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Suggest treatment for left frontal benign stage-II atypical meningioma

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Posted on Mon, 4 Sep 2017
Question: Hi,

This is regarding health issue of my mom aged 50yrs suffering from Left frontal Benign Stage-II(Atypical) Meningioma from last 5+ years. Brief history of the case is as follows:


August 2012 (Surgery-I)
Pre Diagnosis: She was very fit & active in all her activities. She had no symptoms as such.
Diagnosis : On a fine day, suddenly she got fits/seizures and when CT scan was performed, it was diagnosed with Tumour in brain which was there from last 4 years and had grown in significant size and pressuring other parts. This made mom's right side semi paralysed with difficulty in speaking. So, doctor suggested for an immediate surgery.
Post-Surgery: Doctor couldn't remove tumour completely because of its position(sticked to CNS) and sent the tumour samples to Biopsy. Even post-surgery, mom was unable to use her right half and had difficulty in speaking. For which, doctor said it will improve upon time and by doing physiotherapy.
Biopsy Result: Tumour turned out to be Grade/Stage-I benign tumour and doctor suggested us to not to worry about residual part and it will have less impact as its benign and stage-I tumour and asked to continue the anti-seizures medicines.

Interim:
She was getting unpredictable seizures even after continuing the prescribed medicines and we used to have monthly/quarterly check-ups with the surgery doctor and also MRI scans with/without contrast whenever suggested. Every time he used to say its normal but mom was experiencing very bad days with unpredictable seizures.

April 2014 (Surgery-II)
Pre Diagnosis: As always seizures strike again and this time it was non-stop and continuing for an hour which turned into 2, 3 hours and had to admit her again :(
Diagnosis: It got to know from MRI Scan that tumour’s size again got increased and this time tumour branched out and created sub tumours in different directions and again doctor suggested for surgery, as tumour was too reactive.
Post-Surgery: Again, doctor couldn't remove tumour completely and sent the tumour to biopsy. This time also it had impact on the right limbs.
Biopsy Result: Tumour has upgraded his stage and its now identified to be Stage-II Benign and Atypical tumour which has good chances to recur at a rapid rate. So suggested Radiotherapy right after surgery.

May 2014 (Radio Therapy)
Treatment: 35 days Rapid XXXXXXX Radiotherapy started and mom had to visit for treatment sessions.
Post-Treatment: As usual, she had to experience worse side-effects of the treatment and the seizures have become quite common for her.

Interim:
She was getting unpredictable seizures even after continuing the prescribed medicines and we used to have monthly/quarterly check-ups with the surgery doctor and also MRI scans with/without contrast whenever suggested. Every time he used to say its normal but mom was experiencing very bad days with unpredictable seizures.

May 2017 (Hospitalization-I)
She again was getting prolonged seizures and had to hospitalize her for some time and doctor has added 2 more medicines to the list and again assured that its quite common and normal. But, it was horrible experience even to see. Imagine how bad it would be for mom.

August 2017 (Hospitalization-II)
She again was getting prolonged seizures and had to hospitalize her for some time and doctor has added 1 more medicines to the list and the same thing is going on.

Current Situation
Mom got very much weak because of seizures and giddiness and with powerful medicines and its continuing from last 5 years. I am currently looking for some serious permanent cure for this horrible disease and get rid of it at the earliest and relieve mom from all this, so that she can spend rest of her life happily.

Any suggestions/help would be really appreciated.

Thanks a lot in advance.
XXXX
doctor
Answered by Dr. Ishu Bishnoi (4 hours later)
Brief Answer:
Treatment of Frontal Meningioma and need some information

Detailed Answer:
Hi XXXXXXX thanks for asking from HealthcareMagic.

I can understand your concern. I am a neurosurgeon and I regularly operate meningioma cases.

First, I'll tell you about Meningioma. It is a benign tumor with good prognosis. Even type II Meningioma is not a bad tumor. If excised completely with dural and bony margins, it will usually cure permanently. This tumor arises from membrane covering brain (dura, arachnoid cap cells). It does not directly cause seizures. But, if it is causing pressure on brain tissue and secretes some chemicals, which can cause seizures. Complete excision can relieve pressure and secretion of chemicals. Thus it would have definitely reduced seizures frequency.

