Ask doctor Landolfi (cont.)

Hello again, Dr. Landolfi;

If someone has a primary brain or spinal tumor, but at a later point develops an unrelated cancer at another site (such as breast cancer), does the brain or spine tumor site pose an increased risk as a site for possible metastasis from the other cancer? Does it make it easier for the other cancer to move into that site?

As always, Thank You!

Bruce

no. there is something called a collision tumor. patients with meningiomas and pituitary tumors can have metastases to those sites, usually described from breast cancer. Dr. Landolfi

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Hello again Dr. Landolfi;

At a recent tumor conference, one neurosurgeon stated that medical science has gotten as good as it needs to be to remove tumors, and that now emphasis needs to be placed more on prevention. What are your thoughts on this?

Thank you, Dr. Landolfi;

Bruce

How due we do prevention when we can't identify who is at risk. i thinke there have been alot of surgical advances over the past 5 years but by no means have we reached a plateau. newer techniques such as endoscopic neurosurgery that is being used for other types of neurosurgery my be used routinely for tumors in the future. dr. landolfi

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Hello again Dr. Landolfi;

Most of us survivors have some sort of deficits. Do you have an opinion as to whether these deficits were caused by the tumor or the treatments? (I know that this is an unfair question in that each case is very different. But how about the average patient?)

As always, thank you!

Bruce

most deficits are caused by the tumor. deficits can worsen or new deficits occur from complications of treatment, most commonly, surgery. Dr. Landolfi

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Hello again, Dr. Landolfi;

There seems to be a difference of opinion regarding ependymomas of the brain. Some say that they are gliomas in that they arise from supportive tissues (ependymal cells). Others disagree and say they are not gliomas. What is your feelings?

Thank you,

Bruce

they are not gliomas (or astrocytomas). they arise from ependymal cells.

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Hello again, Dr. Landolfi;

Many times we have heard about the "lifetime" dose of radiation, and how we cannot get anymore once this level is met. What exactly is the "lifetime amount", and is it true that we can have no further radiation? What about Cyberknife and Gammaknife?

Thank you, as always

Bruce

the lifetime amount varies according to disease. when all else has failed i have reirradiated people particularly when they are more than 5-10 years from prior irradiation. radiosugery(gamma knife and cyberknife) can be used depending on tumor type even if patient has had prior irradiation-the dose is adjusted accordingly. dr. landolfi

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Hello again, Dr. Landolfi;

Is it possible for a person with multiple tumors to have one be an ependymoma, and the other be a sub-ependymoma?

Thank you;

Bruce

yes. subependymoma is an anatomical description. Dr. Landolfi

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Sorry for the tardiness...

Our question:

If chemotherapy is usually not successful against ependymomas, why then is it used?

Thank you, and happy holidays!

Bruce

because there are not many options and a small percentage of patients may respond. Dr. Landolfi

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Hello again - I hope you are having a good holiday season.

We have heard that spinal ependymomas can occur anywhere along the spine. What is the worst place for one to occur?

Thank you, (as always)

Bruce

They most commonly occur in the cervical and lower spine. The cervical spine lesions can cause arm and leg problems and at times can be removed. The lower spine can cause, leg, bowel and bladder problems. From a prognostic point of few, they are about the same. There are certain ependymomas of the lower spine that can be more aggressive even as a low grade. Dr. Landolfi

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Hello again, I hope for the best for you and your's in 2008!

Some of our members (particularly spine tumor survivors) state that they have almost unbearable pain after treatment. The usual medications are either non-effective, or carry such bad side effects that they are not used. Do you know of any new treatments or medications to help these people? Any ideas on how they should deal with the crippling daily pain?

Thank you, Doctor.

Bruce

the pain is due to either the spine itself or the spine nerves. if conventional meds don't work, narcotic may be helpful. also there are spinal cord stimulators and pumps that can be used for pain. a good pain program will include psychologists as almost all people with pain have depression and can become a viscious cycle if not appropriately treated, including the depression. Dr. landolfi

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Hello again Dr. Landolfi;

What specialists should post surgical survivors see besides their neurologist? (i.e. neuropsychologist, neuroopthomologist, etc.)

