Glioblastoma is the most aggressive and deadly type of glioma (even brain cancer) that accounts for up to 45% of malignant brain tumors. The percentage five-year survival forecast is not promising (<5%) and has not improved in the recent 30 years. Treatment for glioma is ever evolving with newer techniques and technologies and customized individual plan including surgery, chemotherapy, stereotactic radiosurgery (radiotherapy), targeted therapy and combination therapies. The disease is fast and agile, and the researchers are hunting for the cure on a GBM AGILE platform – an adaptive, fast, incentivized, rational clinical trial model.
What are the different types of gliomas?
How do gliomas present? What are the symptoms of glioma?
Who is prone to gliomas? What are the risk factors of glioma?
How do gliomas progress? What are their complications?
Can gliomas be detected early?
How do doctors diagnose gliomas?
What are the different treatment options available for gliomas?
What are the possible side effects of the treatments?
What happens after glioma treatment?
What are the chances of recurrence of glioma?
What is the prognosis of gliomas?
What is it like returning to normal life for a person with glioma?
Glioma is a tumor in the central nervous system, i.e the brain and the spinal cord and is one of the most common types of primary brain tumors. It originates in the glial cell that surrounds and supports the nerve cells. It is characterized by the abnormal growth of brain cells and the spread of cancer to cells within the central nervous system. Gliomas affect brain function and may be life-threatening depending on their location and rate of growth. Glioma may occur in people of all ages but are more common in male adults.
Glioma is also called an intra-axial brain tumor due to its growth being both within the substance of the brain and the normal brain tissue.
The type of glial cells involved in the tumor and its structure determines the type of glioma. Based on the glial cells involved different types of glioma include;
Based on the structure of the tumor, glioma is categorized as;
There is no specific cause of glioma, anyone can suffer from glioma, however, it is more likely seen in adult males. Some of the underlying risk factors of glioma include but not limited to;
The signs and symptoms of glioma will depend on the type of glial cell involved, the size and the rate of growth. Since glioma presses on the brain and spinal cord, most of the symptoms with will be related to neurological aspects. Most common symptoms include;
People of all ages can develop glioma; however, it is more common in adults than in children & males than in females. People who are frequently exposed to ionizing radiations from atomic bombs and people who have previously undergone radiotherapy for any cancer are more prone to glioma.
Glioma progresses from a low-grade glioma to a higher-grade glioma which is fatal and life-threatening. A patient with low-grade glioma may survive several years after treatment but it gradually progresses to high-grade glioma.
The symptoms become more severe as one progresses from low to high grade. Some of these complications include:
Currently, there are no methods to detect glioma at an early stage and in addition, the symptoms of glioma would be mistaken for other diseases, since they are seen in various other diseases as well. Studies are in progress to help in early detection of glioma for early treatment and faster outcomes.
Gliomas usually affect people in their 50s and 60s. Glioma is known to affect less than 6 out of 100,000 persons, hence it is usually considered as a rare tumor. However, gliomas constitute 80% of all the tumors of the central nervous system.
In case of any visible sign or symptom, consult a physician who may refer you to a neurologist or a neurosurgeon for further investigations. Diagnosis is usually made by the doctor on the basis of:
The treatment options for glioma are based on the type, stage of cancer, location of the tumor and other factors like overall health, age, and sensitivity to certain medications. Gliomas are usually managed by different treatment options that include surgery, radiation therapy, chemotherapy, & targeted therapy.
Surgery:
Being the first-line option, the object of surgery is to remove as much of the tumor as possible. With advancements in surgical technology, neurosurgeons today have many options to protect as much healthy brain tissue as possible while removing the tumor. Some of the advances in the surgical removal of tumors include:
Stereotactic/open biopsy:
In cases where surgery may not be a safe option, primarily due to inaccessible location of a tumour or sensitive location that carries a high-risk for damage to neurological function, a stereotactic or open biopsy may be considered. This helps to obtain tissue for a diagnosis. Even though a biopsy is not a treatment; it helps in the analysis of the tissue and planning the best course of action. A stereotactic biopsy is a less invasive way to obtain the tissue sample, as compared to an open biopsy.
