Virtual Brain Tumor Board Podcasts

Right Thalamic Lesion, 23 year old Female

VBTB — Wed, 15 Apr 2009 16:28:17 GMT

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This 23 YO female patient of Dr. Michaels' presented with a lesion in the right thalamus and some hemisensory disturbance. This underwent biopsy stereotactically and discussion was held about management.

Suprasellar/Skull Base Masses, 53 year old Female

VBTB — Wed, 22 Apr 2009 14:40:07 GMT

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This 53 YO female patient of Dr. Michaels' presented with an extensive skull base mass that was initially operated back in October 2006 with debulking. She had post radiation therapy. She now presents with recurrence down into the craniocervical junction with recurrence in the frontal fossa as well. Discussion was had about potential treatment options for a recurrent debulking due to relief of compression against the brain stem vs supportive care only.

Mass in the Right Cerebellum, 87 year old Male

VBTB — Wed, 29 Apr 2009 13:33:22 GMT

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This is an 87 YO male patient of Dr. Sorenson's who presented with dizziness and unsteadiness. He had a lesion in the posterior fossa initially felt to be possibly a stroke. On further imaging it appeared to be consistent with a tumor. It was felt that this might be a metastasis from an unknown primary since systemic work-up was negative. Surgery was performed and the pathology showed glioblastoma. Discussion was being had with the family about whether they wished to pursue any additional therapy.

Pineal Mass, 31 year old Female

VBTB — Wed, 06 May 2009 14:25:28 GMT

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This 31 YO female patient of Dr. Michael's presented with headaches and a lesion in the pineal region. Tumor markers were negative. At this point observation alone is planned.

Acromegaly, 80 year old Female

VBTB — Wed, 13 May 2009 13:36:50 GMT

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This is an 80 YO female with a pituitary mass and a brief history of acromegaly. This has been treated medically with Octreotide and the patient's tumor has improved radiographically. The significant lesion has decreased markedly in size but she still has some lesion in the cavernous sinus. The question is whether other adjuvant therapy should be done. Discussion centered around the fact that medical therapy will need to continue for the indefinite future. She also would be a candidate for radiotherapy, if she is inclined to do so. This could probably be done with Gamma Knife Radiosurgery in a safe manner. She has opted to be watched for the present time on the medical therapy and serial scans.

Large Right Skull Base Mass, 30 year old Female

VBTB — Wed, 20 May 2009 13:40:05 GMT

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30 year old Iraqi female with history of progressive vision loss and headaches for 5 years. She had an MRI which showed a skull base mass but could not gain access to definitive care due to the war in Iraq. She currently has no light perception in the right eye, and left eye vision is limited to the nasal field only. Her headaches are also progressive and she has balance issues related to her vision. She was referred to our center for definitive care via contacts within the US military.

Recap of surgery for large right skull base mass in 30 year old female

VBTB — Thu, 21 May 2009 13:04:56 GMT

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Pre-operative Images
These preoperative images demonstrate the large, complex right frontotemporal skull base mass that encases the internal carotid artery, middle cerebral artery, and branches of the middle cerebral artery on the patient's right side. Images also document significant midline shift as well as compression of the optic nerves. Digital subtraction arteriogram pictures demonstrate the significant vascularity associated with the tumor with displacement of most of the normal arterial tree in the middle cerebral distribution.

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Recurrent right frontal tumor in patient with previous low grade glioma, 25 year old Female

VBTB — Wed, 27 May 2009 13:47:28 GMT

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This 25 YO female previously presented to conference with a history of a right frontal low grade oligoastrocytoma that was operated several years ago. She presented with a nodular recurrence in the right lateral anterior horn of the ventricle and this was operated on. Pathology now appears to be a grade 3 astrocytoma. She has undergone radiation therapy and now has begun chemotherapy. She has a new nodular type area in the posterior more lateral component of the margin of resection. Discussion centered about watching this, seeing the effect of chemotherapy, or going back in and surgically removing this. There was some discussion about the ?pseudo progression? that could be seen after radiotherapy and particularly with Temozolomide. However, most individuals felt that this likely represented tumor, although the exact grade cannot be determined since it may or may not reflect that is seen in other areas.

Left temporal tumor and history of malignant transformation of an oligodendroglioma, 60 year old Male

VBTB — Wed, 03 Jun 2009 12:49:53 GMT

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This is a 60 YO male with a history of an oligodendroglioma diagnosed 11 years ago. He underwent radiation therapy after stereotactic biopsy. He has been followed. In 2007 he presented with a focal recurrent mass. This was operated on and was found to be a high-grade glioma. Since he had previous radiation he received brachytherapy to the cavity. He also was placed on concurrent Temozolomide. He did well, weaned off steroids, and performance status improved; however, he most recently presented 6 months after brachytherapy with lethargy, headache, and increasing speech problems. Scan demonstrates marked T2 signal abnormality and also a shaggy appearing enhancement of the T1 pattern around the cavity. Discussion was held whether this represents radiation necrosis versus recurrent tumor. It was felt that a biopsy would be needed to establish definitive diagnosis but most likely would have some mixture of both pathologies. The patient is really not desirous of further surgery at the present time. He is also not sure about chemotherapy. It was opted to place him on steroids to see if his performance status improves then revisit the idea of a different chemotherapy since there has been recurrent growth and, if this is tumor, it would be a failure of the chemotherapy.

