0:08
Hello I'm James Ausman.
0:11
I like to introduce a session on glioblastoma Gliomas. How should we treat brain tumors are about one to two percent of all tumors in the body metastases about one out of every four patients with
0:24
cancer as a metastasis to the brain, so the the most common brain tumor, It's a secondary brain tumor,
0:31
but of the primary brain tumors, gliomas represent about thirty percent.
0:38
Of those about eighty percent of those are glioblastomas and twenty five percent of the prayer of primary brain tumors are many germans. There are other tumors to it's cranial fringe, Yoma,
0:52
Megillah by stoma acoustic neuroma. We're going to talk about those tumors in another session at this meeting,
1:02
so the real problem is what do I do. I do. How do I do the best thing I can do from a patient?
1:09
Well, what do we know
1:11
from the data? We know if we do the best section we can, and then we go ahead and treat a patient with radiation therapy. About one out of ten will survive two years. Ten percent to your survival.
1:26
If we give them making came a therapeutic agent drug called Temozolomide
1:33
that the survival goes up to twenty five cent in two years at significant.
1:41
That leaves us with the question of is one of these other things that that are being done in. Are they going to be valuable and they're gonna make a significant effect on the long -term survival and
1:53
dance quality Survival.
1:56
Well, A couple of things have been done when they find a study has been done, dish to show that the mortuary respect, the longer you'll have years of survival.
2:09
So that's led to brain mapping, Andor, detailed work and trying to find ways to reset the most amount to re, you can
2:19
Cleopatra, Charlemagne, Charlemagne Pankey, and is going to talk about that. She's from Germany, As as a dung lot of work on it, She looks at the fluorescence in the tumor. They inject a dye
2:32
that the rest as I am during the operation, Sir, you see the margins of the tumor. We look at the amar.
2:42
They look at fiber tract imaging
2:46
used neuro navigation problem, which has probably been programmed with all that in at the end uses ultrasound to make sure they got everything up Real question Is we know that glioblastomas extend
3:01
beyond the local area. A thirty percent of them are localized, so how do we get to that part of the tomb? Also other things had been done
3:12
immunotherapy, Linda Liao, who said of neurosurgery at U. C L. A
3:18
has worked on immunotherapy for tumors, and that is on the in in an effort to try to get to the tumor. That's beyond what we see on the
3:28
A doctor Poodle Valley, Who's ahead of neuro -oncology at Md Anderson, that the in the United States. We'll talk about the work they're doing looking at the genetic analysis of a tumor
3:42
in and trying to find what abnormal genes they have because if they find some that are in a certain pattern, those that tumor might be more sensitive to chemotherapy, and it, for example,
3:54
oligodendrocyte Elma is one of those jokers,
3:59
Dr. Ian Lee is also a neurosurgeon at. Hermann Brain tumor Center at Henry Ford Hospital in Detroit in L. Come in on their experience,
4:10
so that what we should learn from these people is what do I do with a glioblastoma No matter what country I'm yet everybody doesn't have all this advanced technology. Does it make a difference. Is
4:23
it going to make an increased meaningful quality of life Survival The people that's what you want to know.
4:33
Or not you still have the standard treatment, witches, games, resection, chemotherapy and radiation therapy, but as there are things that you can use in your location that allow you do a better
4:44
job for your patient,
4:46
so they're going to showcase of a glioblastoma and they're going to talk about this.
4:52
Then they're gonna show second case. A second case of a low grade glioma heart appeared to be a low grade glioma. Certainly by imaging. It extends from the frontal lobe down to the brainstem where
5:04
you can't resected lesions,
5:08
but, but the most important thing to do
5:11
is to get a generous tissue sample so that you can determine exactly what kind of a tumor it is and then there may be some chemotherapy as an elegant under, as that may be helpful,
5:24
and now present their case and talk about their
5:28
ather eat 'em as a moderator of this session. Is she from Aga Khan University in Karachi? It? He has an assistant Ah? Sean Ali Khan who works with him at the same university,
5:42
So that's the faculty comes from around the world
5:46
and you'll see how they think about these cases, seizure cases, you see, and you and I are troubled by them. How do I do or whatever how can I do the very best I can for my patient. That's what
5:58
you want to know.
