Can this be Gammaknifed?

Can this 45 year old with grade 4/5 hemiparesis be offered gammaknife treatment? [I dont think so, considering proximity to brainstem, but just to be sure...]

Lesion measures 3.0X2.9X2.2 cms.

Question resolved:
As many of you suggested, the lesion is not suitable for gammaknife radiosurgery primarily because of mass effect on the brainstem which may even be aggravated by tumor swelling after radiosurgery. In fact, microsurgical excision is the primary option.
Outcome:
I could excise the lesion completely without new deficits [Subtemporal approach]. Hemiparesis is improving. Interestingly the fourth nerve comes from underneath the tent rather than between its leaves as they commonly describe.

Are we against the elderly? High grade glioma in the elderly – Do we condescend to sub-optimal therapy?

86-year-old man, developed recent onset of memory disturbance, general fatiguability and visual disturbance initially attributed to cataract. CT scan is suggestive of high grade glioma with mass effect in the right temporal lobe. Other than for mild attention span deficit and hemianopia, he has no deficits. He has good insight and judgment. Comorbid illnesses are unstable angina and well controlled diabetes. He and his relatives are afraid of surgery (who isnt?), risks of GA and ask “I am 86 yr old… can you give some medicines and manage this for one or two years?”

What do you do?

The options range from

1. Operative decompression [as total and safe as possible], ‘full’ radiation, chemotherapy.
2. Biopsy [open/STB] and adjuvant therapy [may be - palliative and less than full RT]
3. Do nothing definitive. Symptomatically treat with steroids, anticonvulsants, counselling for the terminal event.

Consider this ...

Substitute the 86 year old with a 30 year old young man.

The surgeon immediately offers option number one. Most of the time we do not offer or even consider options two and three. Why is that?

Is it because we are prejudiced against the elderly?

“He is 86 year old. Why take the effort and risk of resecting the tumor, subjecting him to the ‘stresses’ of surgery and GA at this advanced age? He could very well develop post op life threatening post op complications."
"Hasn’t he lived enough?"

Life expectancy statistics_____________________________

Life expectancy at birth in India is 64.35

Life expectancy for an 86 year old will be 87.30 [calculated from life table analysis, considering various risk factors]. Upper quartile being 87.85. That is around one and a half years of life left.

-With aggressive treatment of GBM, median survival is 8 months to one year.
-With no treatment it is 1-2 months
-With “suboptimal treatment” [like option two] it is 3-4 months.


That is, with optimal treatment, you are giving him 50-75% of the rest of his life back.

On the other hand, consider the case of the 30 year old man with life expectancy of 72 years, [42 years left]:
Even with aggressive treatment, you are only giving 2.4% of the rest of his life back. Even if he is a long term survivor of GBM [3% of GBM patients survive 3 years or more], that gives him back only 7% of the expected life span

So isn’t it in keeping with sound logic to offer aggressive treatment for the elderly with good KPS? Even eight months of quality life would mean so much for an 86 year old man.

Nobody has lived enough.