Right Parietal Recurrent Mass in a Long Term GBM Survivor, 53 year old Male

VBTB — Wed, 10 Jun 2009 13:38:16 GMT

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This 53 year old male patient of Dr. Sills' is a long-term survivor with glioblastoma. He was first diagnosed in 1998 at which time he underwent surgery with radiation therapy and combined chemotherapy with an unknown agent, but suspected to be an IV agent. He had a recurrence about a year later and had additional surgery. He then presented to our center and in 2001 had surgery for what turned out to be radiation necrosis. He developed an external hydrocephalus that was shunted. He has been stable since that time with a reasonable performance status and baseline left hemiparesis, but full independence of his ADLs. He has been scanned every six months with no evidence of recurrence. Most recently, he has had some headache and some worsened left hemiparesis. A scan now shows signal intensity around the previous resection cavity. Discussion was had that this most likely represents tumor at this late date. It was recommended that a biopsy be done, however, to prove that this indeed is active tumor, particularly given his long term survival status. He has never been treated with Temozolomide so if this proves to be glioblastoma and, in particular, if he has appropriate receptor status, then this might be the best initial agent for him.

Suprasellar Mass, 53 year old Female

VBTB — Tue, 16 Jun 2009 21:36:58 GMT

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This 53 year old female patient presented with headaches. She had a suprasellar mass noted. Endocrine work-up was normal. She underwent an endoscopic transventricular biopsy, since the mass presented near the foramen of Monroe. This turned out to be a glioblastoma. Discussion was had about options at this point. It was felt that aggressive surgical debulking would be very unlikely to help her clinical situation. Recommendation was for standard fractionated external beam radiotherapy with combined chemotherapy with perhaps an accelerated scheduled of Temozolomide given the lack of surgical options.

Fourth Ventricle/Pineal Region Masses, 56 year old Female

VBTB — Wed, 24 Jun 2009 14:43:51 GMT

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This 56 year old female patient presented with headaches and some neck pain. She had a scan done that was suspicious for a cranial mass and also had a very small, well circumscribed lesion in the 4th ventricle. Review of the images suggested this is quite small and the exact diagnosis is obscure. Given the symptom pattern, it was felt that this was not likely to be the cause since she has no hydrocephalus. Consensus of the panel was for observation alone with follow-up imaging in short term since the rest of her neural axis appears clear

Cervical Spine Mass, 47 year old Female

VBTB — Wed, 01 Jul 2009 13:02:04 GMT

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This 47 year old female patient of Dr. Weaver's presented with some hand weakness, which developed over several weeks time. Over the past six months, the patient perceives that this has gotten slightly worse, although objectively on testing this has not been noted by her surgeon or her neurologist. She has had a cervical spine lesion noted that is well circumscribed and brightly enhancing. Metastatic work-up and imaging of the rest of the neural axis has been negative. CSF sample has also been negative. Discussion was had about the merits of biopsy versus observation. The panel was fairly evenly divided between these two. Those who favored observation cited the patient's clinical stability and lack of image progression and suggested immunosuppressive therapy empirically to see if her symptoms would stabilize or improve. Those who favored biopsy felt that this might likely be a neoplasm given the brisk enhancement and if the patient symptomatically feels she is progressive, then a diagnosis is in order.

Pituitary Stalk Mass, Female in her 40's

VBTB — Wed, 08 Jul 2009 12:59:31 GMT

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This is a patient in her 40's who presented with headache and was noted on MRI to have a mass in the pituitary stalk. Endocrine panel is fairly unimpressive at this point and visual function is normal. Discussion was had about a possible differential of the mass reflecting an inflammatory process such as lymphocytic hypophysitis or sarcoidosis, lymphoma, or metastatic disease. Again the panel is somewhat divided but the overall flavor was one of observation with follow-up serial imaging to see if the lesion progresses or if new symptoms develop. It was felt that if biopsy is done it would need to be done via transcranial route rather than transsphenoidally and that pituitary function is likely to be made worse by any surgical procedure.