6:01
And see what you learn from them,
6:03
so we appreciate your coming up. It's worthwhile Thank you very much, But we can start with our first case. The three year old gentleman came with the complaints of expressive, his faith, heroic
6:15
ability, and be able can do for two months. On examination. He will detect fake, and there were quite accepting, and reputation paints an incredible picture, The free up Amirite down in
6:26
September, two thousand and seventeen short, left for, I tell Nico. And can you please go to the next flight? My leave social. There are many images will just go. Okay, The thirty one you can
6:41
see the lesion in the left grateful
6:45
load. Next one, please,
6:48
Okay, Fair that and he went was contrast, and you can see the lesion in the left parietal lobe and then extending medially today to fill up the hornet's next, please.
7:00
At the next debate yet, so we the say he felt that he went with Von Trapp in the next one place, then we have to end up there, admitted the. The you can see, and then we go to the player
7:20
microwave the food.
7:24
We are limited by the time we just want people to the theft the next one place, so he underwent to a neuro navigation guide you to be a me.
7:40
And Reagan and interpret, give you the tumor was inherent to the Lake Macquarie, and especially the medial part of the humor, and could we, but we were able to do maximum say perfection into his,
7:53
and that is the pathology came to Gbm, glioblastoma, W too great for him, and as you can see the post of an Mri, for some, if not all enhancement. Along the medial margin of the left bracket
8:07
second cavity just after the next image, we can see the of the T one and the next one, human post contrast.
8:18
The thanks that Stewart minimal. You know you can see on the medial margin that we thought it'd be the next one place.
8:30
The next week, the.
8:42
The theme
8:44
and the last one left image of this kid with
8:49
okay.
8:51
The court will be the moderator here, but I think we can start the discussion like
9:00
all the while you have a different approach, and you know the different things like that important question that would be whether we will do awake or will do asleep. And what are the of you would
9:16
think in this patient? And if gentlemen were fifty three year old, what he'd be would have seventy three, seventy five, You're you know these question that we would like to discuss with the panel
9:29
the weekend guard with
9:36
Dr. Cleopatra, if you would like to hear your thoughts. So I am a neurosurgeon in Germany, I am practicing twenty six years in different universities. I I in minds with the professor or Netscape,
9:53
and then I move in Austria, and now I am currently in Cologne, since eighth year, same professor of neurosurgery and I am very specialized in.
10:06
Brain tumor surgery, and especially in glioma surgery, and as you know, we use here standard on a standard case, as seen some twelfth, thirteen years, now, the as clause five, the Queen, as
10:26
its or treating Leone months, so use fluorescence techniques, especially in this Asap, What's all? What do an awake craniotomy or sits on the left side? It's on a very eloquent areas? It's own
10:43
the speech area. It's modern or considered, though
10:48
it's a look went, and in addition to five L. A, because it's very
10:57
very common floor gliomas who have a nice roast, go to the reception so. The thing is, it's the only addition what we would make more spirit in Germany than Islam it, and so we are very familiar
11:19
here with a fluorescent techniques, and another thing is Of course an electrophysiology and electrophysiology, but if you do, I'll wait for y'all to me then. I think in every department
11:33
automatically you do also elect the do what you hear. Think that it mentioned that lets you perform this rite,
11:46
electrifying
11:49
and a couple of them for, for,
11:53
Yeah, and so and then neuro navigation. Yes, it's a. It's a very good thing, but The the big the big think. If you use your obligation is for
12:09
for prepare it exactly the front yard to me, so if you go into that two more than and I, it such a tumor. You have such a big brain shifts. That's you and not a flaw. No, then your vacation for.