Thank you!

Bruce

Certainly they should be seen by their neurologist/neuro-oncologist. In addition they should f/u with their neurosurgeon as the surgeon wishes. A neuropschological evaluation is more pertainent to brain tumor patients, or spine patients who may recieve therapies that can effect cognition. If a patient has eye problems related to their neurological disease, a neuroophthalmologist would be good to see. Dr. Landolfi

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Hello again, Dr. Landolfi;

I heard somewhere that once any brain tumor reaches a grade four, it is then a GBM. Is this true?

Bruce

a grade 4 glioma is a glioblastoma multiforme. that is correct.

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Hello again, doctor;

I was wondering, what are the most interesting/promising clinical trials happening right now that relate (or may relate) to ependymomas?

As always, thanks!

there areb several chemotherapy trials for recurrent ependymomas. it is hard to say which are promising, but the fact that trials are avaialble is encouraging. a goos resourse is the NIH clinical trials page or Virtual trials.com dr. landolfi

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Hello again;

This weeks question -

In the past, radiation treatment was prescribed for those patients that received a less than total resection. Is this still "standard operating procedure", or has it changed?

Thank you - as always

Bruce

still standard for anaplastic ependymomas. a wait and see for lower grade tumors is still appropriate although some may radiate. dr. landolfi

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Hello again, Dr. Landolfi;

After treatment, we need to be followed by an expert. Would you recommend a neurologist, a neuro-oncologist or other, and WHY?

Thank you!

Bruce

I recommend a neuro-oncologist or a neurosugeon who specializes in brain and spine tumors. These people are the experts in making treatment decisions. They can read their own MRI or CT scans, do an appropriate neurological exam, and most important, make timely and approprioate treatment decisions. Dr. Landolfi

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Hello again;

Here is a question about psychiatrists - if a "regular" one cannot relate to our special "neurological stuff", should we then seek out a neuro-psychiatrist?

Thanks you, as always!

Bruce

yes. but they typically don't do counseling, so you may nedd both

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Here's another one...

When dealing with tumor patients whose future can be uncertain, how do you provide quality care without becoming emotionally attached?

Thank you,

Bruce

This is a very difficult question to answer. The truth is you are never completely emotionally detached. I try to maintain an appropriate distance so that I am able to continue on as this type of medicine is very difficult to practice. I think one can provide excellent medical care and be compassionate without becoming emotionally attached. I like to know about the personal lives of my patients so that we interact on both a professional as well as a personal (in the realm of professional) level. I think this gives the patient's comfort. Of course, at times it is very difficult to maintain emotional distance especially when dealing with children with brain tumors (as I am a parent) or with patients that may remind meu of my own family members ( parents, brothers, sisters, etc.). Dr. Landolfi

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Hello again Dr. Landolfi;

With ependymomas being rare, I was wondering if a treatment plan is devised by the doctor by using his/her experience, or is the available data taken into the decision making process?

As always, Thank you!

Bruce

they are not that rare. they are less common than other types of central nervous system tumors. physicians use their own experience of course coupled with what makes scientific and medical sense when deciding on a treatment approach. there is data in the literature to help guide physicians, and this data is absolutely part of the decision making process. dr. landolfi

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Good morning, Dr. Landolfi;

I heard on TV that brain injured people have a higher risk of getting Alzheimer's disease in later years than "normal" folks... Is this also true for brain tumor survivors? Why?

Thank you!