Multiple Thoracic Lesions, 68 year old Male

VBTB — Wed, 15 Jul 2009 13:18:08 GMT

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This 68 year old male patient was referred with a history of multiple back surgeries involving fusion, the last of which was in 2001. He has now presented with some progressive flank pain, back pain, as well as some subjective weakness in the proximal legs. MRI obtained shows multiple lesions in the thoracic spine that are plaque-like in some areas and more discreet in other areas. Systemic work-up has been negative except for some calcified granulomas in the lung. The CSF profile was also benign. The panel felt that a biopsy would be appropriate to make a diagnosis given the extent of disease and the fact that his symptoms have progressed. Observation could also be considered with further follow-up imaging and repeat CSF sampling.

Left Parietal Mass in GBM Patient, 48 year old Female

VBTB — Wed, 22 Jul 2009 12:40:20 GMT

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This 48 year old female was diagnosed a little over three years ago with glioblastoma. She was treated with debulking surgery, radiotherapy with combined Temozolomide, and then six months of adjuvant Temozolomide. She did very well until October of 2008 when she presented with a recurrent mass in the left parietal region. This underwent Gamma Knife Radiosurgery due to its focal nature. She was also then placed on Avastin. She has improvement on MRI appearance of the mass and she stabilized clinically. She has now presented with some contralateral motor weakness that has been quite devastating to the point that she is wheelchair bound. This has been associated with some increased enhancement around the margins of then previous tumor area and increased signal on T2 MRI. Discussion was had that this likely represents some extra recurrent tumor with the possibility of radiation necrosis from the Gamma Knife. Biopsy was felt to be most likely indicative of both of these processes. The question is whether it would change management. The overall flavor was for treatment with steroids and perhaps other adjunct such as hyperbaric oxygen or heparinoid compounds for possible radiation necrosis with continuation of her chemotherapy regimen. It was not felt that going back to Temozolomide would be helpful since this likely represents recurrent tumor as a failure of Temozolomide despite the previous time of treatment. The surgical options were felt to be quite limited given the deep location of the lesion.

Bifrontal/Biparietal Lesion, 66 year old Male

VBTB — Wed, 26 Aug 2009 13:36:00 GMT

This 66 YO WM presented with a bifrontal parietal region lesion. Surgery was undertaken and the pathology was consistent with a plasmacytoma. The tumor that was superficial to the inner cortex was resected and cosmesis was achieved using a titanium cranioplasty. He is now set to undergo radiation therapy and the response should be excellent.

Left Frontal Mass, 21 year old Female

VBTB — Wed, 02 Sep 2009 14:30:00 GMT

This 21 YO female patient of Dr. Helms & Dr. Sorenson presented with headaches and vision loss. A cystic lesion was seen with a small nodule. This was operated upon and pathology was of a pleomorphic xanthoastrocytoma. Discussion was had about the pathologic features of this lesion and plans for adjuvant therapy.

Right Parietal Mass, 57 year old Female

VBTB — Wed, 23 Sep 2009 14:12:00 GMT

This 57 YO female patient of Dr. Sills has been discussed at a previous conference. She has a remote history more than 30 years ago of melanoma and has had a more recent history of demyelinating disease. She presented with bilateral adrenal masses and biopsy of this revealed lymphoma. The brain lesion was biopsied via stereotactic approach and the pathology was also consistent with a B-cell lymphoma. She has received two cycles of high-dose Methotrexate therapy intravenously and has shown a dramatic response to her intracranial disease. Interestingly enough, she did not have any change in the lesion on high dose steroids prior to the biopsy. She is currently planned to have her CSF samples for cytology and, if positive, she will have intrathecal therapy added as well. Otherwise, the plan is to continue five cycles of intravenous chemotherapy for the brain lesion and then consider adjuvant chemotherapy for the adrenal lesions, which are felt to be metastatic from the brain.

Thoracic Spine Mass, 58 year old Male

VBTB — Tue, 29 Sep 2009 16:31:00 GMT

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This 58 YO male patient of Dr. Michael's presented with back pain and some weakness in the legs. MRI imaging revealed a cystic and solid lesion near the conus. This was operated upon and found to be fairly well encapsulated. Pathology was an ependymoma. Gross total resection was performed. Based on six month postoperative imaging, this lesion looks stable. Discussion was had about possible adjuvant therapy but it was opted to watch this for now with irradiation at the first sign of any progression.

Left Jugular Bulb Enhancement, 44 year old Female

VBTB — Wed, 11 Nov 2009 15:24:00 GMT

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This 44 YO female presented with double vision and headaches. Imaging of the brain revealed left jugular bulb enhancement. A CT scan was performed which revealed no abnormal bony destruction. It was felt that this likely represented thrombosis within the jugular bulb. A lumbar puncture was performed and her pressure was found to be over 35. An MRV confirmed obstruction of the left sigmoid sinus jugular bulb region. She was started on anticoagulation in addition to Diamox therapy.