12:28
Or checking exactly the margins and I think they already if you have a real time fluorescence. Technique, it's an additional advantage. Another think what we use your use of
12:46
which there are sound in in combination with your vacation,
12:53
and so try to fix this problem with a brain shift at the end of the surgery with the with higher resolution ultrasound to heat. I suppose this is this what we do here in Germany that so stunned the
13:13
Okay. Thank you. Thank you for creating to rename. Would you like to? I
13:20
like it, I think Dr. Challa Bucket covered nearly all of the important factors here. I, I think handedness and language function the location of the critical. Functions structures around the
13:35
tumor are crucial in terms of making those decisions. Nothing the surgeons on the team here would agree. I'm a neurologist neuropsychologist
13:46
to the medical therapy of this after resection, but of course we interact with it closely with our neurosurgeons, I think functional mapping prior to surgery, and our institution also uses the
13:58
right cases, interpretive and Mri scans. To further define the extent of protection as to Dr. J Lumpur convention, a gross total resection is the goal, but if that's not feasible, the maximum
14:13
safe resection would be that the next adopt darkness wire was the former chair of neurosurgery here at Md Anderson Cancer Center, Where I currently am, I was one of the first stirred to show that
14:26
the extent of resection the more more a where you are able to get out the. What are the survival and that has then been brought into the modern datasets through efforts from you see yourself, his L
14:39
A. So I think it's fairly well accepted that if you can get maximum safe resection, and get know as much of a resection as possible that that certainly ups at the other end, Ok, we can discuss the
14:53
chemo and radiation bought shortly, but I know that other surgeons on the right have probably have a little bit. Ask Dr. Doctor telling me he would like to add the fight against
15:09
Miami. I'm not entirely all a neurosurgeon at the and careful department here at Atlanta. I've been here pretty much
15:19
twenty five or more years now, and I think I agree with everything that has been said in terms of the average deduction. And here we want to move closer to an Mri as well as the I cryptography prior
15:32
to surgery, And that's the of how we are men, whether or not to do the surgery awake or your life, So with the
15:40
you know, after Mri shows that the legion is within a centimeter of functional language of areas. That's That's your help out. Usually I determined whether or not we would do this way. And of
15:54
course you know handedness, and in the end a lot of other neurocognitive in speech testing is would be useful to determine what what what what would actually wait. We map when we do the awake
16:06
craniotomy, and other than that, I think everything else has been said. Quite well, You, I agree with the neuro navigation. The they interrupt, But you know electric cord call graphy and motor
16:19
strip mapping, and and and then you know on them. At the at the Tv that you know usefulness of you know extent of her section Under the goal is really to maximal safe section. In this particular
16:34
case, I probably would also do sub vertical mapping because I think the the concern is not really the cortical language areas, because it's pretty soup out superior to that, but it's really the
16:48
support hilarious deeper down and then as far as reception. I think you're probably would. Also. If if safe reset the non enhancing areas of tumor is it does look. There are some residual non
17:03
enhancing areas to rinse well, but but other than that, I know I agree with everything that's been said. I guess I'm up next to my name is Emily. I'm a neurosurgeon at the Ford Hospital Detroit co
17:17
-director of the brain tumor center along with Dr. Wilbert for her to prove all it goes pretty well.
17:23
So, I, I, yeah, I. I don't want to echo everybody, but everybody else has said. I agree with everything
17:30
that everyone else is that I think Doctor. The. I would probably have better functional napping or functional imaging that I have. I at least at our facility, Our Fm rise. I think are pretty good
17:40
for lateralization, but not so good for localization, and so especially for the receptive speech area. I think I would still probably do it awake, regardless of the functional imaging unless it
17:50
very clearly showed that. At lateralization was on the other hemisphere which you wouldn't expect for a right handed person and I think you know our practice here has been mainly to U. C
18:01
interpretive amirite. That's mainly because Leland is a relatively recent addition to our armamentarium. Of certainly. We've made it. We've started to incorporate Leland more into our ugly almost
18:15
surgeries, and I think the one thing that has changed. Other than politically leland, the other thing that's changed for me in the last probably five or six years. Instead, I moved away from
18:26
bipolar stimulation and reports of modern Porsche stimulation, especially for sub cortical stimulation for for motor speech mapping, and one of the really nice things about monopole or stimulation,
18:39
in addition to probably a lower risk of seizure is the fact that you can they had these sucker, Polish stimulate stimulators now so that you can stimulate and respect at the same time. Let me make
18:50
one more point and that is about post operative imaging,
18:54
typically that are still institutions where the post -op imaging is not necessarily done, and then patients go on to treatment, and it always becomes a bit of a challenge to interpret the later in
19:05
that, just because you don't know what was felicity, and but was not the timing of that seems to be also important, and Md Anderson, where I work, we. I tend to do that within forty eight hours
19:17
of surgery as early as possible, but beyond seventy two hours and ninety six hours. That is a concern that the inflammation following surgery might cause changes in the imaging that meet and make it
19:28
subsequently difficult to interpret,
19:32
and so I just wanted to make the point The other thing maybe our neurosurgical colleagues can address is
19:38
how much is the control of bleeding in intraoperatively and leaving. Clean cavity at the end of the surgery, in all the feasible, an important, in terms of subsequent, the things that happened to
19:52
the patience. I have one more question from the pan of that guy. Would I got offered to Patrick and asked her again, What if the location of the lesion, It not involving the partakes, and it is
20:05
more a particularly deep with your tragedy changed In any way, Will you do it differently? Would you be worried about the white tracked by those are easy? Will be in your mind that you will you
20:20
will have the same plan as for this title, so I normally we do. I very rarely loaned to the coronation before surgery, so we go through that tracks still get a feed through the navigation pictures.