Bruce

Some papers in the literature have suggested that traumatic brain injury is a predisposing factor for the development of Alzheimer's disease. Certainly patients with traumatic brain injury may have significant memory problems. The literature is scant and larger studies are being done. They are looking at several etiologic factors for this relationship. With regards to brain tumor patient's, there is no relationship between surgical removal, chemotherapy, or radiotherapy and the development of Alzheimer's disease. Certainly patients who have metastatic brain tumors who receive whole brain radiation may be at increased risk for developing a non-Alzheimer's dementing illness more similar to a multi-infarct (stroke) type of memory problem. Dr. Landolfi

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Hello again, Dr. Landolfi;

Some folks believe that vitamin "D" deficiencies can lead to tumors. Do you, and is this deficiency looked for in patients having tumors?

As always, THANKS!

Bruce

IN NO WAY RELATED TO TUMOR FORMATION BUT HAS BEEN SPECULATED TO BOOST RADIOTHERAPY ALTHOUGH DATA IS SCANT. I DON'T RECOMMEND VITAMIN D FOR MY PATIENTS. DR.LANDOLFI

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Hello again;

This may seem like a strange question, it is! We keep hearing about the benefits of medical marijuana. What is your opinion on this controversial subject - can it help a tumor survivor?

As always, thank you!

Bruce

Regular marijuana that is smoked works very well for nausea in patients receiving chemotherapy. Marinal, the pill form, does not work as well. I don’t support it use as it is an illegal substance. Dr. Landolfi~

Hello again!

How important is good nutrition and exercise for post-surgical survivors? Do they increase chances for survival, or quality of life?

As always, thank you!

Bruce

No overall effect on survival directly. Good nutrition and exercise help for quicker recovery, better quality of life and can improve survival be helping to avoid potential complications. For example, being ambulatory can reduce the risk of DVT and pulmonary embolism which can lead to death. Dr. landolfi

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Hello again Dr. landolfi;

Have you ever heard of an ungraded 100% resected intermedullary spinal cord ependymoma recurring at the same place, or elsewhere in the CNS pathway?

As always - thank you!

Bruce

i'm not sure what they mean by ungraded. it may be a tumor transitioning with both low and high grade qualities. as far as recurrence, even 100% resected tumors can recur.dr. landolfi

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Hello again;

I may have asked this question before - If I did, I apologize!

The decision to receive radiation treatments after surgery is usually made by the patient, on advice from his/her doctor. In your opinion, is this treatment warranted for complete resections? How about for less than complete resections?

Thank you, Dr. Landolfi

Bruce

for low grade ependymomas, radiation is not typically recommended for complete resections. In the cases of incomplete resections, and can be considered. A personal opinion is that would depend on the amount of residual disease and the location of the tumor. For anaplastic tumors, radiation therapy is recommended for complete or sticking complete resections after surgery. Dr. Landolfi

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Hello again, Dr. Landolfi;

I have hearing loss that is "probably" due to damage my ears received during radiation treatments, because they were in the pathway. Is there any way to tell positively if the damage was caused by the radiation? Can any such damage be predicted prior to treatment?

As always, Thank you!

Bruce

No side effect of radiotherapy and so one must assume that it will occur at some point after the radiation is completed. One can certainly get an audiogram to evaluate the hearing prior to the treatment and then again in follow-up at various intervals after the treatment. It doesn't matter what the etiology of the hearing losses if I can respond to hearing aids. Also, if there is a toss-up between reduction in hearing and the tumor recurring, most patients would want the tumor treated to prevent recurrence and accept hearing loss that may occur. Dr. Landolfi

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Hello again;

Most of us are experiencing deficits. Is there any way to know if these were caused by the tumor, or the treatments?

Thank you

Bruce

Usually deficits are caused by the tumor but at times they worsened or new deficits develop as a result of surgery. Is very difficult to separate the mouth. One way is to have baseline neurological exam before, then after, in several months after any surgical procedure. Chemotherapy is unlikely to cause worsening deficits except in the case of perhaps neuropathy. Radiation induced damage usually takes years to develop. Dr. Landolfi

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Hello again;

Another question, please;

Once a patient receives a "lifetime dose" of radiation, does that affect other sources of radiation, such as X-rays or CT scans?

Thank you, Dr. Landolfi

Bruce

No. They are not therapeutic treatments with focused radiation to particular area. It may other therapeutic radiation regimens if they are required at another time. Dr. Landolfi

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Hello again!