Left Infraorbital Mass, 75 year old Male

VBTB — Wed, 25 Nov 2009 14:38:00 GMT

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This 75 YO male with a left infraorbital mass presented with numbness in the V2 distribution. He has a prior history of squamous cell carcinoma. Biopsy of the left infraorbital nerve was performed and it was positive for perineural spread. PET scan was negative for systemic disease. Discussion was had regarding the appropriate options. The patient did undergo Gamma Knife Radiosurgery to the trigeminal region in addition to this being followed by fractionated radiation therapy. The patient is now over one year out and is doing well with no evidence of local disease.

Sacral Nerve Sheath Tumor, 62 year old Male

VBTB — Mon, 02 Mar 2009 01:47:10 GMT

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This is a 62 YO male patient of Dr. Weaver?s who presented with severe back and pelvic pain. He was found to have a large pre-sacral lesion. Imaging characteristics were suggestive of a possible nerve sheath tumor. Stereotactic biopsy had already been done and the diagnosis was a ganglioneuroma. This was approached from an anterior peritoneal approach with an internal capsular debulking and gross total resection. No further adjuvant therapy is needed given that pathology showed a low grade lesion.

Oligodendroglioma, 55 year old Male

VBTB — Mon, 02 Mar 2009 01:47:33 GMT

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This is a 55 YO male patient of Dr. Watridge's who presented with the relatively acute onset of speech deficit and hemiparesis. He was unable to get an MRI due to a pacemaker. CT revealed a stippled calcification within a lesion with some acute hemorrhage. This was a very large lesion and impacted the posterior horn of the lateral ventricle on the left side. It was opted to explore this surgically and at surgery a firm, rubbery lesion was found. It did have a plane of separation from surrounding tissue. There was some subacute hemorrhage. The final pathology appears to be consistent with a low-grade oligodendroglioma, which was felt to fit the patient?s clinical presentation. No further adjuvant therapy was recommended at the present time.

Orbital Apex Lesion, 75 year old Female

VBTB — Mon, 02 Mar 2009 01:49:01 GMT

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This 75 YO female was submitted from Australia who presented with some visual decline as well as a partial 3rd and 6th nerve palsy on the right side. Imaging revealed a lesion in the orbital apex and cavernous sinus on the right side. It was opted to explore this with an open procedure and a firm, grayish appearing mass had been found. Pathology came back with chronic inflammation in the respiratory epithelium and wall of the sinus with no evidence of malignancy. Discussion was had about further adjuvant therapy. It was recommended a short course of steroids with consideration of a full work-up of possible sinus disease. A research reminder was also carried out for 3 open studies including the quality of life study with patients and caregivers, the newly diagnosed glioblastoma Gliadel/Temozolomide study, and the metastatic tumor Gliadel study.

Right Posterior Frontal Lesion, 66 year old Female

VBTB — Mon, 02 Mar 2009 01:49:20 GMT

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This 66 YO female with a right posterior frontal lesion presented with some apraxia. The lesion was largely nonenhancing with only a small amount of enhancement posteriorly. Functional mapping suggested close localization but no overlap with leg areas. It was opted to explore this via open excisional biopsy. This was done and at surgery there were found to be no significant borders or planes around the lesion. Intraoperative pathology was of an intermediate grade glioma. Subtotal resection was performed. Final pathology was suspicious of an anaplastic astrocytoma. Based on this pathology, it was recommended that concurrent radiation/chemotherapy be delivered. Post radiation would be just as well, given the patient?s advanced age and the subtotal resection.

Cystic Craniopharyngioma, 49 year old Female

VBTB — Mon, 02 Mar 2009 01:53:25 GMT

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This 49 YO female who has been previously presented with a suprasellar mass that was a cystic craniopharyngioma drained endoscopically. She presented with recurrent drainage procedure. Initially it was aspirated postoperatively down to a small size. She represented for another evaluation and it had reaccumulated. She was unable to have an aspiration done. Discussion was had about possible approaches at this point. It was recommended that she could have a craniotomy for removal of the lesion. She could have simply declotting of the cannula catheter with repeated aspiration, or could simply go ahead with external beam radiotherapy. Radiation oncology commented that the risk of visual decline should be fairly low. Opinion was divided on attempted further manipulation of the catheter versus continuing with radiotherapy at this time.

Recurrent Glioblastoma, 45 year old Female

VBTB — Mon, 02 Mar 2009 01:53:42 GMT

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This is a 45 YO male with a history of glioblastoma that has been operated. He is undergoing combined chemo/radiotherapy. He presented with some new lesions seen on the right side on FLAIR and T2 image. No T1 enhancing image was seen. Discussion was had that this likely represented real tumor progression and not pseudo-progression or simply post radiation change. It was opted to go ahead and complete his course of radiotherapy/Temozolomide, and then re-image him several weeks later to assess whether there would be any role for recurrent debulking.

