A 54-Year-Old Woman With Recurrent Headaches and Seizures

Brian D. Kavanagh, MD: This tumor board conference will focus on the case of a 54-year-old woman with a 2-month history of headaches and seizures, who was diagnosed as having a primary brain tumor. The key features of the diagnostic work-up and management strategy will be presented, and relevant topics of ongoing basic research will be discussed. First, Dr. Manning will present the case history.

Matthew A. Manning, MD: The patient is a 54-year-old woman who pre-sented in December 1996 with a rightsided headache and generalized seizure. A magnetic resonance imaging (MRI) scan of the brain at that time was normal. In January 1997, the woman experienced another severe headache and a second seizure. Repeat radiographic imaging again was interpreted as normal, and anticonvulsants were started. Her headaches continued to worsen, and an MRI performed in February 1997 revealed a right frontal enhancing brain mass that appeared to be a primary brain tumor.

The patient’s medical history is remarkable only for asthma and mild emphysema. The family history included a grandmother with gastric cancer. The patient had been taking estrogen replacement therapy since menopause 3 years earlier, and she was allergic to peroxide.

The patient is married and has three healthy children. She works full time in the family business. She smoked one to two packs of cigarettes daily for 30 years, but she quit smoking 3 years previously. She does not drink alcoholic beverages or use illegal drugs.

A review of systems revealed no complaints other than the previously noted neurologic symptoms. Karnofsky performance status was 90. Physical examination, including a detailed neurologic examination, was entirely normal for a woman of her age in generally good health. Laboratory studies, including a complete blood count and serum chemistries, were normal, and a chest radiograph demonstrated no infiltrates or mass lesions.

On March 11, 1997, the patient underwent a right frontal craniotomy with gross total resection of what was identified histopathologically as a glioblastoma multiforme. There were no postoperative complications or neurologic deficits.

The patient was then enrolled on the Massey Cancer Center 96-12 protocol, through which she received 50 Gy of wide-field, conventionally fractionated external-beam radiotherapy, followed by 24 Gy administered via four weekly concomitant stereotactic boost treatments, for a total of 74 Gy to the tumor bed. The patient has also received three of four planned cycles of carmustine (BCNU [BiCNU]) therapy, administered intravenously at a dose of 80 mg/m²/d for 3 days every 8 weeks.

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