Wednesday, May 21, 2008

Let's not write his eulogy just yet, and put down that damned shovel!

Teddy ain't dead yet, so let's all calm down - here, breathe into this paper bag for a minute or two and then we will get on with todays lesson...

First of all, speculation at this point is a mugs game. Instead, let's stick to what we know - which, frankly, isn't that much. The unknowns lap us five times before the knowns even get off the starting blocks. So let the suckers run, we are taking stock, not racing around with our locks alight.

So what do we know? We know that the Senator has a malignant glioma in the left parietal lobe. At this point I have heard nothing about the size of the tumor or the aggressiveness of the cancer, but those two bits of information are a necessary starting point for any assessment of prognosis, but I still wouldn't speculate because that would be above my pay-grade, in spite of all my actual training and experience.

Like I said, we will be sticking to facts as we embark on this intro to neuropathology, and we will start with what a glioma actually is...a glioma is a tumor of the primary central nervous system that involves the glial, or non-neuron (support) cells of the CNS. Glia cells are the majority of brain cells, outnumbering neurons by about 10:1. Glia cells manufacture myeluing and transfer glucose to neurons to provide the energy requirements of the nerve cells. Gliomas usually manifest intracranially, but can form in any part of the Central Nervous System (CNS), such as along the spinal cord or optic nerves. Further, gliomas fall into three categories, and are named by the cells they most closely resemble, ependymomas arise from ependyma tissue. In adults, an ependymoma usually arrises in the spinal cord. Oligodendrogliomas are believed to originate from the oligodendrocyte cells, or from a glial precursor cell. The third, and most common, gliomas are astrocytomas. They are tumors that arise primarily in the astroglia cells and rarely migrate outside the cranial vault. Astrocytomas comprise about 75% of neuroepithelial tumors.

What I have heard thus far indicates that Senator Kennedy has an Astrocytoma, but I have heard nothing about what grade the tumor has advanced to. About 15 years ago the World Health Organization (WHO) established a four-tiered grading system of histologic guidelines in an effort to reduce confusion in diagnosis.

The lowest grade astrocytomas (grade I and II) are the rarest CNS tumors diagnosed, while the highest grade (grade IV) astrocytomas, glioblastoma multiforme (GBM) are the most common CNS malignancies, and the second most common brain tumors diagnosed. Low grade astrocytomas are usually operable and the 5-year survival rate is above 90%. High grade astrocytomas, however, are frequently treated with palliative (pain and symptom control) measures. Untreated grade-IV astrocytomas are usually fatal within weeks of diagnosis, but with treatment survival and quality of life can be extended significantly.

We have all heard the term "inoperable brain tumor" since we were children. But most people don't know why that is. Tumors are usually not inoperable because of where they are located in the brain, although in rare instances that is a consideration. No, what makes the tumor inoperable is usually the structure of the tumor. High-grade Astrocytomas tend to "branch out" sending tendrils into the surrounding normal parenchyma. This characteristic makes complete resection of a stage IV astrocytoma impossible, and there is almost always a recurrence.

There are treatments available, however, and advances are being made every day - literally. One of the greatest weapons that we now have in our arsenal that did not exist when I started my career is the Gamma Knife. No blade, and no blood - the Gamma Knife is gamma radiation targeted with surgical precision at the malignant tissue. As imaging technology improves and is able to discern and define in ever-increasing clarity smaller and smaller anomalies; and this improved imaging is coupled with Gamma Knife technology that is becoming ever more precise and able to excise ever-smaller areas of abnormal cells, the outlook for patients diagnosed with a high-grade Astrocytoma is no longer limited to "here is your prescription for Dilaudid, and since it's going to make you puke, here is your prescription for compazine."

The outlook is not a pleasant one, but they are going to proceed with Chemo and radiation, so the fight is not being ceded just yet. Teddy Kennedy has access to the best healthcare and latest technology and the resources to secure them.

Without actual, clinical data, it is impossible for anyone to say for sure what he and his healthcare team are up against, so all thats left is speculation. And I already said I wasn't going to do that. But that's just me. Plenty of people are going to - so remember that that is exactly what they are doing...they are speculating. Even the folks who have the data are speculating at this point, Please keep that in mind when you hear the overwrought bleating of the media and the sheeple over the next couple of days.