Brain Lesion in the Left Temporal Area with Unusual Dreams, 55 year old Male

VBTB — Mon, 02 Mar 2009 02:19:28 GMT

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This 55 YO male patient of Dr. Watridge presented with some terrifying dreams and was found to have a brain lesion in the left temporal area. This appears to be cystic. Discussion was had and the overall recommendation was for either observation or an open excisional biopsy, depending on the patient?s preference. The overall feeling that this is likely a glioma of some type and will likely come to diagnosis by biopsy at some point.

Temporal and Pontine Lesions, 47 year old Female

VBTB — Mon, 02 Mar 2009 02:19:37 GMT

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This 47 YO female patient of Dr. Watridge presented with multiple complaints of different symptoms including headache and vague complaints of fatigue. She had an MRI done several years ago that revealed a lesion in the pons. It was worked up and not felt to be demyelinating. A more recent MRI showed a new lesion in the anterior left temporal area that is ill defined and somewhat expands out. The overall feeling is that this likely represents a neoplasm that is worrisome given the expansile nature and the extension posteriorly. The overall recommendations were surgical incisional biopsy for determination of diagnosis and removal if possible after mapping by functional MRI and/or other physiologic testing.

Large Thalamic Tumor, 41 year old Female

VBTB — Mon, 02 Mar 2009 02:19:46 GMT

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This 41 yo female patient of Dr. Sorenson?s presented with hydrocephalus and headache. She was found to have a large thalamic tumor. This was biopsied endoscopically. The pathology returned glioblastoma. She also had a shunt placed for the hydrocephalus. Discussion was had about possible open surgical resection versus adjuvant therapy. The overall feeling was in favor of external beam radiotherapy with combined chemotherapy followed by adjuvant chemotherapy. It was felt that surgical intervention would likely be too high risk

Nasopharyngeal Carcinoma, 31 year old Male

VBTB — Mon, 02 Mar 2009 02:20:02 GMT

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This 31 YO male has been previously presented with a skull base mass with a nondiagnostic transnasal biopsy. A left pterional approach was made for direct approach to the middle fossa for biopsy. This revealed what appears to be consistent with a nasopharyngeal carcinoma. Discussion was had about adjuvant management. We plan to give him adjuvant chemotherapy first then follow with radiation therapy and further chemotherapy as needed.

History of Renal Cell Carcinoma with Two Brain Lesions, 66 year old Male

VBTB — Mon, 02 Mar 2009 02:20:15 GMT

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This is another follow-up of a 66 YO male with a history of renal cell carcinoma who presented with two brain lesions. A frontal lesion was resected after he presented with seizures. He had another lesion in the left atrial trigone that had been followed. Previous conference had recommended possible surgical removal of the trigone lesion and it was planned to discuss this with him, however, on the morning of his planned visit, he came in with a sudden loss of consciousness. CT scan revealed a devastating intracerebral hemorrhage that was felt to be most likely from the lesion and he expired.

Multifocal Glioblastoma, 56 year old Male

VBTB — Mon, 02 Mar 2009 02:20:24 GMT

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This 56 YO male patient of Dr. Sills? presented in December 2007 with a right temporal lesion with partial seizure. He had this lesion resected and was found to be a glioblastoma. He had high-dose brachytherapy treatment protocol. He subsequently developed in January 2008 a lesion in the left and right atrial trigone region. This was followed conservatively but began to enlarge and he had Gamma Knife radiosurgery to the site in May 2008. He has refused external beam radiation therapy. He now presents with progression of the lesion in the trigone region. He has been on Temodar throughout. Discussion was had about the rationale for possible surgical resection versus external beam radiation and change of chemotherapy. It was felt that he is going to be at some high risk for radiation necrosis because of his previous treatments. There was some feeling that he might be at a less risk of necrosis with resection of the lesion, however, there is certainly some risk for resection. The overall feeling is that he could get a second line of chemotherapy as well at this point, given that the lesion has progressed on Temodar. Dr. Jason Weaver gave a brief presentation on the staging and terminology for spine oncology.

Right Parietal Occipital Non-enhancing Expansile Lesion with Behavior Abnormalities, 15 year old Male

VBTB — Mon, 02 Mar 2009 02:20:34 GMT

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This 15 YO male is a case sent in from Montana. This child has had severe behavioral abnormalities for a number of years. During part of the work-up for his psychiatric admission, he was found to have a right parietal occipital nonenhancing expansile lesion at the cortical surface. It was felt that this likely represents low-grade glioma of some type. It was totally unrelated to his behavioral presentation. He has had EEG monitoring both acutely and on an extended basis and this was not found to be associated with his rage spells. Recommendation was made for surgical resection for diagnosis and treatment.

