Brain Tumors

A lot of the medical topics I know the most about are those that have affected someone close to me, or myself. Naturally I tended to do the most research on these subjects as I was trying to find helpful information for the person affected.

In the case of brain tumors, the person I knew was a good friend of mine from work. Sadly, the information I found was not helpful because the type of brain tumor my friend had was nearly always fatal.

I had known her for about two years. She joined our department as a new hire from another company. She immediately fit right into our group and she and I developed one of those work friendships where you stop into each other's cubes and talk, both about business and personal lives, go out to lunch occasionally, and enjoy each other's company during the day. We had often said we should really get together outside of work but hadn't gotten around to it. Little did I know that we would never have that opportunity. I wish we had acted on our plans.

One day at the beginning of the year 2000, January 7th, to be exact, we were both attending a goodbye party after work for a colleague and my friend mentioned she had a terrible headache. She left relatively early. It was a Friday, and I didn't think anything more about it over the weekend, as she had been prone to headaches before.

That Monday she called her manager and left a message - over the weekend her headache had become unbearable and she had gone to the emergency department of her local hospital. A CT scan revealed the bad news: she had a brain tumor.

She and her husband went for the best possible care; she had an operation at Sloan Kettering to remove the majority of the tumor. A few tendrils were not able to be removed but they hoped the radiation afterward would eliminate them.

She chose not to have chemotherapy and tried natural remedies instead, using a new juicing machine she bought. She consumed her antioxidants faithfully, grinding up vegetables and fruits in the juicer to ensure as much consumption as possible of the valuable ingredients.

Sadly, it did not help. The tumor came back that summer. By September 6th she was gone. Her tumor was a glioblastoma, the most aggressive type of brain tumor. Few people survive it more than a year.

This entry is for you, Vicki.

What types of brain tumors are there?

There are two major kinds of brain tumor: primary and metastatic. Metastatic brain tumors have spread from another part of the body and are actually made up of cells from the other cancer. Primary tumors originate in the brain. This essay will focus only on primary brain tumors. There are also brain tumors that specifically develop in children. This will just focus on those that are common in adults.

Tumors can be either benign (non-cancerous) or malignant (cancerous). However, unlike other tumors, even benign brain tumors can be dangerous.

Tumors can harm the brain in various ways: they can destroy brain cells, cause damage by producting inflammation of the brain, or cause swelling that compresses other areas of the brain and increases pressure within the skull.

Primary brain tumors can grow from within brain cells, the meninges (membranes around the brain), nerves, or glands.

The cause of primary brain tumors is unknown, although there are theories that everything from cell phone use to radiation or microwaves can cause them. There are a few inherited conditions that seem to increase the risk of brain tumors. Otherwise, the following risk factors are associated with an increased chance of developing a primary brain tumor:

• Being male (except for meningiomas)
• Being white (they are less common in other races)
  Being older (most brain tumors are in people 70 years of age or older). My friend was only 36.
• Exposure to radiation or certain chemicals at work (formaldehyde, vinyl chloride, or acrylonitrile).

In adults, gliomas and meningiomas are the most common types of tumors. Gliomas are derived from glial cells such as astrocytes, oligodendrocytes, and ependymal cells. Together they account for half of all primary brain tumors, and 90% of adult primary brain tumors. The gliomas are subdivided into 3 major types:

• Astrocytic tumors - these include astrocytomas (less malignant), anaplastic astrocytomas, and glioblastomas (most malignant). Although astrocytomas are less malignant, unfortunately they can change over time to more malignant forms.
• Oligodendroglial tumors - can also vary from low grade to very malignant. Some brain tumors are a combination of both astrocytic and oligodendrocytic tumors. These are called mixed gliomas.
• Glioblastomas - the most aggressive type of primary brain tumor. These may or may not arise from a prior lower grade primary brain tumor. This was the tumor that afflicted my friend.

Another relatively common type of brain tumor is the meningioma. This tumor arises in the meninges, the tissue surrounding the brain. You're more apt to get this type of tumor if you're a woman between 40 and 70 years old. Meningiomas are usually benign (90%) but depending on their location in the brain, can still produce devastating consequences.

There are a number of other brain tumors that are much less common than these types and I won't go into them for the purposes of this entry.

What are the symptoms?