20:41
We have the navigation of brain lip into how we do. We try to fix that too majority in relation nation with the lot to get up the Eu. Before the show dream,
20:59
Did you read the fans of all this except nations do, but normally? Normally, when though know this and she and what a thought before and do for gliomas, and I think the only one but you use here
21:22
in a standard method. This,
21:25
in addition to this what's in another conference is using. It's a fun little, and I. I think all the other things it's it's the same like the At watch also. For example the units
21:43
are okay.
21:47
Yeah, he has tied by elected jump in my. I think. Even if it were were more sub cortical. I'm gonna come right up to the part of the surface. I think that you know all the same things would
21:56
certainly buy one you know
22:01
you know imaging and Dth Rick telegraphy, and then just to answer.
22:09
What's strange about E the stasis? I. I do think that it is important to to you know, Maintain he mistakes this and try not to leave a big Ikeme atonement I in the cavity after surgery up, you
22:22
know, for for a couple of reasons one is human could get post -op swelling the complications and neurologic complications due to that, but but also for post -op radiation manning, because it's
22:34
really hard to you have a lot of extra. Staff that that's difficult, difficult to differentiate what's residual. Then what's not that does complicate you know the up postoperative radiation
22:48
to rehab a picture, and let this gentleman will fix three year old, and what is really going to have a peculiar to seventy three or seventy five, With your approach her with trained for that
23:01
patient.
23:03
I think Yeah, you know it's not. Exactly, I don't think the age alone is the most important factor. Although certainly know if they're I guess what we call the key, the supra, or extra elderly.
23:18
Like over eighty. You might change your posts lately, but I think really.
23:22
You know. There's pretty good evidence that suggests that. Although
23:26
the older you are, you may not have the same kind of survival with maximal treatment, there's still certainly a benefit compared to not treating maximally.
23:37
I think really for him for an older person. I think. What's going to limit your reception as you're related to functional mapping, and even if they're very old that they can tolerate an awake
23:48
craniotomy with mapping, then I'd still go for it,
23:53
okay and Dr. Liu. You would like to somebody
23:58
comes of age, but he couldn't.
24:01
Yeah. I don't think the issue is really chronological. Age and it's it's really up. You know performance status, functional status as well as medical condition, and and you know how other patient
24:16
can tolerate was a long surgery, and functional mapping, and and and the interpretive language mapping, so so I, you know I would agree with doctor, The
24:31
doctor. Rubin, Would you like to read something or we can move to the next page? I,
24:37
too, I like to add that. After that has been achieved, maximum safe resection, Obviously a patient in his sixty's The standard of care here would be to proceed to the stoop regimen with chemo
24:53
radiation honored by Temodar for six months. That's what we use and are going to clinical trials that may be appropriate for a patient like this, depending on the. Functional status post surgery,
25:07
I just want to emphasize the need for that post operative imaging within a certain period of time, so that we don't lose that window and have imaging confusion later when you tried to assess
25:19
response to therapy down down the road when the chemo and radiation has been provided so. An obviously molecular market market testing is huge in these patients, so to do those kinds of things
25:32
fairly quickly after surgery, so that one decision making comes up that those decisions can be made based on what we understand of the at least a basic molecular markers that I think are now being
25:43
performed worldwide,
25:45
sur mer, Hear the question I've wanted to ask and how it cakes if your guys in the United States. Is that a molecular fingerprint of the tumour? With with Id age and lives in Gmt October, How weak
26:05
enough the group? I see a person certain.