Glioblastoma, 34 year old Female

VBTB — Mon, 02 Mar 2009 02:20:44 GMT

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This is 34 YO female case also sent in from Montana. This woman had a right anterior basal ganglia region lesion that had stereotactic biopsy after she presented with headache and N/V. The stereotactic biopsy revealed glioblastoma. She underwent combined radiation therapy with Temodar. She presented with progression of the lesion shortly after this. The role for surgical resection was debated. It was felt that this could be done given her young age and be similarly aggressive after this. It was recommended to consider a non-traditional schedule of Temozolomide.

Right Acoustic Neuroma with Arachnoid Cyst of the Posterior Fossa, 37 year old Male

VBTB — Mon, 02 Mar 2009 02:21:03 GMT

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This 37 YO male patient of Dr. Segal had a history of seizure that was onset in 2002. He was imaged and noted to have a right acoustic neuroma, an arachnoid cyst of the posterior fossa as well as an ill defined area in the left anterior temporal lobe. He had surgery for the acoustic and this was followed with Gamma Knife radiosurgery. The temporal lobe lesion has been followed conservatively. He has had no further seizures with anti-epileptic therapy. He currently had a scan done that shows some enlargement of the lesion compared with previous. Discussion centered around the fact that this lesion is enlarging and in the absence of symptoms, it would be nice to have a diagnosis. On the other hand, it is felt to be clinically and radiographically stable and could continue to be observed. Most likely it is felt to represent a glioma of some grade and attempt at resection could be done safely using monitoring techniques and functional imaging.

Left Frontal Cystic Mass with Seizure, 34 year old Female

VBTB — Mon, 02 Mar 2009 02:21:12 GMT

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This 34 YO female had a history of a single seizure and let frontal cystic mass. It was felt that this mass extended down to but does not involve the corpus callosum. It was recommended that she undergo surgery to remove the mass, however, this is being postponed in her home country of Japan. It was felt that while it was not true emergency, it should be done on a fairly urgent basis. The overall feeling is it likely represents some type of low grade glioma that could be aggressively resected.

Parasellar Chondrosarcoma, 32 year old Female

VBTB — Mon, 02 Mar 2009 02:21:23 GMT

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This 32 YO female presented with cranial nerve deficits on the right side of cranial nerves III and IV. Several years ago she had a biopsy done of a parasellar lesion, which turned out to be chondrosarcoma. She then underwent external beam radiotherapy followed by Gamma Knife radiosurgery boost and a cycle of chemotherapy. She presents now with a stable clinical course but questionable enlargement on a scan. Discussion was had that this likely is a surgically treatable disease after radiation has been given; however, investigation should be done. Proton beam radiotherapy is an alternative.

Multifocal Anaplastic Astrocytoma, 66 year old Female

VBTB — Mon, 02 Mar 2009 02:21:33 GMT

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This 66 YO female with a history of left-sided motor weakness and a right non-enhancing anterior frontal lesion. She also had similar posterior enhancement. The anterior lesion was operated on and resected and found to be an anaplastic astrocytoma. She just finished radiotherapy with combined Temozolomide during radiation. She is still feeling somewhat fatigued. Her scan shows signal progression in and around the corpus callosum but no enhancement. This is all seen on FLAIR imaging. The posterior is not really enlarging. Discussion was had about various options at this point. It was felt that she would be a reasonable candidate to continue on Temozolomide that is being planned on an adjuvant basis with careful imaging follow-up and consider of a clinical trial if she fails.

Lesion on the Occipital Bone, 34 year old Female

VBTB — Mon, 02 Mar 2009 02:21:44 GMT

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This 34 YO female with a history of breast cancer underwent bone scan and was found to have a lesion on the occipital bone. This was biopsied and found to be breast cancer that was overlying the torcular. Limited biopsy was done. Discussion was had about management at this point. We opted to try to do radiation rather than aggressive resection unless the patient has absolutely no other evidence of disease. Dr. Madison Michael presented a talk on the medical management of growth hormone secreting tumors.

Apoplectic Pituitary Gland, 46 year old Male

VBTB — Mon, 02 Mar 2009 02:22:04 GMT

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This 46 YO male presented 8 days after onset of severe headache and some visual compromise. He had a mass in the pituitary fossa that appeared to be hemorrhagic. This was operated upon and found to be an apoplectic pituitary gland. The patient?s cranial nerve deficits improved over the course of 2-3 weeks. Pathology confirmed the apoplectic pituitary findings.

Lesion in the L2 Vertebral Body, 64 year old Female

VBTB — Mon, 02 Mar 2009 02:21:54 GMT

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This 64 YO female with a history of breast cancer diagnosed six years ago has had multiple negative PET/CT scans. She presented with a lesions in the L2 vertebral body picked on a bone scan. This was biopsied and found to be breast cancer. Discussion was had about management at this point. If this is truly isolated disease and no other sites, then she could have a gross resection of this from an anterior aggressive spinal reconstructive approach. If the lesion appears to involve the pedicle, then this could be done from posterior, that is a somewhat more complex approach requiring sacrifice of a unilateral L1 root. If the patient does not wish to have surgery or is found to have other sites of disease early in staging, then stereotactic radiosurgery would be the preferred treatment for the lesion.

