Thema: Presse: An Unconventional Treatment of GBM
Presse: An Unconventional Treatment of GBM
Katja[a]
26.08.2003 11:55:55
Case Report: A Favorable Outcome for an Unconventional Treatment of Glioblastoma Multiforme
By Evan Ross, LAc
Standard care for a glioblastoma multiforme (GBM) is well known: surgery and then radiotherapy, occasionally followed by radiosurgery and ultimately some form of chemotherapy. The flavor of the month is presently timador, but prior to that it has ranged from high-dose tamoxifen to vincristine or BCNU. Unfortunately, standard care yields standard results: results that are usually unfavorable. One oncologist described treating a GBM conventionally as "reshuffling deck chairs on the Titanic after it hit the iceberg."
This case presentation describes treatment of a grade IV GBM in an unconventional yet remarkably effective manner. It is remarkable not only for its unusual Western medical approach, but also for its successful use of a vast array of complementary and alternative medicine modalities.
Presentation
A 25-year old, right-hand-dominant male with a history of bilateral retinoblastoma presented with severe unilateral headaches on the right, transient weakness and isolated focal convulsions of the left lower extremity. His left eye had been enucleated in 1972 and his right eye treated successfully with cryotherapy. The patient was evaluated for his current symptomatic presentation by his internist at Cedars-Sinai and sent for a neurologic consultation. Neurologic examination revealed a well-nourished, well-developed male in mild psychological distress. He reported job-related stress and difficulties with his girlfriend of several years, both of which he felt were contributing to his condition and which his psychotherapist reportedly diagnosed as panic attacks. Visual fields were intact in the eye not affected by the retinoblastoma. Sensation to pinprick was normal. Cranial nerve function was normal as well, but deep tendon reflexes were increased mildly on the left. There were also mild strength deficits of the left upper and lower extremities. An MRI was recommended, but the patient refused. Ten days later he presented again, his headaches having worsened and having been vomiting for several days. He was now experiencing mild respiratory distress and increasing weakness on the left side.
An MRI revealed a moderately well-circumscribed six-centimeter mass in the right frontal parietal region. No gross infiltration of the corpus callosum was noted, but there was significant edema resulting in its compression, as well as a severe midline shift. The fourth ventricle was also severely compressed. The patient was placed on Dilantin 300mg. TID, Decadron 8mg.TID and Zantac 75mg. BID prophylaxis for ulcer. A CT-guided stereotactic biopsy was performed at Cedars-Sinai two days later, and initial pathology favored GBM.
Treatment
The patient underwent a craniotomy at the University of California, San Francisco (UCSF) three weeks later, where a subtotal resection (<50%) was achieved. Subsequent pathology at UCSF, the University of California, Los Angeles and the Mayo Clinic confirmed GBM. The patient was offered participation in a clinical trial of radiation with a BCNU boost at UCSF but opted instead for a protocol at the Cedars-Sinai Comprehensive Cancer Center consisting of high-dose carboplatin (724mg/m2) with autologous stem cell rescue, combined with high-dose methotrexate (55g.). After six months of treatment, the tumor shrank by >50% postoperatively. Midline orientation and the fourth ventricle were found to be normal on MRI. The patient was neurologically asymptomatic at this point, aside from a 5% postsurgical deficit. Stereotactic radiosurgery was recommended, and the patient underwent the procedure at approximately 2000 Gy with no significant gains. After careful consideration, another craniotomy was recommended to remove the remains of tumor still visible on MRI. The patient requested Gliadel to be implanted during surgery, and the request was granted. However, during resection the fourth ventricle membrane was pierced. Having planned for this contingency prior to the procedure, 10 mg of methotrexate was injected into the CSF intra-operatively instead. The patient tolerated the procedure well, and a gross total resection with clear margins was achieved. Two more rounds of lower-dose methotrexate (25 g and 40 g, respectively) were administered subsequent to surgery prophylactically, and the patient was released from treatment one year and three months from diagnosis. Biannual MRI scans reveal no recurrence of disease, and the patient now practices integrative medicine himself at Cedars-Sinai.
Perhaps now is an appropriate time to tell the reader that the above-named patient is also the author of this article, seven plus years since diagnosis. Now let me inform you of all the things that do not appear in the above case report.