27:24
Just bring through the second case, very quick, said thirty three year old right handed male with whiteside, cited secondary generalized fear. For one year on examination. There were no
27:34
neurological deficits and debt free pre -op Mri showed left front lawn contrast enhancing, and can he moved to the next,
27:47
Okay, so? It's good to hear believing in the left front with me ever again. It was extending to the emperor to bolster next face was slight enhancement. There ain't a came next hit. The two
28:01
uncles. Contrast to play clarinet, The next you can cooking much of this okay, So Sunday was done the yep. But there was no one ever get indicted left frontal. Every cleaning ought to be maximum
28:17
fifty section blow. Then should look great and clearly about them, and they stop. Apology came as only the great to the next place. They are post -op scandals of the stowed away. Sunday. We
28:33
wanted to discuss the phone. He got the desk. That's what was the crossing. The that can be. Mike. Can you go back to the previous like this? We're we're just chewing. Go back, Go back to the
28:46
game and and weaken the Gucci slides back East.
28:52
Okay, Yeah, We can stop here. The question is what would what would be the recommendation I know from? Let's say, Linda, What would you think about it And what were the ignition? Think about it?
29:11
What will kill people on it? I was just asked to you know a deal flows. What are your thoughts about him
29:18
What you to come in
29:19
and the way you see in this picture is merely kept me. It's a. It's a disaster disastrous to tomorrow. That means that it sounds funny in an bend area, athletes, and then year old, so
29:36
that's the
29:38
end.
29:40
It goes on
29:44
in the brains, The in the beginning of the brainstem, It goes in front so.
29:51
Why thing to oppose the atmosphere
29:57
to,
29:60
we would certainly go over to the extent that respect put on the cross, and it seems that preoperative Mri scanners that you don't have so many contrast enhancement here so. I. Reward through the
30:25
viola will try that at five a
30:29
by, but I don't think that you will have a very good response here in this case, and and also the tracks dogra grapheme, before
30:43
and now wakes shot, Agree, I don't think that it brings more benefits
30:51
because the. In those a elephant areas, and and the tomorrow, especially if the patient has has no serious problem before surgery, and do, and then we would recommend off lucky to have a weekend,
31:15
or
31:19
or shopping here. What are your thoughts about it? Yeah, you know him from a handful of Sony Hack stuff you know from Michigan. Right, Yeah, so I, I agree fully with Dr. Trial packet, saying
31:36
I guess the one caveat to that would of knowing that this and I'll go with centrically and there we. We have some knowledge that I would potentially almost perhaps do not for us as avidly as other
31:49
types of wheel as astrocytomas do, so, I think this is probably one also anticipating a largely low grade tumor that we would probably rely more on and chopper them right rather than fluorescence.
31:59
I think the the problem with this lesion, As after Trump hockey was saying that it is the extent of the lesion. It is the dangerous, really dangerous part of the legions to the fact that it
32:09
involves. Not only the insular, but also the anterior perforated substance, which I think actually will ultimately
32:16
necessitate a subtotal resection, so I think for this, I would certainly do in the wake of the patient can tolerate, and I would definitely focus. I'm trying to get a gross total resection of the
32:27
contrast enhancing portion at least, and then whatever the non enhancing, leave them whatever we could safely do with the functional mapping that would allow us to do. I do have some doubts as to
32:39
the pathology and the presence of enhancement. There would make me think that this is probably more likely to be an anime classic lesion rather than low -grade
32:47
and so for the purposes of the biopsies, you know for what I would give to the pathologist, I would tell I would especially focus in on that contrast enhancing portion in order to provide as
32:57
accurate as pathological diagnosis as possible,
33:01
right, Great, Yeah, Thank you, Yeah, is you know is this message over here? Ignatius, I was not ignition uses as an audience who was a panelist. I don't know if you can the most intimate
33:14
invite a join here Kobe, or be deserting the sending a message, and for some reason
33:23
he was not heard by some of the ideas. Okay, so to show, Yeah, it makes sense the end. What you said, Oh, been a
33:32
doctor, put a body is up as oncologist in Md. Anderson.
