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Case
Report: A Favorable Outcome for an Unconventional Treatment of Glioblastoma
Multiforme
Evan
Ross, LAc
 Standard
care for a glioblastoma multiforme (GBM) is well known: surgery and then
radiotherapy, occasionally followed by radiosurgery and ultimately some form of
chemotherapy. The flavor of the month is presently timador, but prior to that it
has ranged from high-dose tamoxifen to vincristine or BCNU. Unfortunately,
standard care yields standard results: results that are usually unfavorable. One
oncologist described treating a GBM conventionally as "reshuffling deck
chairs on the Titanic after it hit the iceberg."
This
case presentation describes treatment of a grade IV GBM in an unconventional yet
remarkably effective manner. It is remarkable not only for its unusual Western
medical approach, but also for its successful use of a vast array of
complementary and alternative medicine modalities.
Presentation
A
25-year old, right-hand-dominant male with a history of bilateral retinoblastoma
presented with severe unilateral headaches on the right, transient weakness and
isolated focal convulsions of the left lower extremity. His left eye had been
enucleated in 1972 and his right eye treated successfully with cryotherapy. The
patient was evaluated for his current symptomatic presentation by his internist
at Cedars-Sinai and sent for a neurologic consultation. Neurologic examination
revealed a well-nourished, well-developed male in mild psychological distress.
He reported job-related stress and difficulties with his girlfriend of several
years, both of which he felt were contributing to his condition and which his
psychotherapist reportedly diagnosed as panic attacks. Visual fields were intact
in the eye not affected by the retinoblastoma. Sensation to pinprick was normal.
Cranial nerve function was normal as well, but deep tendon reflexes were
increased mildly on the left. There were also mild strength deficits of the left
upper and lower extremities. An MRI was recommended, but the patient refused.
Ten days later he presented again, his headaches having worsened and having been
vomiting for several days. He was now experiencing mild respiratory distress and
increasing weakness on the left side.
An
MRI revealed a moderately well-circumscribed six-centimeter mass in the right
frontal parietal region. No gross infiltration of the corpus callosum was noted,
but there was significant edema resulting in its compression, as well as a
severe midline shift. The fourth ventricle was also severely compressed. The
patient was placed on Dilantin 300mg. TID, Decadron 8mg.TID and Zantac 75mg. BID
prophylaxis for ulcer. A CT-guided stereotactic biopsy was performed at
Cedars-Sinai two days later, and initial pathology favored GBM.
Treatment
The
patient underwent a craniotomy at the University of California, San Francisco
(UCSF) three weeks later, where a subtotal resection (<50%) was achieved.
Subsequent pathology at UCSF, the University of California, Los Angeles and the
Mayo Clinic confirmed GBM. The patient was offered participation in a clinical
trial of radiation with a BCNU boost at UCSF but opted instead for a protocol at
the Cedars-Sinai Comprehensive Cancer Center consisting of high-dose carboplatin
(724mg/m2) with autologous stem cell rescue, combined with high-dose
methotrexate (55g.). After six months of treatment, the tumor shrank by >50%
postoperatively. Midline orientation and the fourth ventricle were found to be
normal on MRI. The patient was neurologically asymptomatic at this point, aside
from a 5% postsurgical deficit. Stereotactic radiosurgery was recommended, and
the patient underwent the procedure at approximately 2000 Gy with no significant
gains. After careful consideration, another craniotomy was recommended to remove
the remains of tumor still visible on MRI. The patient requested Gliadel to be
implanted during surgery, and the request was granted. However, during resection
the fourth ventricle membrane was pierced. Having planned for this contingency
prior to the procedure, 10 mg of methotrexate was injected into the CSF
intra-operatively instead. The patient tolerated the procedure well, and a gross
total resection with clear margins was achieved. Two more rounds of lower-dose
methotrexate (25 g and 40 g, respectively) were administered subsequent to
surgery prophylactically, and the patient was released from treatment one year
and three months from diagnosis. Biannual MRI scans reveal no recurrence of
disease, and the patient now practices integrative medicine himself at
Cedars-Sinai.
Perhaps
now is an appropriate time to tell the reader that the above-named patient is
also the author of this article, seven plus years since diagnosis. Now let me
inform you of all the things that do not appear in the above case report.