In my friend's case, headache was her first, primary symptom. Later on when the tumor returned after surgery, she developed difficulties in thinking and speaking.The most common symptoms of a brain tumor are:

• Headaches - usually worse in the morning
• Nausea/vomiting
• Changes in speech, vision or hearing
• Problems balancing or walking
• Changes in mood, personality, or ability to concentrate
• Problems with memory
• Muscle jerking or twitching, including seizures or convulsions
• Numbness or tingling in the arms or legs

Unfortunately, many of us get headaches, including some that cause nausea or vomiting (such as those who suffer from migraines). So if you are a hypochondriac who gets migraines, you have probably been to the hospital a few times thinking you had a brain tumor.

A stroke can also cause very similar symptoms. It is very important to go to the hospital immediately if you start having any of these symptoms.

How are brain tumors diagnosed?

The following tests may be used to confirm the presence of a brain tumor and/or identify its location and type:

• CT scan or MRI of the head
• Electroencephalogram (EEG) - a test that shows the brain waves
• CT-guided biopsy (to determine the type of tumor)
• Biopsy during surgery to remove the tumor
• Examination of the cerebral spinal fluid, which may show cancerous cells

What treatments are available for brain tumors?

Treatment depends on the size and type of tumor. In some cases, the goal may only be to relieve symptoms, improve quality of life and the comfort of the patient. Other tumors may be curable.

If a tumor is accessible, surgery is usually done to either try to remove the whole tumor or at least "debulk" it. Afterward radiation and/or chemotherapy may be used to try to eliminate the rest of the tumor.

Corticosteroids may be used to reduce swelling and inflammation. Other medications may be provided to relieve specific symptoms such as seizures.

There are various methods of operating on brain tumors that are used at hospitals specializing in the treatment of brain tumors. The Gamma Knife is a non-invasive way to eliminate tumors. This link will explain more details: http://pennhealth.com/neuro/gammaknife/.

Another type of non-invasive surgery is the Cyber-Knife, described in the following link: http://www.phillycyberknife.com/cyberKnifeTechnology.html

There are also newer medications, chemotherapy and other promising treatments. Two new methods have been developed to more effectively target the brain tumor:

• Gliadel Wafers: These wafers are implanted directly at the site of the tumor during the brain surgery. They then slowly release potent chemotherapy agents (BCNU or carmustine) at the site where the tumor was removed to kill any remaining tumor cells that may still be present.
• Gliasite Radiation Therapy System: The Gliasite Radiation Therapy System is an implanted radiation delivery device consisting of a tube with a balloon and a port. The balloon is placed into the location of the tumor at the time of surgery. The balloon is filled with a liquid radiation solution by the radiation physician for a specific period of time, thus directly treating the area. More information is available on the website listed below for the Wallace Kettering Institute.

The following link has a wealth of information about brain tumors, clinical trials, and new medications that are available: http://www.virtualtrials.com/

There is also a section on survivor stories that should be inspirational to anyone who has been diagnosed with a brain tumor. Some glioblastoma patients have beaten this terrible tumor and lived many years. This site also has detailed information on treatments that are available.

One important drug, Temodar, is often used for glioblastoma patients. My friend started on it right before she passed away, when it was newly approved. Unfortunately it was too late for her, but has been found to prolong the lives of many patients.

Will you get a brain tumor?

Probably not, although they are becoming more common among adults in the past 25 years, probably due to the aging of the population.

Lifetime risk of a brain tumor:
Males have a 0.66% lifetime risk of being diagnosed with a primary malignant brain tumor and a 0.50% chance of dying from a brain tumor. Females have a 0.54% lifetime risk of being diagnosed with a primary malignant brain tumor and a 0.41% chance of dying from a brain tumor. (Data taken from the Brain Tumor Society website: http://www.tbts.org/itemDetail.asp?categoryID=383&itemID=16635)

General information for this article was taken from the MedlinePlus website, the National Cancer Institute website, and the Wallace Kettering Institute of Neuroscience website, http://www.wkni.org/index.cfm, as well as other websites specifically cited above.

The Guinea Worm

This is a picture of a Guinea Worm emerging from the skin of an unfortunate sufferer.

I decided for my second post to talk about something you're not likely to get here in the Western Hemisphere, so I chose Guinea Worm Disease, also known as Dracunculiasis, since it was one of the first diseases I read about simply out of curiosity rather than trying to figure out what my own symptoms were.

I had read about the Guinea Worm in my old Merck Manual and thought it sounded hideous. Having just looked it up on the Internet to find out if any new treatments had been developed since my original reading, I was sorry to learn that the treatment has remained the same: slow extraction of the worm by gradual traction. This is a picture of the process.

What is Guinea Worm Disease?