33:38
And he looks at things in a different way, probably more cerebral rate, and the show just look at things, so a veneer. What are your thoughts about this slight enhancement in here? Would you
33:51
sneak a single biopsy of? Would you recommend a good chunk of the tissue to
33:58
heal so typically when we see you like this in Md, and a snow neurosurgical colleagues often attempt. I get enough tissue for molecular diagnosis to be accurate, which I think is very important
34:10
here, and as was mentioned, and housing areas like that which might happen in low grade tumors and don't necessarily always mean something high -grade
34:19
should be sampled. I think, because that might be the highest yielding terms with a correct diagnosis, so there are some nuances to this whole case. Here, the patient is less than forty years of
34:29
age and as you are aware of. Putting this patient into a high risk versus low risk category depends on the extent of resection, so maximum safe resection quote unquote, gross total resection, as
34:42
defined by the neurosurgeon was what was used in archaeology, ninety eight or two to defined the lower risk group. In this case, I suspect that may not be necessarily possible, because of the the
34:52
nature and the location of the the tumor there, thus the site of the tumor. So the next thing that's really important, I think is to understand the molecular makeup of this tumor, Because that
35:03
might define prognosis and all kinds of. Basically what a surgical maximum resection is not attainable. So I would ask the neurosurgical colleagues to get me as much tissue as possible, including a
35:15
separate biopsy off the enhancing area, so did the pathologist can give us an accurate diagnosis, and the reason I would say that is. As a general sense, that, if it is an article, general
35:25
glioma, whether a disgrace to our great three, that seems to not matter as much in the setting of adjuvant treatment that we give, now, so if this patient as residue the disease more than one
35:37
centimeter the duma is about three or four centimeters, I think in size, which is generally constructed, be one of the the unfavorable prognostic, factors, but almost certainly this patient. If
35:48
it is a true while ago would have won't be nineteen your coordination. That would allow providing radiation followed by chemotherapy. That as you know, has provided excellent survival in these
35:58
patients, double the survival in that subset. Particularly to other points I wanted to make, and histology is that there are micro deletions in the one P and nineteen Q areas that the probe may
36:11
faith to you know attached, but that doesn't always mean true. Call deletion because you've talked more all chromosome losses that that that defined an alligator and Oklahoma, too hard cases where
36:24
the probes made it to point, and then subsequent Us. Next generation sequencing showed that there were micro deletions in these chromosomes, and it was not a true or promise, alarm loss, and
36:35
those patients did not do as well as you would suspect with a great tournament interview, so to do a good thorough study of the molecular makeup and make sure that. You get that information, of
36:46
course, ideas mutation almost always happens in these patients, and as a good prognostic marker in general, If this turns out to be a great to Hollywood and Oklahoma, with not none of the other
36:56
unfavorable market status you would expect with the standard treatment of radiation, followed by chemotherapy, for, we typically use Pcv In some cases, we may go to temozolomide that is being
37:09
defined with the Cornell study that's ongoing, and we hope to get sounds from that. But that I think me perhaps complement the surgical approach, even if it is not satisfactory to give the patient
37:20
desperate message
37:23
for you would prefer Pc. The working was automated. At least in this case, given that moniker finding raid, so I think the data that exists in a larger randomized study is for Pcb. And these two
37:39
are not equivalent treatments that was automated. Some one of functional alka, later that causes methylation or articulation and Dna repair, based on
37:48
the presence of additional things like Dna repair enzymes being active with a Cc. A new end up broke our busiest to trap. You know Ccm years of my functional outcome, Later conscious cross -linking
38:02
and causes a somewhat different method of salkeld. So just because there are alligators, I would not switch them if the patient has comorbidities that might be limiting in terms of using Cc, and
38:14
you, I think that's certainly a consideration. I don't know we have the right answer yet, but I would wait for the Cornell study, which is now a growing steadily, and hopefully we'll get some
38:23
preliminary results in the next two years or so that my God is better.
38:30
We didn't know if I can ask you a question. Linda. Can you hear me? Yes, okay, so the diamond will be heard from people from Europe. And you know from Michigan, and densest, Ah, But then what
38:46
about and I've got the first English is the insult from China is not yet, But you know what about those cases. Bandwidth don't have the photographs. He. He don't have a way to new. We set up that
39:02
many places you don't have those molecular biology labs do understand the molecular biology of. What would you recommend and doing this kind of case?
