Multidisciplinary approach to malignant gliomas

Primary malignant brain tumors are among the most difficult human malignancies to manage. Other common tumors such as in the lung or breast generally can be cured if caught at an early stage. A 2 cm adenocarcinoma in the peripheral lung field without mediastinal or systemic metastasis can be cured. A small breast carcinoma which has not invaded into the regional lymph nodes can generally be removed with the expectation of permanent control. However, a 1 cm glioblastoma in the anterior right frontal lobe, even with gross total resection and maximum adjunctive radiation, will recur and cause death within a year or two. There is no realistic possibility of cure or even long-term survival. These patients pose unusual management problems. They require different medications such as anticonvulsants and steroids. There are neurocognitive problems and the quality of life is usually worse than for the other common malignancies. They require a multidisciplinary approach with health care providers skilled in a variety of disciplines. Malignant gliomas have two components. There is the main bulk of the tumor (the ring enhancing portion seen on the MRI) and the infiltrating portion than cannot be seen by any imaging method. Local control has improved over the past ten years, but control of the infiltrating portion is still lacking. It is likely that some form of biologic approach will be needed to seek out and kill these infiltrating cells that travel with such ease within the white matter tracts of the brain. Perhaps selective delivery of self-destruct genes to these cells will be possible. Perhaps the search and destroy potential of the immune system can be harnessed. If so, this incurable cancer may some day be brought under control. The effort involved will be extensive both in the laboratory and in the clinic.