An Integrative Approach
One of the best things that one particular neurooncology team did for me was to say, "There´s really nothing we can do for you." While I do not advocate their approach, which was essentially to issue a death sentence, I took it as an opportunity to be proactive. I began rigorously pursuing a multitude of complementary medicine modalities. Indeed, if not for my integrative approach, I am convinced I would not be alive today. The most difficult part was that there was no one else familiar with the array of approaches I was employing who could guide me. I, therefore, consulted numerous experts, gathered as much information as I could, and when I was satisfied that I had heard the range of opinions, I sat in quiet meditation and listened to what my instincts told me would be most helpful to me. Ultimately my approach was to attempt to offset the side effects of aggressive Western treatment, allowing myself to tolerate higher doses at closer intervals with fewer side effects. The results were both a consistent regression of disease and increased quality of life, both during and after treatment. Indeed, even after two stem cell transplants performed six weeks apart, I did not require a blood transfusion, nor did I vomit, lose my hair or suffer other related symptoms that patients are often forced to endure, such as bacterial and fungal infections, insomnia, gastrointestinal problems and the like. I attribute these unusual results to the complementary modalities I carefully chose.
Body
In retrospect, my approach was quite systematic. I addressed the physical body - the disease itself - via Western medicine but also with herbs, supplements and diet to boost my immune system. I researched the herbs and supplements that were prescribed by an Ayurvedic physician (Ayurveda is to India as Oriental medicine is to China) so as to prevent any known herb-drug interactions and began eating a diet based on macrobiotic principles. The diet made it possible for my immune system to spend less time processing hormones and pesticides, thus providing more energy to fight the disease. I allowed myself to eat whatever my body would tolerate during chemotherapy in the interest of staying nourished as the first priority. Once the worst of the symptoms had passed, I resumed the macrobiotic approach. Acupuncture and yoga managed my nausea and pain, while light weightlifting and daily qi gong breathing exercises kept me feeling strong.
Mind
I addressed the mental and emotional aspects of my illness via psychotherapy, guided imagery and reading. I found a psychologist who specializes in the "Simonton method," created by physician and cancer survivor, O. Carl Simonton, MD. This approach to wellness allows the patient to create a health plan that focuses on understanding the factors that contributed to the onset of the disease without "blaming" the patient for its occurrence. It helped me to take responsibility so I could be empowered to change those things that were standing between me and full recovery. Guided imagery allowed me to "communicate" with an image I created of my tumor. By doing so I was able to discern to some degree why it was present, what it wanted and what it needed me to change about my life in order for it to go away. To the Western mind, this might seem like inner theatrics or pure imagination. It took me little time to realize that the answers to my questions were coming from somewhere within me - the same place the tumor came from. To confirm these newfound notions, I began reading the works of respected physicians and authors well known for their work in the field of mind-body medicine, from Bernie Siegal to Andrew Weil and Deepak Chopra.
Spirit
I addressed my spiritual issues in a very profound manner. I spent two days in a tepee with a shaman. While he by no means guaranteed my recovery, he helped me to understand the spiritual etiology of my illness. I consider my time with him to be a major turning point in my recovery - the point at which I changed from being a powerless victim of circumstance to an unusual soul who had been given the chance to transform his life in a trial by fire.
Upon my recovery, I made a commitment to be of service to others in some capacity. I decided to pursue an education in acupuncture and Oriental medicine, since I experienced such difficulty integrating traditional and complementary medicine myself due to the lack of people educated in both subjects. Now more than seven years later, I treat many patients with cancer in my own practice at Cedars-Sinai. Surely it would have been easier to open a small office somewhere in Beverly Hills, but I chose to pioneer the integration of Oriental medicine into mainstream culture by opening my practice at Cedars-Sinai. I consider it vitally important that my practice be located at a major institution like Cedars-Sinai, not only because of the opportunity to collaborate with some of the best physicians in the world, but because it is crucial that this country learn to practice these two systems of medicine together so that we can help patients to take advantage of the best of each in a safe, managed environment - an environment sorely missing from my own treatment plan.