It is an infection caused by the parasite Dracunculus medinensis. It is spread through unclean drinking water, and as such, is totally preventable.

The way it works is, the worms emerge from the skin of an infected person when they (the worms, that is) are mature. If the person is entering a pond or stream that is a source of drinking water, the worm can then release larvae into the water, which are then eaten by "water fleas;" there they develop into the next, infective, stage, within 10-14 days.

People become infected by drinking water with the fleas in it, thus starting the whole process over again in a vicious cycle.

Once a person ingests the fleas, the Guinea Worm larvae are released from the fleas as the fleas are digested, and these larvae cleverly find their way to the small intestine, where they are able to go through the wall and into the inside of the body cavity.

Once there, they happily ensconce themselves for the next year or so. The female worm grows to a size of two to three feet in length, about the width of a strand of spaghetti.

Once she is fully mature, the female worm migrates to a site where she can bore her way out of the body, usually the legs. A blister then develops where she is trying to get out, and after 2-3 days it will rupture. At any point after that if the worm is exposed to water, she will release larvae.

What are the symptoms?

There are usually no symptoms until about a year after a person becomes infected. A few days to a few hours before the worm emerges, the person may develop a fever, swelling and pain in the area. Although the worm mostly affects the legs, it can appear anywhere else on the body.

Patients often develop secondary bacterial infections from the worm, and this can cause disabling complications, which can seriously disrupt their lives.

How is it treated?

There is only one treatment for Guinea Worm. Once the worm emerges from the wound, it must be pulled out a little at a time each day and wrapped around a small stick. This can take weeks or even months.

The only other way to get rid of this worm is to remove it surgically before the ulcer forms.

Aspirin or ibuprofen can ease the pain and antibiotic ointment can prevent infection.

Will you get it?

Probably not. This disease is endemic in Africa, mostly in the Sudan, where civil war is making eradication difficult. Asia is now free of the disease, as are several African countries.

Since 1986, a number of health organizations have been working to eradicate the disease. The annual number of cases has declined in that time from 3.2 million to about 32,000 in 2003, which is very good news indeed.

The disease is only common in remote rural villages and in areas visited by nomadic groups. Anyone who drinks standing pond water contaminated by people with Guinea Worm Disease is at risk for infection.

Preventing it is a matter of educating the people to drink only water from underground sources that are free from contamination, to prevent people with Guinea Worm Disease from entering ponds and other bodies of water used for drinking water, and to filter any unsafe drinking water with a cloth, to remove the fleas, before drinking. Unsafe water can also be treated with an approved larvicide.

The source of this information was the Center for Disease Control's (CDC)website.

Appendicitis

I consider myself somewhat of an expert on appendicitis. Not only have I had it myself, but my husband (boyfriend at the time) had it, and I diagnosed it immediately when I heard his symptoms. In my own case, I knew I had appendicitis several days before the doctors figured it out, to my detriment.

It all goes back to my childhood when even then I was fascinated by medical subjects. I was a huge fan of Cherry Ames, Student Nurse, and all of the sequels. I also got caught up in another nurse series about a nurse called Sue Barton. In one of the Sue Barton books, Nurse Sue herself becomes sick with appendicitis. Although the books were for kids, they did describe the symptoms quite accurately. And when I got those same symptoms when I was about 23 years old, I knew I had appendicitis.

In my case, the symptoms had happened more than once. One day I had noticed a kind of gnawing pain in the pit of my stomach that didn't go away for several days. I popped Tums periodically and assumed it was indigestion. It did go away and I forgot about it - until a month or so later it came back, and got worse. The pain persisted until it finally moved downward. I got myself driven to the local hospital emergency room and they checked me out, decided I had gastritis, and sent me home with a shot of Demerol! I asked, "Aren't you even going to do a white blood count?" (as even then, my hypochondriacal knowledge included the fact that appendicitis causes the white cell count in the patient's blood to become very high due to the infection in the appendix). The resident in charge of the ER said "No, you don't have appendicitis, don't worry, go home." Later on the pain persisted so I called them again and they said to put a hot water bottle on my stomach! (Do not do this if you have symptoms of appendicitis. It makes it worse).

To make a long story shorter, 5 days later I ended up in the hospital with a burst appendix and was in for 10 days recovering from a nasty operation and getting IV antibiotics until I was well enough to go home.

So, in order to prevent this from happening to you, I will let you know more information about appendicitis than you ever thought you would need or want to know:

Appendicitis:
What is it?