An
Integrative Approach
One
of the best things that one particular neurooncology team did for me was to say,
"There's really nothing we can do for you." While I do not advocate
their approach, which was essentially to issue a death sentence, I took it as an
opportunity to be proactive. I began rigorously pursuing a multitude of
complementary medicine modalities. Indeed, if not for my integrative approach, I
am convinced I would not be alive today. The most difficult part was that there
was no one else familiar with the array of approaches I was employing who could
guide me. I, therefore, consulted numerous experts, gathered as much information
as I could, and when I was satisfied that I had heard the range of opinions, I
sat in quiet meditation and listened to what my instincts told me would be most
helpful to me. Ultimately my approach was to attempt to offset the side effects
of aggressive Western treatment, allowing myself to tolerate higher doses at
closer intervals with fewer side effects. The results were both a consistent
regression of disease and increased quality of life, both during and after
treatment. Indeed, even after two stem cell transplants performed six weeks
apart, I did not require a blood transfusion, nor did I vomit, lose my hair or
suffer other related symptoms that patients are often forced to endure, such as
bacterial and fungal infections, insomnia, gastrointestinal problems and the
like. I attribute these unusual results to the complementary modalities I
carefully chose.
Body
In
retrospect, my approach was quite systematic. I addressed the physical body -
the disease itself - via Western medicine but also with herbs, supplements and
diet to boost my immune system. I researched the herbs and supplements that were
prescribed by an Ayurvedic physician (Ayurveda is to India as Oriental medicine
is to China) so as to prevent any known herb-drug interactions and began eating
a diet based on macrobiotic principles. The diet made it possible for my immune
system to spend less time processing hormones and pesticides, thus providing
more energy to fight the disease. I allowed myself to eat whatever my body would
tolerate during chemotherapy in the interest of staying nourished as the first
priority. Once the worst of the symptoms had passed, I resumed the macrobiotic
approach. Acupuncture and yoga managed my nausea and pain, while light
weightlifting and daily qi gong breathing exercises kept me feeling
strong.
Mind
I
addressed the mental and emotional aspects of my illness via psychotherapy,
guided imagery and reading. I found a psychologist who specializes in the
"Simonton method," created by physician and cancer survivor, O. Carl
Simonton, MD. This approach to wellness allows the patient to create a health
plan that focuses on understanding the factors that contributed to the onset of
the disease without "blaming" the patient for its occurrence. It
helped me to take responsibility so I could be empowered to change those things
that were standing between me and full recovery. Guided imagery allowed me to
"communicate" with an image I created of my tumor. By doing so I was
able to discern to some degree why it was present, what it wanted and what it
needed me to change about my life in order for it to go away. To the Western
mind, this might seem like inner theatrics or pure imagination. It took me
little time to realize that the answers to my questions were coming from
somewhere within me - the same place the tumor came from. To confirm these
newfound notions, I began reading the works of respected physicians and authors
well known for their work in the field of mind-body medicine, from Bernie Siegal
to Andrew Weil and Deepak Chopra.
Spirit
I
addressed my spiritual issues in a very profound manner. I spent two days in a
tepee with a shaman. While he by no means guaranteed my recovery, he helped me
to understand the spiritual etiology of my illness. I consider my time with him
to be a major turning point in my recovery - the point at which I changed from
being a powerless victim of circumstance to an unusual soul who had been given
the chance to transform his life in a trial by fire.
Upon
my recovery, I made a commitment to be of service to others in some capacity. I
decided to pursue an education in acupuncture and Oriental medicine, since I
experienced such difficulty integrating traditional and complementary medicine
myself due to the lack of people educated in both subjects. Now more than seven
years later, I treat many patients with cancer in my own practice at
Cedars-Sinai. Surely it would have been easier to open a small office somewhere
in Beverly Hills, but I chose to pioneer the integration of Oriental medicine
into mainstream culture by opening my practice at Cedars-Sinai. I consider it
vitally important that my practice be located at a major institution like
Cedars-Sinai, not only because of the opportunity to collaborate with some of
the best physicians in the world, but because it is crucial that this country
learn to practice these two systems of medicine together so that we can help
patients to take advantage of the best of each in a safe, managed environment -
an environment sorely missing from my own treatment plan.
Conclusion
My
healing incorporated unconventional Western and non-Western treatments. There is
nothing miraculous about me as an individual. Rather, the miraculous nature of
this case presentation lies in the successful integration of two types of
medicine, each of which has advantages and disadvantages. I have no doubt that
my "favorite outcome" was achieved by the combination of both,
creating a sum greater than either of the parts.
Evan
Ross, LAc, is a board-certified acupuncturist, herbalist and doctor of Oriental
medicine. He is the Complementary and Alternative Medicine Advisor to the
National Brain Tumor Foundation and serves on the Professional Advisory Board
for the Center for Integrative Health, Medicine and Research in Los Angeles. He
maintains a private practice in the medical towers at Cedars~Sinai Medical
Center, specializing in complementary oncology care and pain management.
Source: http://www.cedars-sinai.edu/3988.html
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