Conclusion
My healing incorporated unconventional Western and non-Western treatments. There is nothing miraculous about me as an individual. Rather, the miraculous nature of this case presentation lies in the successful integration of two types of medicine, each of which has advantages and disadvantages. I have no doubt that my "favorite outcome" was achieved by the combination of both, creating a sum greater than either of the parts.
--------------------------------------------------------------------------------
Evan Ross, LAc, is a board-certified acupuncturist, herbalist and doctor of Oriental medicine. He is the Complementary and Alternative Medicine Advisor to the National Brain Tumor Foundation and serves on the Professional Advisory Board for the Center for Integrative Health, Medicine and Research in Los Angeles. He maintains a private practice in the medical towers at Cedars~Sinai Medical Center, specializing in complementary oncology care and pain management.
© Copyright 2000-2003 Cedars-Sinai Health System. All rights reserved.
Privacy Policy
By Evan Ross, LAc
Standard care for a glioblastoma multiforme (GBM) is well known: surgery and then radiotherapy, occasionally followed by radiosurgery and ultimately some form of chemotherapy. The flavor of the month is presently timador, but prior to that it has ranged from high-dose tamoxifen to vincristine or BCNU. Unfortunately, standard care yields standard results: results that are usually unfavorable. One oncologist described treating a GBM conventionally as "reshuffling deck chairs on the Titanic after it hit the iceberg."
This case presentation describes treatment of a grade IV GBM in an unconventional yet remarkably effective manner. It is remarkable not only for its unusual Western medical approach, but also for its successful use of a vast array of complementary and alternative medicine modalities.
Presentation
A 25-year old, right-hand-dominant male with a history of bilateral retinoblastoma presented with severe unilateral headaches on the right, transient weakness and isolated focal convulsions of the left lower extremity. His left eye had been enucleated in 1972 and his right eye treated successfully with cryotherapy. The patient was evaluated for his current symptomatic presentation by his internist at Cedars-Sinai and sent for a neurologic consultation. Neurologic examination revealed a well-nourished, well-developed male in mild psychological distress. He reported job-related stress and difficulties with his girlfriend of several years, both of which he felt were contributing to his condition and which his psychotherapist reportedly diagnosed as panic attacks. Visual fields were intact in the eye not affected by the retinoblastoma. Sensation to pinprick was normal. Cranial nerve function was normal as well, but deep tendon reflexes were increased mildly on the left. There were also mild strength deficits of the left upper and lower extremities. An MRI was recommended, but the patient refused. Ten days later he presented again, his headaches having worsened and having been vomiting for several days. He was now experiencing mild respiratory distress and increasing weakness on the left side.
An MRI revealed a moderately well-circumscribed six-centimeter mass in the right frontal parietal region. No gross infiltration of the corpus callosum was noted, but there was significant edema resulting in its compression, as well as a severe midline shift. The fourth ventricle was also severely compressed. The patient was placed on Dilantin 300mg. TID, Decadron 8mg.TID and Zantac 75mg. BID prophylaxis for ulcer. A CT-guided stereotactic biopsy was performed at Cedars-Sinai two days later, and initial pathology favored GBM.
Treatment
The patient underwent a craniotomy at the University of California, San Francisco (UCSF) three weeks later, where a subtotal resection (<50%) was achieved. Subsequent pathology at UCSF, the University of California, Los Angeles and the Mayo Clinic confirmed GBM. The patient was offered participation in a clinical trial of radiation with a BCNU boost at UCSF but opted instead for a protocol at the Cedars-Sinai Comprehensive Cancer Center consisting of high-dose carboplatin (724mg/m2) with autologous stem cell rescue, combined with high-dose methotrexate (55g.). After six months of treatment, the tumor shrank by >50% postoperatively. Midline orientation and the fourth ventricle were found to be normal on MRI. The patient was neurologically asymptomatic at this point, aside from a 5% postsurgical deficit. Stereotactic radiosurgery was recommended, and the patient underwent the procedure at approximately 2000 Gy with no significant gains. After careful consideration, another craniotomy was recommended to remove the remains of tumor still visible on MRI. The patient requested Gliadel to be implanted during surgery, and the request was granted. However, during resection the fourth ventricle membrane was pierced. Having planned for this contingency prior to the procedure, 10 mg of methotrexate was injected into the CSF intra-operatively instead. The patient tolerated the procedure well, and a gross total resection with clear margins was achieved. Two more rounds of lower-dose methotrexate (25 g and 40 g, respectively) were administered subsequent to surgery prophylactically, and the patient was released from treatment one year and three months from diagnosis. Biannual MRI scans reveal no recurrence of disease, and the patient now practices integrative medicine himself at Cedars-Sinai.
