edure 'hen the "atient sho'ed the "rogressi*e signs& the di use or o!al !ranial

disease sym"tom"s& or one o s"e!i i! signs rom tumor


12/15

e ound ring enhan!ement or this "atient.

)he treatment in 7 M are steroid thera"y& "alliati*e thera"y& radiothera"y& !hemothera"y&

radio !hemothera"y !om%ination.Steroi2 T"era>-

>e,amethasone is use ul to redu!e edema around the tumor& so it !an redu!e the

sym"toms and !an %e "re"ared o"eration. u%seLuent intra*enous dose o 10 mg 4 mg 4

times "er day. Analgesi!s su!h as a!etamino"hen !an %e used to !ontrol heada!he. +1&2&6&10-

Palliati eT"era>-

urgery is the treatment o 7 M "atients 'ith histo"athologi!al !on irmation o the

diagnosis. )otal e,!ision generally im"ro*e neurologi!al un!tion& redu!e edema and !an

in!rease the sur*i*al rate. S ome tumours !an %e remo*ed !om"letely others !an %e remo*ed

only "artially or not at all. artial remo*al hel"s relie*e sym"toms %y redu!ing "ressure on

the %rain& redu!ing the si e o the tumour to %e treated %y radiation or !hemothera"y and

12

Hea2 CT scan


13/15

"rolonging sur*i*al. = the study& 7 M "atients 'ho had total rese!tion 2 year sur*i*al rate

is a%out 1 H. +1.6& -

Ra2iot"era>-

Radiothera"y a ter surgery !an redu!e the tumour si e. )umors treated %y !on*entional

radiothera"y 'ith a total o 5000 6000 !7y o radiation ea!h ra!tion in se*eral dire!tions.+ &10-

C"e!ot"era>-

Te!oBola!i2e. tudies ha*e "ro*en that the !om%ination o a small daily dose o

temo olomide& a !hemothera"euti! drug& irst together 'ith radiothera"y and then on its o'n

"rodu!ed a modest im"ro*ement in the sur*i*al o "atients 'ith minimal additional to,i!ity .

)emo olomide is also indi!ated or the treatment o "eo"le 'ith malignant glioma sho'ing

re!urren!e or "rogression a ter standard thera"y.

Car!ustine &a ers. a er im"lants are a ne' 'ay o gi*ing !hemothera"y or %rain

tumours. )he 'a er is made o gel that !ontains a !hemothera"y drug. >uring %rain surgery

to remo*e some or all o a tumour& the surgeon "la!es u" to 'a ers in the s"a!e 'here the

tumour 'as. ome !lini!al trials ha*e sho'n that using !hemothera"y 'a ers as 'ell as

surgery and radiothera"y hel"s "eo"le 'ith glioma li*e longer. + -

e /ust ga*e to this "atient sym"tomati! thera"y 'as steroid thera"y. )here 'as "lanned

!raniotomy rom neurosurgery to this "atient or "artial remo*al tumour& %ut the amily and

himsel re used to do o"eration.

7 M "rognosis is determined %y the aggressi*eness o thera"y and Luality o li e o

"atients a ter treatment. Gsually "atients !an li*e only 1 year. ased on the data in de*elo"ed

!ountries& 'ith early diagnosis and a""ro"riate treatment through surgery ollo'ed %y

radiothera"y& 5 year sur*i*al rate +5 years sur*i*al- ranged rom 50 60H and a sur*i*al rate o

10 years sur*i*al ranged rom 30 40H. rain tumor thera"y in $ndonesia in general the

"rognosis is still "oor& %ased on o"erati*e measures !ondu!ted in se*eral hos"itals in Ja(arta.+1&2& -. @or this "atient the "rognosis is %ad and on the 12 th day !are "atients or!ed to go home %y

himsel .

13


14/15

Treat!ent

Gra2e Palliati e Ra2iot"era>- C"e!ot"era>- Sur i al Rate

$ 9 5 years sur*i*al

rate 'as 5H$$ 9 45 54 7y&

deli*ered in 1. to2.0 7y ra!tions

)emo olomide 5mg m2 day on days 121 o 2 d !y!l

5 years sur*i*al

rate 'as 50H& a

sur*i*al rate o

10 years

sur*i*al ranged

rom 30 40H$$$ 9 60 7y in 30 35

ra!tions andad/u*antemo olomide 5mg m2 day&usually 1 1.5h

%e ore radiation.ost radiation

thera"y: !ontinuetemo olomide athigher doses o

150 200mg m2 day = or 5d e*ery 2 d

C9+ "ro!ar%a ine &lomustine &*in!ristine -: lomustine +CCNG-130 mg m2 on day 1>lus "ro!ar%a ine 5mg m2 on days 21>lus *in!ristine 1.4mg m2 on days and2 administer e*ery6'( or u" to 4 !y!les'ith de erred