Neurocysticercosis with Expanding Brain Lesion, 33 year old Male

VBTB — Mon, 02 Mar 2009 02:22:15 GMT

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This 33 YO male presented with seizures and had multiple brain lesions and a left parasagittal lesion. The presumed diagnosis was neurocysticercosis based on the appearance of the lesions in a Hispanic male. He underwent oral treatment for this and was placed on anticonvulsants. He came back with worsening right-sided motor function. The left parasagittal lesion had grown significantly. It had a lot of enhancement and a necrotic appearing center. He underwent a biopsy and was fount to be glioblastoma. Discussion was centered around further adjuvant therapy. It was felt that he should go ahead and be treated aggressively with radiation then chemotherapy despite the infectious process and continue on separate treatment for this.

Suprasellar Mass, 54 year old Male

VBTB — Mon, 02 Mar 2009 02:22:24 GMT

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This 54 YO male presents with intermittent swallowing difficulty. He was found on imaging to have a suprasellar mass. This appears cystic with the possibility of some solid component. A dermoid or epidermoid was felt to be a likely diagnosis. Discussion centered around the fact that this was likely asymptomatic and could be observed with serial radiographs for the present time.

Clivus Lesion and Intermittent Right Sixth Nerve Palsy, 33 year old Male

VBTB — Mon, 02 Mar 2009 02:22:34 GMT

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This 33 YO male presented at the last conference with a clivus lesion and intermittent right sixth nerve palsy. The biopsy was performed since the last conference and pathology is of a chordoma. Plans were made for aggressive surgical removal followed by possible radiotherapy to any remnant. There seems to be no role for chemotherapy at this time.

Remote History of Breast Cancer Presents with Neck Pain, 79 year old Female

VBTB — Mon, 02 Mar 2009 02:22:45 GMT

This 79 YO female with a remote history of breast cancer presents with neck pain. She has a lesion seen in the C2 body with bone scan and increased activity to that area. Discussion was had about the possibility of this being a metastatic lesion. It was felt that this could degenerative or metastatic. Discussion was fairly evenly divided about continued observation versus biopsy. Recommendation was made for additional staging of the rest of the body to see if there are other breast cancer lesions as well as serum markers. CT guided biopsy could be done with fairly low risk.

Transient Global Amnesia with Anterior Left Temporal Lesion, 67 year old Female

VBTB — Mon, 02 Mar 2009 02:22:57 GMT

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This 67 TYO female patient of Dr. Sills? presented with an episode of transient global amnesia. She had a scan done and this revealed an anterior left temporal lesion. This lesion appeared to have the possibility of small hemorrhages in it. She has been asymptomatic since this episode. She is a cardiac patient and an extra dose of medication at presentation. Most individuals on the panel felt the lesion was asymptomatic and could be observed. It might likely represent a small occult vascular malformation rather than neoplasm, however, close observation should be done.

Lesion in the Brain Stem and the Conus, 42 year old Male

VBTB — Mon, 02 Mar 2009 02:23:09 GMT

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This 42 YO male patient with a complex history of hemiparesis. He had a lesion in the brain stem and the conus. Biopsies were done of the lumbar lesion and it was felt to represent a juvenile polycystic astrocytoma grade 1, although it was also termed as malignant. The patient underwent external radiotherapy in fractionated fashion to both lesions and then had Gamma Knife radiosurgery boost to the brain stem lesion. He is now presenting with worsened motor function. Imaging documents continued expansile process in the craniocervical junction and also the lesion in the region of the conus. Discussion was held that this could likely represent radiation effect in both areas, particularly given the high dose given to the brain stem. There was some concern about the diagnosis but outside review has confirmed that this is indeed a polycystic astrocytoma, however, there is great suspicion about use of the term ?malignancy? in reference to the lesion. The patient is also currently getting Temozolomide chemotherapy and it was recommended stopping this, not do further radiation, and consider a biopsy to determine if radiation necrosis is indeed the appropriate diagnosis. High dose steroids and/or hyperbaric oxygen could possible be done if this is indeed found to be the case.

Multiple Brain Lesions with a History of Breast Cancer, 49 year old Female

VBTB — Mon, 02 Mar 2009 02:23:19 GMT

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This 49 YO female patient of Dr. Weaver has a history of breast cancer and presented with multiple brain lesions. She had previous whole brain radiation and seemed to do well but now she has some new lesions that have developed with expansion of the other lesions. She has no symptoms at present. Discussion was had about repeat radiation versus intrathecal chemotherapy versus simple systemic chemotherapy. Current recommendation was for systemic chemotherapy only, given her lack of symptoms and the limited choice of other good options.