Surgery for the treatment of glioma, especially high-grade gliomas is usually followed by radiation therapy. High-energy beams, such as X-rays or protons to kill tumor cells are delivered as an external beam radiation from a machine outside the body. There are several types of external beam radiation currently used and under study for the treatment of glioma. The timing and type of radiation to be given depend on the type of glioma, its grade and prognostic factors like age and medical status of the person.
Chemotherapy is a type of cancer treatment that uses one or more anti-cancer drugs as part of a standardized chemotherapy regimen. Chemotherapy is usually used in combination with radiation therapy to treat gliomas.
Targeted-drug therapy: Use of drugs that act on cancer cells and selectively destroy only cancer cells by targeting on specific abnormalities within cancer cells. By blocking these abnormalities, targeted drug treatments can cause cancer cells to die.
Combination therapy: Radiation therapy to treat gliomas is also usually combined with the use of chemotherapy drugs in the form of a pill.
Various treatment options will have different side effects. Some of the commonly seen side effects include:
After treatment, the patient should be well observed for response and side effects of the treatment used. Additionally, since glioma affects the functioning of the brain, such as speaking, motor skills, vision etc, the patient may need to undergo few rehabilitation programmes to help with a fast recovery. These include;
There is a high chance of glioma recurring even after successful treatment. Patients initially diagnosed with low grade glioma may survive several years after treatment but may eventually progress to a high-grade glioma.
Few possible reasons for recurrence are:
Since most of the residual cancer cells are located in the resection margin, it may seem relevant that tumor would occur in this area.
The prognosis i.e the outcome of treatment and impact on the longevity of the person depends largely on the grade and type of tumor cell origin. It is generally seen that individuals with oligodendrogliomas and ependymomas do better than those with astrocytomas or mixed tumors after appropriate treatment. Similarly, gliomas of grade 1 and 2 have very better chances of survival followed by grade 3 gliomas. Generally, the worst outcome is expected for Glioblastoma multiforme or a grade 4 glioma.
Returning to normal life may not be as easy for a person with glioma. It is generally seen that different degrees of neurological impairment may be present even after treatment. A direct injury to structures of the brain that is responsible for cognitive, motor, speech and sensory functions may drastically compromise the ability to self-care and independence of the person. Further, side effects of radiotherapy and chemotherapy may lead to further functional deficit. As a result, rehabilitation plays a crucial role in post-operative management & recovery for glioma patients.
Glioma may be suspected in presence of a number of symptoms like recurrent seizures associated with changes in a person’s behaviour and personality that may be associated with various types of neurological problems like problems of vision, speech difficulties, cognitive impairment, loss of strength or feeling in a part of the body changes in gait along with symptoms associated with increased pressure in the head leading to headache, nausea, vomiting, and drowsiness.
Magnetic Resonance Imaging (MRI) of the brain is the most important radiological investigation for diagnosis of a glioma. With an MRI, it is also possible to define the extent of the disease and evaluate whether the tumor can be safely removed surgically.
Surgery is usually the first preferred treatment option for a newly diagnosed glioma in a majority of cases. An extensive surgical removal, as far as safely feasible results in improved treatment outcomes irrespective of the type or subtype of the glioma.
In case of a surgically inaccessible tumor, a piece of the tumor can be either taken by a surgical resection or by biopsy (stereotactic or open biopsy), to confirm the diagnosis and get more details about the tumor characteristics after a pathological examination. With a molecular characterization and examination, it may be possible to define the exact subtype of the tumor and assess the prognosis for further treatment decisions. Other treatment modalities include chemotherapy, targeted drug therapy, and radiation therapy.
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About Author –
Dr. Ravi Suman Reddy, Senior Neuro & Spine surgeon, Yashoda Hospitals – Somajiguda
MCH (NIMHANS), Advanced training in Stereotactic Radiosurgery (Brain Lab Academy – Germany). His expertise includes frameless stereotactic neurosurgery, minimally invasive spine surgery, spine stabilization, nerve radiofrequency ablation, cranial micro neurosurgery, cranio-spinal trauma, and endoscopic surgery.
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