Now coming to your mother's tumor. You mentioned that it is a frontal meningioma. If it was frontal convexity meningioma and size was less than 6cm, I think it could have been completely excised.

Because frontal convexity meningiomas are one of the most simple meningiomas to treat. To confirm, I need to see her "MRI images".
It would be very nice if you can send me her current and past images.

Also, I need complete information about her seizure medication. You have not mentioned the names.

She is having recurrent and refractory seizures most likely due to brain damage and radiation toxicity. I don't know whether complete removal of tumor at this stage will cure her seizures or not. It can only be said after seeing images.

Hope you got my point. If any doubt, do let me know.
Thanks. Take care.


Above answer was peer-reviewed by : Dr. Arnab Banerjee
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Follow up: Dr. Ishu Bishnoi (8 hours later)
Thanks for the review doctor.

I have shared the MRI reports after radiotherapy and also recent follow-up visit prescription for medicines. Its been almost 3 years since shez done with 2 surgeries and radiotherapy.

Considering the frequency of seizures, doctor has suggested additional medicine - Gardenal and Petril and asked not to worry, its quite normal. But it does not seems so seeing the mom's experience from front.

Could you please tell what could be the next course of action to get rid of this focal seizures(effecting only right hand) and tumor permanently.

And also some details about new medicine, as its controlling fits after 10 mins of its consumption. if suppose she gets fits for 7-8 times a day and it is prolonging everytime atleast for 30 mins. In order to stop it, we had to give it. Not sure how much it is recommended to do so to control seizures and how much impact it may cause.

Regards,
XXXX
doctor
Answered by Dr. Ishu Bishnoi (1 hour later)
Brief Answer:
Review of report

Detailed Answer:
Hi XXXXXXX welcome back.


I have read your mother's reports. There is significant size residual lesion on left frontal, parietal and frontotemporal region. There is edema of brain. The reactive change in brain are the reason behind such refractory seizures. Consult your doctor whether she is fit to undergo complete excision of it. Because at least, that will remove pressure over brain.
Radiotherapy can not give complete cure from tumor.

She is currently receiving lacosamide, levetiracetam, phenobarbital and clonazepam for seizure control. Her seizures are refractory. The dose of each drug except phenobarbital is high. the prescription is ok. In refractory seizure, neurologists give such prescription.
I am not in favour of further adding drug or increasing dose after it. Because the main culprit behind seizure is still there. Tumor removal can not guarantee 100% seizure control, but at least control of seizure on medication.

My advise is to consider surgery for tumor and then observe course of seizure. If still no control, we can give phenobarbital 60mg BD or add valproate. She will develop side effects which your family has to bear.

Hope it will give you some clear idea. Still in doubt, do let me know
Thanks. Take care.
Above answer was peer-reviewed by : Dr. Nagamani Ng
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Follow up: Dr. Ishu Bishnoi (48 minutes later)
Thanks for the follow-up response.

She already underwent surgeries twice and doctor is saying complete tumor removal is not possible as its sticked to CNS and any attempt to remove it will be a big risk to life.
would it be still advisable to go with 3rd surgery ?

"My advise is to consider surgery for tumor and then observe course of seizure. If still no control, we can give phenobarbital 60mg BD or add valproate. She will develop side effects which your family has to bear.
"
For this statement, can i know more about the side effects expected?
doctor
Answered by Dr. Ishu Bishnoi (2 hours later)
Brief Answer:
Side effects of surgery and drugs

Detailed Answer:
Hi XXXXXXX welcome back.


I agree with your doctor that surgery is risky. But meningioma adhered to brain is not a contraindication. Currently your mother is suffering a lot as you mentioned in history. If she improves with time, you can avoid surgery. But she is continuously deteriorating, what options do you have?
In such case, surgery is considered based on risk versus benefit ratio. You can discuss it with your neurosurgeon. As time will pass, this tumor will grow bigger and bigger, then what? She will be having more seizures and pressure symptoms. Thats why I am suggesting you surgery. And if she is conscious, oriented and her other organ functions are okay, then she will benefit maximum at this time. You need to discuss all these points among your family and with your doctor.

