14 yo girl with progressive R sided hemiparesis Options

[waelkh]

That is the case of 14 years old girl. This girl was in our clinic last year in February.

At those moment she has the right side hemiparesis (2 points), the decreasing of the sensitivity in right extremities. In NMR signs of the tumour of the left hemisphere (we send you the slides). Then the surgery was done. It was astrocytoma with light signs of anaplasia. It was a complication on 4 day after surgery - hemorrhage into the postoperative area. But we treated this complication conservatively and during next months there were good results. Now signs of light right side hemiparesis, but the control MRI shows the signs of prolonged growth of the tumour. How do you think what is better tactic in that case, and what approach is better to use?

Also we can send the histology material .

Thank you very much.

Nikolay Krutelov
St. Petersburg, Russia

MRI Dec 15, 2001:

Mri Jan 22, 2002:

[waelkh]

St. Petersburg: The parents ask if it is necessary to do the second operation? The symptom regressed after the first operation and now the girl has practically no sign of paresis.

Henry Marsh: What was the initial pathology?

St. Petersburg: Astrocytoma grade 2.

Henry Marsh: The two scans I have seen are not directly comparable. I think one is enhanced and one is not. However, I assume that the evidence is strong that the tumour has grown between the time of the two scans? If not, and if she has little deficit, I would do nothing at the moment. If it definitely has grown larger she will need more treatment. The original histology is very important - if the tumour looks malignant she probably should just have radiotherapy/chemotherapy. If the pathology does not look very maligfnant I suppose one will need to operate again but it would be a difficult and dangerous operation. We probably should review the pathology slides.

Henry Marsh: Are you certain the tumour has grown larger since the first follow-up scan?

St. Petersburg: Yes, we think that the tumour had growth in one year after first operation. We will send you pathology slides on Monday.

Henry Marsh: What approach did you use for the original operation? Do you think she has speech in the left hemisphere?

St. Petersburg: Through the second temporal gyrus.

Henry Marsh: Did she have any dysphasia afterwards?

St. Petersburg: She did not have any problems with speech.

Henry Marsh: If I was to operate on her I would try to do it with her awake to minimize the risk of hemiparesis but she might be too young to tolerate this and it is quite a specialized technique. You need a very good anaesthetist.

St. Petersburg: So we can we come back to this case after histology slides will be investigated by your specialists

[This message was edited by Greg Foltz MD on 02-06-02 at .]

[waelkh]

Dear Dr. Foltz,

Prof. Iova asked me to send histology images of the tumor of the 14 yo girl with progressive R sided hemiparesis.

Thank you very much for your attention.

With best wishes,

Sergey Popov
St. Petersburg, Russia

[waelkh]

We have reviewed the histology images with our neuropathologists. As seen in images 2, 3 and 4, there are 2 populations of cells arranged in a uniform hypercellular pattern. Elongated spindle-shaped cells are prominent in the left portion of image 2. A separate population, notable in images 3 and 4, demonstrate small hyperchromatic round cells with features possibly suggestive of oligodendroglioma. There is no evidence of mitotic figures or necrosis in these sections. The fourth image also demonstrates a few gemistocytic astrocytes. The fifth and sixth images demonstrate a region of inflammation, with lymphocytic infiltration and possible perivascular cuffing. The seventh image demonstrates microcysts within the specimen. The vessels shown do not exhibit endothelial hyperplasia.

The images are most consistent with low grade mixed glioma or low grade astrocytoma. Additional immunocytochemical stains for GFAP and MIB are recommended. The history of recurrence with the associated features is concerning for possible malignant progression.

Greg Foltz MD
Seattle, Washington

[This message was edited by Greg Foltz MD on 02-27-02 at .]