Perhaps now is an appropriate time to tell the reader that the above-named patient is also the author of this article, seven plus years since diagnosis. Now let me inform you of all the things that do not appear in the above case report.
An Integrative Approach
One of the best things that one particular neurooncology team did for me was to say, "There´s really nothing we can do for you." While I do not advocate their approach, which was essentially to issue a death sentence, I took it as an opportunity to be proactive. I began rigorously pursuing a multitude of complementary medicine modalities. Indeed, if not for my integrative approach, I am convinced I would not be alive today. The most difficult part was that there was no one else familiar with the array of approaches I was employing who could guide me. I, therefore, consulted numerous experts, gathered as much information as I could, and when I was satisfied that I had heard the range of opinions, I sat in quiet meditation and listened to what my instincts told me would be most helpful to me. Ultimately my approach was to attempt to offset the side effects of aggressive Western treatment, allowing myself to tolerate higher doses at closer intervals with fewer side effects. The results were both a consistent regression of disease and increased quality of life, both during and after treatment. Indeed, even after two stem cell transplants performed six weeks apart, I did not require a blood transfusion, nor did I vomit, lose my hair or suffer other related symptoms that patients are often forced to endure, such as bacterial and fungal infections, insomnia, gastrointestinal problems and the like. I attribute these unusual results to the complementary modalities I carefully chose.
Body
In retrospect, my approach was quite systematic. I addressed the physical body - the disease itself - via Western medicine but also with herbs, supplements and diet to boost my immune system. I researched the herbs and supplements that were prescribed by an Ayurvedic physician (Ayurveda is to India as Oriental medicine is to China) so as to prevent any known herb-drug interactions and began eating a diet based on macrobiotic principles. The diet made it possible for my immune system to spend less time processing hormones and pesticides, thus providing more energy to fight the disease. I allowed myself to eat whatever my body would tolerate during chemotherapy in the interest of staying nourished as the first priority. Once the worst of the symptoms had passed, I resumed the macrobiotic approach. Acupuncture and yoga managed my nausea and pain, while light weightlifting and daily qi gong breathing exercises kept me feeling strong.
Mind
I addressed the mental and emotional aspects of my illness via psychotherapy, guided imagery and reading. I found a psychologist who specializes in the "Simonton method," created by physician and cancer survivor, O. Carl Simonton, MD. This approach to wellness allows the patient to create a health plan that focuses on understanding the factors that contributed to the onset of the disease without "blaming" the patient for its occurrence. It helped me to take responsibility so I could be empowered to change those things that were standing between me and full recovery. Guided imagery allowed me to "communicate" with an image I created of my tumor. By doing so I was able to discern to some degree why it was present, what it wanted and what it needed me to change about my life in order for it to go away. To the Western mind, this might seem like inner theatrics or pure imagination. It took me little time to realize that the answers to my questions were coming from somewhere within me - the same place the tumor came from. To confirm these newfound notions, I began reading the works of respected physicians and authors well known for their work in the field of mind-body medicine, from Bernie Siegal to Andrew Weil and Deepak Chopra.
Spirit
I addressed my spiritual issues in a very profound manner. I spent two days in a tepee with a shaman. While he by no means guaranteed my recovery, he helped me to understand the spiritual etiology of my illness. I consider my time with him to be a major turning point in my recovery - the point at which I changed from being a powerless victim of circumstance to an unusual soul who had been given the chance to transform his life in a trial by fire.
