How Do Gbm Patients Die – An 80-year-old white man presented to the eye clinic with complaints of right-sided eye blurring of one month’s duration. This was especially noticeable when the patient was trying to read. In addition, he reported severe right-sided weakness for the past five weeks. The patient’s medical history was positive for long-standing hypertension and type 2 diabetes.
Visual acuity 20/20 OD, OS. Grade 1+ relative afferent pupillary defect (RAPD) in the right eye, contrast field showed a right field deficit in each eye. Reflux circumference revealed a right homogenous hemianopia (Figure 1).
How Do Gbm Patients Die
Associated with signs and symptoms, this led to neuroimaging, which revealed a left optic tract mass consistent with glioblastoma multiforme (GBM). The tumor was compressing the left optic tract and midbrain slope cerebrum (cerebral peduncle), causing right RAPD and right-sided weakness. He was referred for neurosurgical evaluation and treatment.
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Gliomas represent the most common type of brain tumor. They originate in the glial cells that support the brain’s neurons, including astrocytes, oligodendrocytes and ependymal cells. GBM is the most lethal form of glioma, accounting for 3% to 4% of all cancer-related deaths.
The World Health Organization defines GBM as a grade IV cancer that is malignant, mitotically active and prone to necrosis.
Optometrists can detect early signs of GBM and possibly improve survival by an average of 12 to 15 months.
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Figure 1. Visual field defects may indicate tumor progression in GBM and warrant further investigation.
GBM is a type of malignant brain tumor that arises from star-shaped glial cells called astrocytes. According to the American Brain Tumor Association, about 80,000 new brain tumors are expected to occur in the United States each year. Of these, GBM will account for approximately 15%.
Although GBM is not the most common brain tumor, it is the most common. Median survival after diagnosis is 14.6 months if the patient undergoes conventional treatment of tumor resection with concurrent radiotherapy and chemotherapy. Therefore, there is a great need to identify new therapies for the prevention and treatment of GBM. The development of proteomic, genetic and epigenetic tools may one day improve survival rates.
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Symptoms of GBM can appear slowly at first and can be very subtle. Patients with GBM may experience headaches, confusion, memory loss, motor weakness, and seizures. Other patient complaints include nausea, personality changes, difficulty concentrating, hemiparesis, blurred vision, and aphasia.
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Cancer is responsible for approximately 25% of all deaths in the United States and is the second most common cause of death after heart disease. The American Cancer Society defines cancer (or carcinoma) as a group of diseases caused by the uncontrolled growth and proliferation of normal cells. A tumor has the ability to invade normal tissues, metastasize and kill the host in which it occurs.
Cancer has environmental, chemical, cellular, and genetic causes, and the host’s genetic makeup and immunobiological status contribute to the process.
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A neoplasm is an abnormal mass of tissue in which cells divide more than they should or when they die. Neoplasms can be benign or malignant depending on their biological activity. Benign neoplasms cannot spread by invasion or metastasis – they only grow locally. Malignant neoplasms are capable of spreading through invasion and metastasis. By definition, the term “cancer” refers only to malignant tumors.
Ocular manifestations of gliomas and GBM are similar to other focal lesions and may include any of the following:
Clinical evaluation for these patients, especially fatigue, dizziness, headache, muscle weakness, loss of appetite, malaise, etc. It is important to carefully review such systems, as clinical evidence of progression may actually precede magnetic resonance imaging (MRI) evidence. In both primary and recurrent GBM, seizures are the most common symptom.
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Thus, new or worsening field defects may indicate tumor progression in GBM and warrant further investigation.
Patients suspected of having GBM or other localized conditions should undergo neuroimaging studies such as computed tomography, MRI, contrast-enhanced positron emission tomography, and brain magnetic resonance spectroscopy (Figure 2).
Obtaining tumor genetics by electroencephalography, lumbar puncture, and cerebrospinal fluid studies can be helpful in determining response to appropriate therapy.
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Figure 2.
Although there is no curative treatment for GBM, standard treatment consists of maximally safe surgical resection, radiotherapy, and adjuvant chemotherapy combined with temozolomide.
