NOPPASIN TAKERNGDEJ, M.D.
Neurosurgery
If anyone still remembers the Thai movie released almost 20 years ago, "The Letter", you surely haven't forgotten the beautiful and pure love between a young woman and a young man from the very first day they met until the day one of them had to depart. The villain in this movie that forced the male protagonist to part ways with the female protagonist forever is a brain tumor named "Glioblastoma (GBM)", notorious for its severity, leading many to dub it brain cancer.
Glioblastoma (GBM) is a brain tumor that can expand rapidly and infiltrate surrounding normal brain tissue quickly, leading to severe loss of brain function in that area. The exact cause remains unknown. Even if physicians excise it, administer radiation, or use chemotherapy to destroy it, it can still recur, prompting doctors to continuously collaborate on developing new treatments to keep pace with the disease.
I have observed this type of tumor for many years and experimented with it to develop therapeutic drugs. During that time, I tried removing several genes that contribute to its growth, yielding certain results; namely, the tumor divides and grows less initially. However, this GBM tumor eventually resumes growth and multiplies just as rapidly as before. This demonstrates that the tumor attempts to adapt itself to survive. Today, medical technology helps treat patients' lives with greater efficiency.
Although the disease cannot yet be completely cured, it can prolong the time for patients to experience happiness and live longer than in the past.
Glioblastoma (GBM : Glioblastoma) is a severe malignant brain tumor developing from glial cells called "Astrocytes". (Astrocyte) This cell type is shaped like a 5-pointed star and plays a crucial supporting role for neuron brain cells (Neuron) in terms of nutrition and repair. Generally, this tumor occurs in 2 ways:
Currently, we can further subclassify GBM brain tumors in detail based on differing genetic characteristics of the tumor. This detailed classification helps us understand disease prognosis and treatment approaches. The primary gene used to distinguish GBM types is the IDH gene, subdivided into IDH-wild type and IDH-mutant, with studies clearly telling us:
Patients with GBM brain tumors of the IDH-mutant type have a post-treatment survival rate of more than 3 years, or approximately 34% . Interestingly, in patients older than 55, most cases are of the IDH-wild-type
Brain tumors usually present with diverse symptoms depending on the tumor's location in the brain. The most common symptoms of GBM brain tumors are:
The primary method for treating GBM brain tumors is surgery because, in addition to confirming the tumor type, surgeons can quickly remove the tumor and increase patient survival chances. Studies show that the extent of tumor resection correlates clearly with the recurrence rate and patient survival. Medical practice categorizes GBM brain tumor resection levels into 3 groups: gross total resection, partial resection, and no resection. Correlating with patient survival rates, these yield 15 months, 12 months, and 7 months, respectively.
Therefore, the group that can have the tumor resected extensively leaving minimal residual tumor will achieve the best treatment outcomes.
Completely resecting a GBM brain tumor is not easy due to the tumor's capability to invade normal surrounding brain tissue. Total resection may not be feasible in every case, especially when the GBM tumor intermingles with nerve fibers controlling arm and leg movement. Removing too much tumor can cause severe disability for the patient. Thus, surgeons must possess expert skill to preserve adjacent neural structures as perfectly as possible.
Achieving success under this concept requires multiple surgical assistant devices, including:
These surgical instruments serve the crucial function of enabling surgeons to map the brain (Brain Mapping) prior to surgery. From this brain map, we understand what each part of the brain controls, whether it can be resected, or if it must be spared to prevent severe postoperative disability.
DTI fiber tracking
Source : Special thanks for images from Dr. Naphasin Theakingdej, Neurosurgeon
Following surgery and determination of the tumor type, radiotherapy begins playing a role in managing remaining tumor cells. Additionally, chemotherapy is the subsequent treatment. Detailed biopsy results are crucial for chemotherapy because biopsy results showing a Methylated MGMT promoter gene achieve better treatment outcomes when receiving the chemotherapy drug Temozolomide. The reason is that patients with Methylated MGMT respond better to chemotherapy because their bodies lack the production of proteins used to repair GBM cells after damage by chemotherapy drugs. We find that 50% of patients in this group have a survival chance lasting longer than 2 years post-treatment compared to patients with Unmethylated MGMT.
For this reason, we understand more clearly why chemotherapy yields different treatment outcomes in GBM brain tumor patients.
Besides chemotherapy, doctors currently attempt to discover new drugs known as Targeted Therapy, such as Bevacizumab (Avastin), a monoclonal antibody that is vital in blocking proteins used for tumor growth from functioning. However, results are still not effective enough to serve as a standard treatment drug for newly diagnosed GBM brain tumor patients, though it may be considered in cases of tumor recurrence. Furthermore, electrical fields are currently utilized to disrupt tumor cell division, known as TTF (Tumor Treating Fields). This device is relatively new and is typically used as an adjunct device in cases of tumor recurrence after treatment.
How good treatment outcomes will be today can be simply evaluated using:
However, modern medical science and excellent treatment technologies can prolong patient lives longer than before.
From what we previously knew—that GBM brain tumor patients would live about 3 months after diagnosis—currently, after patients receive treatment involving surgery plus radiotherapy and chemotherapy, average survival can be extended up to 9-18 months post-treatment, with some cases surviving up to 3 years.
Coming to the conclusion of this movie, for me, "The Letter" did not just introduce us to GBM brain tumors; more importantly, it is a film that makes us reflect on whether we have spent enough time with our loved ones, echoing the question the movie leaves behind: “How much is the word love worth in your heart?”
23/03/64
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