Upon my recovery, I made a commitment to be of service to others in some capacity. I decided to pursue an education in acupuncture and Oriental medicine, since I experienced such difficulty integrating traditional and complementary medicine myself due to the lack of people educated in both subjects. Now more than seven years later, I treat many patients with cancer in my own practice at Cedars-Sinai. Surely it would have been easier to open a small office somewhere in Beverly Hills, but I chose to pioneer the integration of Oriental medicine into mainstream culture by opening my practice at Cedars-Sinai. I consider it vitally important that my practice be located at a major institution like Cedars-Sinai, not only because of the opportunity to collaborate with some of the best physicians in the world, but because it is crucial that this country learn to practice these two systems of medicine together so that we can help patients to take advantage of the best of each in a safe, managed environment - an environment sorely missing from my own treatment plan.
Conclusion
My healing incorporated unconventional Western and non-Western treatments. There is nothing miraculous about me as an individual. Rather, the miraculous nature of this case presentation lies in the successful integration of two types of medicine, each of which has advantages and disadvantages. I have no doubt that my "favorite outcome" was achieved by the combination of both, creating a sum greater than either of the parts.
--------------------------------------------------------------------------------
Evan Ross, LAc, is a board-certified acupuncturist, herbalist and doctor of Oriental medicine. He is the Complementary and Alternative Medicine Advisor to the National Brain Tumor Foundation and serves on the Professional Advisory Board for the Center for Integrative Health, Medicine and Research in Los Angeles. He maintains a private practice in the medical towers at Cedars~Sinai Medical Center, specializing in complementary oncology care and pain management.
© Copyright 2000-2003 Cedars-Sinai Health System. All rights reserved.
Privacy Policy
Katja[a]
Anne[a]
21.03.2004 16:43:29
J Neurooncol. 2003 Jan;66(1-2):139-46.
CD44 expression and tumour cell density correlate with response to tamoxifen/carboplatin chemotherapy in glioblastomas.
Hagel C, Park SH, Puchner MJ, Stavrou D.
Institute of Neuropathology, University Klinicum Hamburg-Eppendorf, Hamburg, Germany. hagel@uke.uni-hamburg.de
In order to identify response predictors for a post-operative glioblastoma therapy consisting of tamoxifen, carboplatin and radiotherapy, expression of 12 antigens was evaluated in 36 newly diagnosed tumours and 13 recurrences. Results were correlated with the clinical course of the disease. Antigen expression was assessed immunohistochemically for CD44s, TGF-beta2, TGF-alpha, progesterone receptor, estrogen receptor, EGFR, urokinase, urokinase inhibitor 1, CD87, p53 protein and Ki-67. Vessel density was determined by labelling of endothelia with von Willebrand factor. Response to chemotherapy correlated positively with cell density (p < 0.05) and negatively with CD44 over-expression (p < 0.02). Further, a positive correlation between age and CD44 expression (p < 0.05) and a negative correlation between age and p53 accumulation (p < 0.01) was found. In tumour recurrences expression of CD44 was significantly higher in local recurrences than in distant multifocal recurrences (p < 0.02), suggesting that CD44 may predominantly be associated with cell adhesion in glioblastomas.
CD44 expression and tumour cell density correlate with response to tamoxifen/carboplatin chemotherapy in glioblastomas.
Hagel C, Park SH, Puchner MJ, Stavrou D.
Institute of Neuropathology, University Klinicum Hamburg-Eppendorf, Hamburg, Germany. hagel@uke.uni-hamburg.de
In order to identify response predictors for a post-operative glioblastoma therapy consisting of tamoxifen, carboplatin and radiotherapy, expression of 12 antigens was evaluated in 36 newly diagnosed tumours and 13 recurrences. Results were correlated with the clinical course of the disease. Antigen expression was assessed immunohistochemically for CD44s, TGF-beta2, TGF-alpha, progesterone receptor, estrogen receptor, EGFR, urokinase, urokinase inhibitor 1, CD87, p53 protein and Ki-67. Vessel density was determined by labelling of endothelia with von Willebrand factor. Response to chemotherapy correlated positively with cell density (p < 0.05) and negatively with CD44 over-expression (p < 0.02). Further, a positive correlation between age and CD44 expression (p < 0.05) and a negative correlation between age and p53 accumulation (p < 0.01) was found. In tumour recurrences expression of CD44 was significantly higher in local recurrences than in distant multifocal recurrences (p < 0.02), suggesting that CD44 may predominantly be associated with cell adhesion in glioblastomas.
Anne[a]