39:18
Well, I mean, I guess it isn't possible for your labor, and yep, quite certain twenties, and and in a, I guess if possible properly, in an effort for an institution that has those things for
39:33
you know for optimal position of of you know patient outcomes, but I guess, if if not possible,
39:40
you know. I a still for for this patient, I or I. You know, I, I think optimal, and you do want to get you know a gross fat small reception, and I. You know I. I. I agree with what everyone
39:55
has said about the the nuances of of this particular case, you know, in a thirty three year old with an on enhancing tumor, Most likely this is an Id. H, one mutated tumor.
40:09
And the the additional enhancements suggested that is probably eight. Perhaps a a low grade were transitioning to a. You know a a great to transitioning to a great three. So what if you are going
40:22
to do surgery? I think of optimally. You want it the most diagnostic sample, so even if you don't have all the, I guess
40:33
you know tools of for awake napping tractography, you know. Everything we talked about before I. I think you know getting a good chunk of of tumor tissue up or for diagnosis. I don't know who to
40:47
call. He said. It is important you know at you skill that we also you know for these kind of very diffuse low -grade tumors. We also do amino acid pet scans, so so he does what we use dopamine,
41:01
but you know there's fat pet and and you know other types of pet tracers that specifically. Are used for defining kind of areas of of highest
41:13
yield went when we do these biopsies, because in these very few serious up or diffuse tumors, and if you're going to do surgery, and you really want to go in there with the goal of getting the most
41:24
diagnostic sample, but, but I guess and answer your question. If you don't have all those tools it, I, I would not necessarily advocate just for a needle biopsy. I would actually say do an open
41:35
biopsy. I get a good chunk of tumor tissue or that that that sounds like a wise, A recommendation. That if you don't have enough technology, if you don't have enough political body, just hope you
41:50
at least get a big chunk, do look into histopathological diagnosis. Upgrade to us his great three, so it's so Mike can be the go ahead to move a few slides ahead, so this patient underwent synergy
42:03
of ignored me. Know what I have found in bucks.
42:08
The extra cost Mike and you will dislike Year will keep on going. Keep on going. Lord. Yeah, Okay, so it's a no go back, Go back of the. The previous likeness
42:23
were tasty, too, or stop doing twenty. Okay, Everybody so so so this actually awake and not an okay, so the awake craniotomy of you know is not really expensive and easy to set up. If you do it
42:35
in a very elaborate way, it becomes difficult night activities that you could audition notice that there was a post of 'em region here, so my question to him that the patient did not have any
42:49
symptoms. Would you go in and recommend the surgeon to remove this. Glad. I think he had one seizure rate. I said, was it. That's all we got them are either. Okay,
42:60
It was surreal. The.
43:05
You can see the clothing on.
43:08
Yeah, I mean. Although it's not pretty to look at. I mean, as long as the patients not having symptoms from it then I wouldn't go back after it. Okay, Impatient did then keep on going and be
43:19
following a routine An Mri. Two months. Can you move forward night?
43:36
I wonder if Dr. Liao has any comments about the degree of hemorrhage that you're seeing here whether an interventionist, yeah, I. I would say this is you know quite a bit of hemorrhage, good,
43:48
Andrew.
43:57
The symptoms or not drink, I'd be surprised that he doesn't have at least some language symptoms, given the location of the fleet and and the size of the hematoma, but I, but if it can't tell, is
44:11
to say your post like a three month post -op scan or an immediate, not when your was
44:20
too so just to rub to you within few weeks, because there was a big he was.
44:28
Okay, so it might get forward, please, So The the the question that I want to ask are dismantling and for the audience to think about is that The there was a resolution of this humor to them over
44:38
time.
44:42
Mike. Can you
44:44
move forward? Peace? I think if there was recurrence the disease was Catholic When we go to the February twenty twenty one, there was some kind of hyper intensity and the superior here. Marginal
44:57
resection cavity, but no uptake in the contrast, but when recently made this month is small
45:07
contrast enhancement the same module that was hyperintense in February as Mike. You can continue to move here. You can seen the Coronel one if you go serve some kind of hyper intensity the next one.
45:28
We couldn't see any I contrast enhancement in February scans, but there are some put into me next month.
45:37
I kick
45:41
next The next.
45:47
They just want to take care of the panel. To the main slight. Very can see that he gets one.
45:57
Next one.