Here is yet another question -

With the devastating diagnosis of a tumor, do you see many patients turning to alcohol or drugs in an attempt to escape?

Bruce

Not typically, no. Some patients with pain from metastasis to the spine (from cancers of the body) may turn to alcohol or drugs if their pain is not adequately treated by their physicians. I have not seen this with brain tumors. I had one patient with an ependymoma of the cervical spine return to alcohol and drugs because of emotional issues, but he also had a history of alcohol and drug use prior to the tumor. Dr. Landolfi

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Hello again Dr.;

Here is yet another question for you:

I personally am biased in favor of the worth of a support group for tumor survivors, and their caregivers/friends. How do you feel? Do you recommend your patients seek out one?

Thank you!

Bruce

Definitely. I am lucky to have Patty Anthony as my nurse. We both recommend support groups and patient education to all of our patients that we treat. I also see patients with trigeminal neuralgia because of the gamma knife radiosurgery treatment that I do on those patients, and recommended the trigeminal neuralgia support group for them as well. I think or group are a central part of the patient's treatment. I believe it is very good to interact with people who are suffering from the same disease but also, at times, it can be difficult to show your vulnerability to those you love the most for fear of hurting them. I think support groups are very important.

Dr. Landolfi

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Sorry I didn't send this out earlier in the day. Have you ever heard of or have an opinion of the "Johanna Brandt Grape Cure Diet"?

As always, thank you!

Bruce

i am not familiar with it. do you have any info?

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Hello again Dr. Landolfi;

Here is another;

Some of us have read that trauma to the spinal cord, or to the spine itself can shorten ones' life expectancy. Is this true for tumors of the spine?

As always, thank you!

Bruce

Significant trauma, particularly leading to the inability to walk or the inability to use the arms and legs can affect ones life expectancy. This would be true if the tumor caused the same deficits. This is due to increased risk of complications of being non ambulatory. Dr. landolfi

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Hello again, Dr. Landolfi;

A number of those who've had treatment for brain tumors, including surgery & radiation have varying degrees of mental fatigue. Some group members take stimulants such as Provigil, Modafinil, and Dexamphetamine. What is your view about treating mental fatigue with these or other medications? Are these medications palliative, i.e. only treat the symptoms, and are they likely to impare or enhance the brain's natural healing process?

As always, I thank you for your answers!

Bruce

I use them routinely. Another is Nemenda, Also Ritalin. Clinically, they enhance the brains function to help the patient lead a more normal life. The damage due to the radiotherapy and chemotherapy will not heal itself and these functions will most likely be permanently impaired although the fuction may plateau. We use these agents to help the brain that can't help itself, so the patient may have an improved quality of life. Dr. Landolfi

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Hello again Dr. Landolfi;

In almost every instance of craniotomy, there are cognitive impairments afterward. How long does the brain continue to heals itself?

Thank you again!

Bruce

cognitive impairments are not a complication of the craniotomy but rather the tissue removed depending on location. in general we can see improvement over 6 months with most occurring in the first 6 weeks. dr. landolfi

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Hello again Dr. Landolfi;

Another question -

There seems to be a common denominator of anger in those who have had brain tumors and/or BT surgery, and being especially angry/mean to caregivers and those close to them. This phenomenon seems to run across different types of tumors. Is this a purely rational, emotional reaction to having the tumor, or is it a more organic physiological response as a result of the tumors presence or surgery?

I want to take this time to thank you for sharing your excellent knowledge and opinions with us. It helps immensely!

In most cases it is any emotional reaction, and quite frankly, and appropriate initial reaction. I would be angry as well. In other cases, it may be due to the location of the tumor (for example, right frontal lobe) which may disinhibit the patient. In other cases, it may be medications. For example, Keppra which is an excellent drug in the neuro-oncology population, for some patients, can cause agitation and irritation, leading to "a short fuse". Dr. Landolfi

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