Clinical Course for Daniel Katz-Stein, Anaplastic Oligodendroglioma

February 1995:  New onset seizure X 2, gran mal.  MRI demonstrated a 2.5 mm by 5mm mass lesion in the right frontal area, just anterior to the motor cortex.  He was given dexamethasone 5 mg q6h, and dilantin and referred for surgery. 

March 1995: Complete surgical resection of tumor, by surgeon Joseph Goodman, Arthur James Cancer Research Center , Ohio State University.  Pathology reported grade 1 oligodendroglioma, with all tumor margins visualized.  No adjuvant therapy.  Recovery from surgery was uneventful.

July 1996: 4 grand mal seizures in 4 hours. He was referred to a neurologist for follow up.  Seizures were diminished with medicine, but were not completely controlled.  He experienced partial complex seizures either daily or weekly. 

July 1999:  New tumor growth demonstrated on annual MRI. 

September 1999:  Complete surgical resection of tumor by Peter M. Black, Brigham and Women’s Hospital, Harvard University .  Pathology reported of a grade2 oligodendroglioma.  Other pathological features of this tumor included a MIB labeling ratio of 8 %, infiltrating into healthy brain tissue, but was not anaplastic.  Full resection of tumor required excision of a portion of the supplemental motor area.  Recovery was complicated by dense left sided hemiparesis and abscess at surgical site.  Hemiparesis resolved to about 80% of pre-surgical function within the first year. 

October 1999:  Abscess evacuated with port placed to drain infection.  Cultures grew P. acnes.  Hospital stay of 21 days included IV PCN G, drain of infection every other day with intraport injection of vancomycin, 2 additional surgeries for port replacement.  IV continued for 6 weeks total.  Port removed in April 2000.

September 2000 – August 2002: 2 years of remission after the second surgery.  He did not have seizures, was able to drive and work 70 % FTE.

August 2002: Myoclonic seizure, with Jacksonian march (foot through leg, upper body and arm) and Todd’s postictal paralysis.  August MRI demonstrated no obvious pathology.  Seizures continued weekly, then daily, then multiple daily.  November MRI demonstrated 3.5 cm parafacine mass, enhanced with Gadolinium.  PET demonstrated enhancement with glucose and methionine, indicating high grade malingnancy. 

December 2002:  Complete resection of tumor by Black.  Pathology reported anaplastic oligdendroglioma, rare astrocyte involvement, +vascular proliveration, minute foci of necrosis, foci of brisk mitoses, MIB1 varies from region to region, 30% – 50%. 

January 2003:  Status epilepticus – 10 – 15 minute complex partial seizures with 5 to 10 minutes in between for 4 hours.  CT and MRI indicated CSF with high protein density, and infection could not be excluded. 

January 2003:  Infection site evacuated.  Gross infection found in dura, skull fragment and surgical cavity.  Cultures showed methicillin sensitive S. aureus and P. acnes.  Further treatment included 8 weeks IV vancomycin and rocephin and 2 weeks oral duracef.   February MRI, although obscured by motion artifact from seizure activity, showed improvement from January postoperative MRI. 

April 2003:  MRI demonstrated 3 cm parafalcine mass that gad enhanced, with some ring enhancement.  April MRI read by one neuroradiologist as “consistent with recurrent abscess” and another neuroradiologist as “recurrent tumor”.  Treatment presumed abscess and IV started with maxipime and metrodinozole.

May 2003:  MRI demonstrated parafalcine mass and cortical mass, enhancement consistent with tumor.  Black recommends radiation, Weinstein clears for adjuvant therapy (chemo or radiation). 

May/June/July 2003: CCF team decides surgery is not an option, composite MRI/PET/CT demonstrates multiple lesions, recurrent and malignant.  Final recommendation is IMRT radiation (31 treatments) with concurrent (42 days) Temodar chemotherapy plus 6 months additional chemotherapy.  

Jan 2004: After 4 courses of  Temodar chemotherapy (5 days on/23 off), MRI is still 'stable,' but starts to experience mini-seizures in his left leg.  His ability to walk decreases from mile to .2 of a mile in two months.  He experiences serve headaches. 

Mar 2004: After 6 courses of  Temodar chemotherapy, MRI shows still stable.   His headaches have reduced by increasing Zonegran, but clinical symptoms remain.  Decide to change to change course of  Temodar chemotherapy to 1/2 strengeth - 6 weeks on/ 2 weeks off.