The appendix is a small organ that is what is called "vestigial," meaning it is no longer a useful part of your body and basically exists to cause you problems, similar to your wisdom teeth. It is attached to your large intestine, usually on the right lower side of the abdomen. However, there are some people whose intestines are twisted or otherwise misaligned and the appendix can be elsewhere. This just makes life more difficult for these people. If you think I had trouble getting a diagnosis as it was, you can imagine what would have happened if my appendix had been on the other side.

Sometimes the appendix can become blocked, either by feces, infection or even swollen lymph nodes. In some cases, an injury can cause this. Some people have a genetic predisposition to develop appendicitis. Once the appendix is blocked, pressure builds up and it becomes inflamed. At this point the person is considered to be suffering from appendicitis and unless the offending organ is removed quickly, it can become a serious or life-threatening condition. The appendix can become gangrenous and burst, scattering nasty microbes all over the unlucky person's insides. This is called peritonitis and it is a Very Bad Thing.

What are the symptoms?

The symptoms of acute appendicitis may include:

• Pain, starting near the belly button, moving gradually downward and to the right
• Loss of appetitite, nausea, or vomiting
• Constipation or diarrhea
• Low fever
• Abdominal swelling

Some people may feel as if they have to make a bowel movement; however, if they have these symptoms they should NOT take a laxative.

One key symptom that often occurs is what is called "rebound tenderness." To find out if you have rebound tenderness, lie on a flat surface such as a bed, press into the abdomen around the area of the pain, and let go suddenly. If it hurts a lot more when you let go than when you first pressed in, you have rebound tenderness. Go to the hospital.

Another symptom that I have not seen listed anywhere, but certainly happened in both my case and my husband's, is profound nervousness. You develop a feeling of panic and feel you can't calm down. It may be a result of the infection causing adrenalin to be released in the system. Of course, if you are a hypochondriac as I am, you may get this feeling any time you think you are about to die of some strange disease. So this is not as definitive as the rebound tenderness! However, since it happened to my husband as well, and he does not tend to panic easily, I felt it was worth mentioning.

How is it diagnosed?

Back in the day, they didn't have all the fancy diagnostics they have nowadays, which is why I was not diagnosed easily. Now, if you arrive at the emergency room with your list of symptoms, they will do all the usual things like check your heart, your blood pressure, and other vital signs. They should do a blood test to see if you have a high white blood cell count from infection or any other signs of disease. Unlike in 1978, they also have ultrasounds and CT scans that can more accurately identify the source of the pain and diagnose the problem much more easily.

How is it treated?

Once appendicitis is clearly the cause of the pain, the patient is operated on and the appendix removed. This can be done through a small incision or else with laparascopic surgery, where there is a thin tube with a camera used to guide the surgeon as he uses several small incisions to access the area. This method results in a shorter recovery time and less scarring.

Will you get it?

You might, but it isn't that common. Lifetime risk of getting acute appendicitis is 8.6% for males, 6.7% for females (Rothrock et al, 2000).

If you suspect you have appendicitis, call your doctor immediately and go to the hospital. It is best to have your own physician overseeing your care, particularly if you have a good relationship with your doctor. But whether it is your own doctor or the doctor in the emergency room, you know when there is something wrong with you. Don't let them send you home without doing the proper tests to make sure they have diagnosed you correctly. Believe me, I know this from experience!

Source of this information was the National Digestive Diseases Information Clearinghouse website.

This is a blog for hypochondriacs

As a hypochondriac, I know that most of my kind are already fascinated with diseases and conditions that most people have never heard of. I for one have read the entire 1982 Merck Manual from cover to cover (since at the time there was no Internet to look things up on). I know more about river blindness, guinea worms, thyroid dysfunction and ebola virus, among other things, than most normal people.

I am also totally hypnotized by the Discovery Health channel's "Medical Mysteries," "Medical Incredible," and various other medically-related shows, to say nothing of "House" with that wonderful Hugh Laurie. Any show that has a mysterious illness every week that no one can figure out, is always a challenge to any good hypochondriac. Tell me your symptoms, I'll tell you your disease -- and then develop the symptoms myself and become convinced I have it.

Both of my parents were medical writers; my mom wrote abstracts for Hoffman-LaRoche's medical magazine back in the 40's and then worked in medical advertising, where she met my dad, who was a medical copywriter. I missed my calling - I probably should have followed in their footsteps. But, as George Eliot said, "It's never too late to be who you might have been." So I thought I'd start a blog to write about medical subjects.