Now coming to side effects of drugs, antiepiletic drugs cause two types of side effects - nervous system effects and other organ effects. Your mother is taking new generation relatively safe drugs. These drugs (lacosaminde, levetiracetam) cause more effects on nervous system. Phenobarbital and clonazepam mainly affect brain, but can also cause damage to other organs. The side effects are
- sedation
- Slowness
- Impaired cognition
- suicidal tendencies
- depression/psychosis
- vertigo
- Phenobarbital can cause cardiac side effects
- Damage to liver, kidney is rare and occur only if very high dose for long duration.

She is showing nervous system side effects as you mentioned in history. It will increase as dose will increase.

It is a very difficult and emotional situation for you. You have to take decision after discussing with your doctor/family and considering props/cons of every step.

Hope it will help you. If still in doubt, do let me know.
Thanks. Take care.

Above answer was peer-reviewed by : Dr. Vaishalee Punj
doctor
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Follow up: Dr. Ishu Bishnoi (18 hours later)
Thanks for the detailed response doctor.

Apart from the long term anti-seizures. Are there any additional care she has to take to recover soon?

Is there any possibility of completely recovery of tumor without surgery?

Do you suggest some natural and home made remedies to be followed at this stage?

Do you suggest any alternative treatment in addition to halopathic medicines like Ayurvedic/Hpomeopathic?

Thanks,
XXXX
doctor
Answered by Dr. Ishu Bishnoi (4 hours later)
Brief Answer:
Follow up and Meningioma treatment options

Detailed Answer:
Hi XXXXXXX welcome back.


Seizure is the most important symptom at current stage. You should observe her for

- Change in consciousness like altered behaviour, confusion.

- Focal weakness on right side like hemiparesis or aphasia

- urinary incontinence

Development of these symptoms mean tumor has grown too much in size or there is significant brain compression.
To catch these symptoms, you should do regular follow up. MRI brain will be needed after every 6 months to 12 months interval. Later on she may require use of steroids and osmotic diuretics to treat brain edema and pressure.

Complete recovery from tumor is not possible without surgical excision. Meningioma does not show good response to radiotherapy. There is no response to chemotherapy.
If size of meningioma is less than 3 cm, stereotactic radiosurgery can be used to treat it. But your mother has meningioma larger than this.

Regarding natural/home remedies/Ayurvedic/Homeopathic treatment, I am not aware of any such treatment. You need to consult an experienced consultant of Ayurvedic/Homeopathic medicine. There might be some treatment. You can start the treatment after discussing pros and cons with doctor.

Hope it will help you. If still any doubts, do let me know.
Thanks. Take care.
Above answer was peer-reviewed by : Dr. Vaishalee Punj
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Dr. Ishu Bishnoi

Neurologist, Surgical

Practicing since :2007

Answered : 901 Questions

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Suggest treatment for left frontal benign stage-II atypical meningioma

Brief Answer: Treatment of Frontal Meningioma and need some information Detailed Answer: Hi XXXXXXX thanks for asking from HealthcareMagic. I can understand your concern. I am a neurosurgeon and I regularly operate meningioma cases. First, I'll tell you about Meningioma. It is a benign tumor with good prognosis. Even type II Meningioma is not a bad tumor. If excised completely with dural and bony margins, it will usually cure permanently. This tumor arises from membrane covering brain (dura, arachnoid cap cells). It does not directly cause seizures. But, if it is causing pressure on brain tissue and secretes some chemicals, which can cause seizures. Complete excision can relieve pressure and secretion of chemicals. Thus it would have definitely reduced seizures frequency. Now coming to your mother's tumor. You mentioned that it is a frontal meningioma. If it was frontal convexity meningioma and size was less than 6cm, I think it could have been completely excised. Because frontal convexity meningiomas are one of the most simple meningiomas to treat. To confirm, I need to see her "MRI images". It would be very nice if you can send me her current and past images. Also, I need complete information about her seizure medication. You have not mentioned the names. She is having recurrent and refractory seizures most likely due to brain damage and radiation toxicity. I don't know whether complete removal of tumor at this stage will cure her seizures or not. It can only be said after seeing images. Hope you got my point. If any doubt, do let me know. Thanks. Take care.