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Text 5
A memorable patient: keep looking for a reason
1. Read the text and discuss what was memorable about this
patient.
Sarah was 22 when she presented with the dreadful signs of a
large space-occupying lesion deep in the dominant parietal lobe. She
was drowsy with a severe headache, had severe dysphasia, and there
was a significant right-sided weakness. The computed tomography
said it all: a malignant intrinsic tumour at the trigone of the lateral
ventricle, probably a glioblastoma.
She rallied a little on steroids overnight and so I performed a cra-
niotomy, having suitably warned her worried family of the likely out-
come and prognosis. I found a very bloody tumour that had some def-
inition from the surrounding brain. The pathologist told me that the
frozen section showed a highly malignant brain tumour, consistent
with the radiologist's diagnosis. The survival from this type of tumour
in this position is measured in months, and there is no evidence that
surgery does much more than relieve the pressure symptoms. Conse-
quently, I completed a cautious internal decompression, stopped the
bleeding, and closed up. She was unchanged, but bled into the tumour
remnant the following day and I had to reopen the craniotomy. That
night I was relieved that she was no worse.
Sarah's tumour was a gliosarcoma. This is a rare and even more
malignant variant of a glioblastoma, in which it is thought that the
new vessel forming factors released by the primary brain tumour in-
duce sarcomatous change in the blood vessels. The news was not
good.
Surprisingly, Sarah started to get better. Her speech improved and
her hemiparesis almost disappeared. She was referred for radiotherapy
and underwent the full six weeks' course. The follow-up scan also
looked good. She lost her job in insurance, but became a police recep-
tionist.
Two years went by, but there was no sign of the tumour on further
scans. By then, Sarah had become a good friend of the hospital, active
in collecting money for the development fund and talking to the press
about her treatment.