radiation thera"y

5 year sur*i*alrate +5 yearssur*i*al- ranged

rom 50 60H

$9 9 60 7y in 30 35ra!tions and

ad/u*antemo olomide 5mg m2 day&usually 1 1.5h

%e ore radiation.ost radiation

thera"y: !ontinuetemo olomide athigher doses o 150 200mg m2 day = or 5d e*ery 2 d

C9+ "ro!ar%a ine &lomustine &*in!ristine -: lomustine +CCNG-130 mg m2 on day 1>lus "ro!ar%a ine 5mg m2 on days 21>lus *in!ristine 1.4mg m2 on days and2 administer e*ery6'( or u" to 4 !y!les'ith de erredradiation thera"y

)'o year sur*i*al rate 'asin 6.66H& threeyear sur*i*al +thelong termsur*i*al- 'asonly 4. H andonly one "atientli*ed longer than

14
http://reference.medscape.com/drug/temodar-temozolomide-342229http://reference.medscape.com/drug/matulane-procarbazine-342101http://reference.medscape.com/drug/matulane-procarbazine-342101http://reference.medscape.com/drug/ceenu-ccnu-lomustine-342127http://reference.medscape.com/drug/oncovin-vincasar-pfs-vincristine-342097http://reference.medscape.com/drug/oncovin-vincasar-pfs-vincristine-342097http://reference.medscape.com/drug/matulane-procarbazine-342101http://reference.medscape.com/drug/matulane-procarbazine-342101http://reference.medscape.com/drug/ceenu-ccnu-lomustine-342127http://reference.medscape.com/drug/oncovin-vincasar-pfs-vincristine-342097http://reference.medscape.com/drug/oncovin-vincasar-pfs-vincristine-342097http://reference.medscape.com/drug/temodar-temozolomide-342229http://reference.medscape.com/drug/matulane-procarbazine-342101http://reference.medscape.com/drug/ceenu-ccnu-lomustine-342127http://reference.medscape.com/drug/oncovin-vincasar-pfs-vincristine-342097http://reference.medscape.com/drug/matulane-procarbazine-342101http://reference.medscape.com/drug/ceenu-ccnu-lomustine-342127http://reference.medscape.com/drug/oncovin-vincasar-pfs-vincristine-342097


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>A@)AR G )A;A

1. ;olegium Neurologi $ndonesia.& Astrositoma in Modul Neuro =n(ologi& erhim"unan

>o(ter "esialis ara $ndonesia& 200 &. #al : 11 122. Bo"a R& Re eret 7lio%lastoma& agian Radiologi @;GN#A &20123. te"hen J.M! hee& $ntra!ranial and "inal )umor in Barge 200 Current Medi!al >iagnosis

and )reathment& 200 & age 60 65

4. )erra ;usuma& M. ai ul $slam agian Neurologi& @; Gnair R G >r. oetomo& ura%aya

5. erdossi e(er/asama dengan 7a/ah Mada Gni*ersity ress& u(u A/ar Neurologi

;linis&Ja(arta 1 6& #al 201

6. Ro""er A#& ro'n R#. 7lio%lastoma Multi orme in $ntra!ranial Neo"lasma. Adams and9i!tor rin!i"les o Neurology. th 8d. 2005. : 546 556

. 8"ito"oieti! Resear!h Cor"oration. 7lio%lastoma Multi orme +7 M- : the disease 8RC

elgium. A*aila%le at: er!%elgium.!om main glio%lastoma multi orme g%m the desease

. eera((ody O& 7aillard @. 7lio%lastoma multi orme. A*aila%le at : Radio"aodia .org

. Ro%ert MC& astie MB. 7lio%lastoma Multi orme : a rare mani estation o e,tensi*e li*er

and %one metastase. A*aila%le at: iomedi!al $maging and $nter*ention Journal.

10. ;um"ulan Re rat dan resus serta !atatan (uliah. A*aila%le at: Re rat resus 4 03B.

11. Bo%era A& Naul 7B. $maging in 7lio%lastoma Multi orme. A*aila%le at: Meds!a"e

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Documents

Case Report 'Glioblastoma