Brief Answer:
It is a recurrent meningioma at same location

Detailed Answer:
Hi XXXXXXX
Thanks for writing in to us.

I have read through your query in detail.
Having read through the report attached I would like to make the following observations.

I have worked in a cancer hospital for some years and seen many patients with similar problems.

There is an area on the outer part of the brain on left side measuring 7.8 cms long and 1.5 cms in width. This contains a rich blood supply as it is enhancing. This means that the tumor area is still occupying a significant amount of space and might be compressing the brain. The date of surgery and radiotherapy is important if surgery was done within last 3 to 6 months then it is more likely to be a portion of the tumor left behind. A brain tumor is usually not taken out entirely due to important structures around the tumor bed. In this case this appearance is the tumor portion which was left behind. That is the reason why they have also given radiotherapy.

If the tumor surgery and radiation was done more than 6 months back then most likely it is a recurrent tumor which means the tumor has started growing again.

I have seen the earlier reports (September 2014) and confirm that the tumor is an atypical meningioma. Atypical meningiomas are neither malignant (cancerous) nor benign, but may become malignant. Grade II atypical meningiomas also tend to recur and grow faster.

Surgery and radiotherapy stops tumor growth in 80 percent of cases.

Hope this answers your question. Please feel free to correct any oversight in my interpretation of your problems and discuss them in detail as per your requirements.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

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Brief Answer:
Complete removal of tumor and radiation is best treatment.

Detailed Answer:
Hi XXXXXXX
Thanks for writing back with an update.

Having read through the reports attached, I would like to give my observations.

1. RT has helped to a small extent but the tumor seems aggressive and is not getting controlled and there are few reasons for this. The removal of meningiomas is graded by Simpsons grading and under this we have 5 categories as mentioned below.

Simpson Grading System for removal of meningiomas.

I     Macroscopically complete removal of tumour, with excision of its dural attachment, and of any abnormal bone. Includes resection of venous sinus if involved.
II     Macroscopically complete removal of tumour and its visible extensions with coagulation of its dural attachment.
III     Macroscopically complete removal of the intradural tumour, without resection or coagulation of its dural attachment or its extradural extensions.
IV     Partial removal, leaving intradural tumour in situ.
V     Simple decompression, with or without biopsy.

RT works best for Simpsons grade I and to a certain extent grade II. I think your mother underwent tumor excision of grade III or IV. With this information, it is unusual to expect good response to RT. This is the reason for such a recurrence.

2. There are many clinical researches taking place to study the best treatment of meningiomas. The latest research says that Simpson grade I has the best outcomes when patient is given radiotherapy after surgery. It is to be noted that your doctor has followed the correct treatment protocol of suggesting radiotherapy after second surgery. For Simpson grades II to IV, there is no significant impact of adjuvant radiotherapy on the recurrence of atypical meningiomas as on date.

This does not mean that we give up easily. Please have a joint discussion with the neurosurgeon and radiation oncologist and then the case is to be handled in the best possible way keeping the patients interest most important.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

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Brief Answer:
Please find tumor related answers below.

Detailed Answer:
Hi XXXXXXX
Thanks for writing back with an update.

Will try to be more specific this time.

1. There is no way to predict the behavior of a tumor unless it is one of the simplest ones. In meningiomas there are three types, grade I typical meningioma, grade II atypical meningioma and grade III anaplastic meningioma. Some tumors might be in the borderline zone and these are upgraded to a more aggressive type on repeat biopsy. What I mean to say that in your mothers case it is possible that the first biopsy was taken from an area of the tumor which had less aggressive cells and this continued proliferating after first surgery and was subsequently found to be grade II.

2. Initially a tumor might contain all benign cells, after reaching a certain multiplication stage the cell DNA can change and the multiplication can get disorderly. At this stage it generates more blood vessels and gets more oxygen from surrounding areas. This then goes out of control and is said to be malignant. At this point it kills all healthy cells around and the cancer spreads.

3. In my experience, the tumor is still over a large area and therefore a discussion must be held with the neurosurgeon whether operating and removing the entire tumor is possible with minimum risks to the patient. Then radiotherapy can then be instituted which can be focused on the tumor bed region.

I have tried to use simplest terms and language in my reply above. If you have any difficulty in understanding please let me know.

Hope your query is answered.
Do write back if you have any doubts.

Regards,
Dr.Vivek

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