The addition of radiotherapy to surgery improves patient survival, and adjuvant chemotherapy shows a significant survival benefit in over 25% of patients.
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However, clinicians must weigh these treatments against quality of life, and less invasive treatment with radiation or temozolomide may be considered only in patients 70 or older.
A patient diagnosed with GBM should be treated and managed by a team of neurosurgeons, neurologists, neuro-oncologists, neuroradiologists, neuropathologists, radiation oncologists, physical therapists, social workers, and translators with extensive experience in brain tumors. ODs can and should be critical members of that team, beginning with diagnosis and continuing through the areas of alignment and vision enhancement.
1. Lewis DN, Ohgaki H, Wiestler OD, et al. World Health Organization Classification of Tumors of the Central Nervous System. Acta Neuropathol. 2007; 114(2):97-109.
End Of Life And Glioblastoma
2. McLendon RE, Halperin EC. Is there a long-term survival benefit for patients with intracranial glioblastoma multiforme? Cancer. 2003; 98(8):1745-8.
3. Cornet PA, Dea TO. Cancer. In: MacPe SJ, Papadakis MA, eds. 2010 Current medical diagnosis and treatment. 49th ed New York: McGraw Hill Medical; 2009: 1450–1511.
4. Hanif F, Muzaffar K, Parveen K et al. Glioblastoma multiforme: a review of epidemiology and pathogenesis through clinical presentation and treatment. Asia Pacific J Cancer Prevent. 2017; 18(1):3-9.
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5. Chittiboina P, Connor DE Jr, Caldito G, et al. Occult tumors presenting with negative imaging: a review of the literature. J Neurosurg. 2012; 116(6):1195-1203.
6. Xie K, Liu CY, Hasso AN, Crow RW. Visual field changes as an early indicator of glioblastoma multiforme progression: two functional vision changes before MRI. Clinical Ophthalmology (Auckland, NZ). 2015; 9:1041-7.
8. Vitucci M, Hayes DN, Miller CR. Gene expression of gliomas: integrating genomic and histopathological classification for personalized therapy. Br J Cancer. 2011; 104:545-53. When I started getting occasional headaches in May 2019, I thought I must be dehydrated from my weekly indoor games.
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I used to use Advil or Tylenol until I was really hungover, so I upped the water and started taking electrolyte supplements.
My headaches became more persistent and I started taking Tylenol or Advil (I didn’t know which). Headaches will subside a little, but they will appear more often. It wasn’t bad and it was a little annoying at times.
Then one day in July I woke up with a headache and realized I couldn’t go to my office. Emily wanted us to go to the emergency room because I had been there so many times. I found the idea ridiculous. According to the ER at the time, it was a gunshot wound and cardiac arrest.
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But once in the ER, the shooting took a turn for the worse. They put me in a room with other guests to wait for the price. I tried to distract the others in the room, a woman was slowly telling me how she had broken her first bone, but my headache was bothering me. I went for my satellite and threw it away.
The doctor looked at us and told me that I had a headache and had been having headaches recently. He underwent basic tests to look for signs of a possible aneurysm.
We got our CT scan which we thought was unnecessary but very good. We waited and the doctor came back and asked to see me and Emily. At first I wanted to see him alone but he said it would be better if he came with me. The first moment of hesitation.
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He took us into his office, and informed me that the CT scan showed a golf ball shaped head.
Everyone has fantasized about winning the lottery before, and many people have fantasized about being delivered terrible medical news. Of course it was. Some scenario where the doctor tells me I have six months to live or something. It was strange when it actually happened.
The doctor’s compassion, shock, tears. The experience was very similar to what I imagined, like Déàu vu. The doctor said it was serious and he would do everything he could.
Gbm Bill Of Rights
I felt like I was in a movie and I would go home and get on with my life. The doctor told us he didn’t know what kind of tumor it was or if it was cancer. I was supposed to be transferred to another hospital, but he gave us a referral and said he would see me right away if I went back to that hospital.
Shocked, of course, I remember being a bit happy about it
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