Question 1

Oligodendroglioma after partial removal: treatment tactics

Accepted Answer

A 24-year-old patient after partial resection of an oligodendroglioma. The tumor was not completely removed due to the risk of damaging important areas of the brain. The neoplasm continues to grow, provoking epileptic seizures.
Available data: medical report, histological study result, postoperative head MRI.

Problem statement

What treatment should be followed after the operation of partial removal of a malignant brain tumor?

Selected Format

Written consultation of two experts: a neurosurgeon and an epileptologist.

Outcome

The German neurosurgeon, director of the university clinic, gave an assessment of the therapy and spoke about the possibilities of its expansion:
This is a diffusely infiltrating glioma. The position of the tumor is unfavorable, it affects the location of important speech centers, especially in right-handers. The tumor was partially resected. It is not possible to determine from MRI images whether areas accumulating contrast have been removed. Images with contrast do not indicate significant contrast accumulation. Most of the infiltrative growing tumor was not removed. Options for surgical treatment with complete tumor removal could only be if the patient was left-handed, had no speech impairment, and had confirmed right-sided dominance of speech (this is very rare). In this case, radiation therapy with concomitant chemotherapy should be initiated.

Professor neurologist, head of the largest epileptology clinic in Germany, gave a conclusion that coincides with the opinion of the neurosurgeon:
With a confirmed diagnosis of oligodendroglioma (IDH-mutated, codeletion 1p19q) after resection not within healthy tissues, there are reasonable indications for additional radiotherapy and chemotherapy. The recommendation calls for radiotherapy first followed by maintenance triple PCV chemotherapy. Additional epilepsy treatment is not required, it is a life-saving therapy that should prevent further epileptic seizures.

Medconsonline Comment

The purpose of the consultation was to receive recommendations on the possibilities of further treatment after incomplete removal of a malignant brain neoplasm. Both consultants agreed that combined radiochemotherapy was necessary.

Consulting expert

Hans Clusmann

Professor, Dr.Med., Director of the Neurosurgery Clinic, Uniklinik RWTH Aachen

Question 2

Scoliosis complicated by spinal stenosis

Accepted Answer

A 70-year-old female patient with Parkinson's disease, scoliosis and spinal stenosis. Complaints of loss of strength and sensitivity of the back and legs. The patient is almost immobilized due to severe, burning pains in the gluteal region. The patient is able to take only a few steps, after which she must immediately find support or sit down. Operative treatment was recommended, but in view of the presence of Parkinson's disease, surgery under general anesthesia was refused due to the risks of cerebral complications.

Problem statement

The possibility of surgical treatment under local anesthesia.

Selected Format

Written consultation

Outcome

The consultation was conducted by Professor Neurosurgeon, Director of the University Clinic of Neurosurgery. After reviewing the spine MRI and a detailed description of the patient's complaints, the consultant gave an optimistic prognosis regarding the surgical intervention. The professor believes that there are no contraindications for intervention under general anesthesia. Qualification of anesthesiologists, technical and medical equipment of his clinic make it possible to carry out operations without risks for patients with cerebral disorders.
The professor believes that in this case it is hardly possible to reduce pain symptoms by conservative methods. In the presence of degenerative changes in the intervertebral discs, instability of one of the segments of the spine can be assumed. Additional functional diagnostics should be carried out, the results of which will also be decisive for choosing the operation format.
It is not recommended to perform the operation under local anesthesia, as the intervention possibilities will be limited and will not bring the expected effect.

Medconsonline Comment

The purpose of the consultation was to confirm the diagnosis and indications for surgical treatment. It was also necessary to find a clinic where a patient with Parkinson's disease could be operated on. Based on the consultation results the patient decided to have surgery in Germany.

Consulting expert

Hans Clusmann

Professor, Dr.Med., Director of the Neurosurgery Clinic, Uniklinik RWTH Aachen

Question 3

Meningioma: management strategy in the absence of clinical complaints

Accepted Answer

After a generally healthy and complaint-free 41-year-old female patient's blood tests accidentally revealed elevated prolactin levels, she was scheduled for brain MRI to rule out a prolactin-producing pituitary tumor (prolactinoma). Suspected prolactinoma was not confirmed, but another incidental finding was a meningioma - a tumor of the cerebral membrane.

Despite the absence of any complaints, the young woman sought the opinion of a neurosurgeon to assess her 1-cm meningioma and health risks associated with it. MRI scans of the brain and their description were provided for evaluation.

Problem statement

CyberKnife radiation treatment had been recommended in Russia. Was this recommendation well-grounded?
Might surgery be necessary instead?
What could be the consequences in case of non-treatment?

Selected format

Written consultation

Outcome

The images were re-evaluated by Prof. Dr. Hans Clusmann, Director of Neurosurgery Department at Aachen University Hospital The consulting expert confirmed the diagnosis of meningioma, as well as its size, specifying its localization in the area of the sylvian aqueduct (the sphenoid bone). The professor did not see any urgent indications for treatment, either surgical or radiation, because, in his opinion, the tumor did not yet have a compressive impact on the brain structures. Only monitoring by once-in-a-year MRI was recommended. Surgery was not indicated until the mass grew up to 2 cm in size. Radiosurgery might only be considered if there were serious contraindications against surgery, which was in that case considered a more effective method of tumor removal.

The consultant did not see any connection between the mass and an increase in prolactin, so he recommended consulting an endocrinologist. However, he found a small cystic structure in the pituitary gland, which was also to be monitored by radiology exams.

Medconsonline comment

From our point of view, the goal of the remote consultation, which was to determine the risks associated with a brain tumor and the need for its radical removal, was achieved. The independent opinion of a highly qualified specialist, such as the head of one of the leading neurosurgical clinics in Germany, enabled the patient to choose a wait-and-watch strategy for the tumor, which due to its small size did not pose a health risk.

Consulting expert

Hans Clusmann

Professor, Dr.Med., Director of the Neurosurgery Clinic, Uniklinik RWTH Aachen