History of Sarcoma with Arm Pain and a Spinal Mass, 67 year old Female

VBTB — Mon, 02 Mar 2009 02:23:30 GMT

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This 67 YO female patient presented with neck and arm pain initially on the right, now more on the left. She has a history of liposarcoma 19 years ago. She has a lesion that appears to expand the foramen on the left side. Discussion was had that this most likely represents a nerve sheath tumor, unrelated to her previous cancer. Recommendation was made to study her with a screening CT of the chest, abdomen, and pelvis to make sure she has no other solid disease and if not to consider surgery for this lesion, given it is successful and should be readily curable at the state that it is.

Non-enhancing Lesion in the Left Frontotemporal Area with Seizure Disorder, 49 year old Female

VBTB — Mon, 02 Mar 2009 02:23:41 GMT

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This 49 YO female patient of Dr. Boop's presented with seizure disorder that was progressive and difficult to control on meds. There was a non-enhancing lesion in the left frontotemporal area. This was subtotally resected and found to be an anaplastic astrocytoma. Recommendations for radiation with concurrent chemotherapy followed by adjuvant chemotherapy was one of the recommendations even though the data is less strong. This recommendation was made in light of the patient?s age and a subtotal resection.

2-Year History of Glioblastoma with New Brain Lesion, 48 year old Female

VBTB — Mon, 02 Mar 2009 02:23:53 GMT

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This 48 YO female patient of Dr. Michael?s presented with a glioblastoma two years ago that was subtotally resected and then a motor strip. She had radiation and chemotherapy and has done very well. She now presents with a new lesion that is deep and peri-ventricular. She had stereotactic biopsy and appears to be a mixture of radiation necrosis and recurrent tumor. Based on this, recommendation was made for consideration of resumption of chemotherapy, most likely with Temozolomide since she did well on this earlier on an extended schedule. Discussion was had about radiosurgical boost to the area and overall the majority of practitioners favored this as having potential benefit.

Ependymoma of the Thoracic Spine with Possible Imaging Recurrence, 28 year old Male

VBTB — Mon, 02 Mar 2009 02:24:03 GMT

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This 28 YO male patient of Dr. Sills' presented in January 2008 with an ependymoma of the thoracic spine. This was gross totally resected and he had no adjuvant therapy. He presents now with possible imaging recurrence. The overall image data is somewhat indeterminate given the lack of symptoms. It was recommended for conservative follow-up at the present time.

Large Left Frontal Lesion with History of AIDS, 35 year old Female

VBTB — Mon, 02 Mar 2009 02:24:14 GMT

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This 35 YO patient of Dr. Sills? had a history of AIDS and a large left frontal lesion that was diagnosed back in July 2008. She had positive toxo titers and presumed positive for toxoplasmosis in the brain and was put on adjuvant therapy. She seemed to do well initially but presented with increasing confusion. Imaging studies documented significant expansion of the frontal lesion as well as a second satellite lesion more posterior. This was operated upon and resected. It turned out to be a toxoplasmosis abscess. She continues on anti-toxo treatment.

History of Breast Cancer and 2-3 Day History of Transient Perioral Numbness, 50 year old Female

VBTB — Mon, 02 Mar 2009 02:24:25 GMT

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This 50 YO female patient of Dr. Michael's with a history of breast cancer debulking over two years. She presented with questionable meningeal enhancement and a 2-3 day history of transient perioral numbness, which has resolved completely. She had an LP done that was negative for malignant cells. She has no solid disease in the brain. She is currently on chemotherapy. Recommendation was made for continued observation and no treatment based on imaging alone.

Cushing's Disease, 51 year old Male

VBTB — Mon, 02 Mar 2009 02:24:36 GMT

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This is a 51 YO male patient of Dr. Qureshi's who presented with stigmata of Cushing's Disease and was found to have lab abnormalities consistent with this. Imaging studies documented a macroadenoma. Plan was for resection with evaluation of possible residual disease by imaging and see what happens to his hormone levels. If this is the case and he still has significant elevation recommendation was made for medical therapy with consideration of focused radiation, since this is a salvage therapy. Review was carried out over the data from several large theories, which have showed that there is a high failure rate with this disease and that most of the patients end up with radiation treatment. Briefly stated was also note of data obtained by patient's caregiver satisfaction with different treatment options for tumors. These data showed a relative high degree of satisfaction in most treatments, highest for surgery and chemotherapy followed by radiation in a lower percentage. There was also generalized good knowledge among patients of the complications and what is involved with these treatments, though again this was lower for radiation than for surgery or chemotherapy. A significant number of patients suggested some episode of depression during their course, which was somewhat improved by treatment.