46:02
Get just one minute to. If you can see in that hyper intensity.
46:09
It was like very recent contentment of like I was last week or two weeks back, So can see that hyper in an area.
46:20
It's been.
46:26
Be place that I was just going through the images, so that unit. This is the law in in me, and then we can see some contrast enhancement. The, if I might, my in,
46:43
guess the chase. Yeah, so I think up.
46:48
True great to all, he got into glioma, which as you know, typically grows over many many years, it's a little unusual for us to see progression with enhancement within, I think less than the.
47:05
In a recovery from those seizure, so, I think it emphasizes the issue of what is the histology of his humor, and of course what is the nature of this enhancement that we are seeing here since no
47:17
other treatment has been given, it is difficult to attribute this to radiation effects or chemo effects, etc, and investment even surgery so far that I understand so.
47:29
In the first instance, I would certainly make sure that if the local pathology is not specialized in terms of neural pathology, that you always send it out to a expert neuropathologist for diagnosis,
47:40
low grade gliomas are notoriously difficult to diagnose, in the sense that there has been lots of discordance between even specialists in diagnosing it just by phenotypic in morphology. We're method
47:55
of diagnosis, so getting molecular markers, making sure that this is indeed a great, too. I'll go and that it does not have any adverse prognostic factors will be crucial in terms of anticipating
48:06
the behavior, so if this turns out to have no one p, ninety two coordination, even if it morphologically has some appearance of Hollywood, and my, I would be worried that this is actually an
48:17
astrocytoma looking like an article, and that is progressing. You know, foster that he would expect in such a patient. What if it was won't be nineteen Kyoko deleted, and there are no other
48:27
adverse molecular factors then ain't no such changes I might tend to watch rather than treat. Because the decision to treat is usually made in a typically after surgery and recovery from surgery,
48:40
and there are instances where patients are observed and not treated at the at that time and then later on, let's say a year later. If the person comes up as to a few and are sometimes, I see a
48:51
patient has been managed in the community for a year without any additional actual treatment, So when they come to me, I'll have to make a decision on whether that I can apply the same data that I
49:01
get in the large studies where the treatment was given immediately after surgery, versus doing that one year later whether I can to keep depend on that information. Well, we know that these
49:13
patients do well from radiation and chemotherapy. If there is message you want humor. In this case, My understanding was there was no residual tumor after surgery, so you would have observed this
49:25
patient any way because of the young age and grocery resection, and I suspect they may have been rested. You'll disease that perhaps was only seen by the made later so that all those factors to
49:37
consider, I would at least do another scan and see if these enhancement goes away. What if it continues to grow that? I think it was for another sampling of the tissue to find out what's going
49:49
Okay to kill The deal? Would you go for the resection? Or what will be your?
49:55
Is he an emphasis patient?
49:57
Yeah, I agree like I could put a volley. I need. Actually, the The enhance her looks quite subtle. If that's what if this is the scan you're referring to and you know, because this patient did
50:08
have that post operative bleed. This could be something. You know vascular leak, and you know, from of the contrast, adjust to that area, and if this was a scan within three months of of the
50:23
last surgery, and the patients are asymptomatic, I would probably just get another scan you know in a month or two just to see if there there is you know true progression or not, and before doing
50:36
doing anything because.
50:38
You know, as was said, I think it's unusual for a low grade article dental glioma to progress within three months, so unusually after surgery, there's so much shift with if you, especially if you
50:50
take out a large tumor, we usually use like the the three month scan as the baseline to compare subsequent scans, Because these these tumors usually grows slowly, and you know you want a good
51:05
baseline, especially if there's Postoperative blood and you know other other know, teach you abnormalities, have one question I did have, and I don't know. If you have this information is data
51:17
you get that. Do you know the key? I sixty seven indexed on this tumor Was that something you you typically get the proliferation and death
51:28
through the yard Index was little. He could, fifty three was negative, and one P nineteen to go deletion, was detected that, too.
51:38
Cause, if if the you know, if the carry sixty seven index is low, and it probably is more of a grade two or lower grade, you know versus a higher grade and I wouldn't expect that it would grow so
51:51
quickly at this point, but but if if you know the subsequent scan in a couple of months shows for the progression.
52:00
You know I, I agree it would be worthwhile to go back in and and get another biopsy and see what's changed.
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