Recurrent Cerebellar Hemangioblastoma

Contributor:

Dr. Chris Ekong

Consultants:

Dr. Michael West
Dr. Mike Tymianski
Dr. Michael Schwartz

Case 2

Age: 63

Sex: Female

History: June 14, 2003: Ataxia x 3 months. Headaches x 2 days. Vomiting x 1 day.

Examination:

GCS 15. Truncal and right arm ataxia.

Impression:

Right cerebellar mass.

June 14, 2003

• Emergency craniotomy done
• Hemangioblastoma excised
• External ventricular drain inserted for the hydrocephalus

June 19, 2003

External ventricular drain removed

June 25, 2003

Developed CSF leak. VP shunt inserted. Excellent results.

July 9, 2004

Routine follow up MRI done.

Progress - July 30, 2004

Patient is asymptomatic.

Would you

a. watch it

b. excise it

c. treat with gamma knife

d. other

September 1, 2004 - Dr. Chris Ekong, Neurosurgeon, Regina

Dear Mike, Mike, Mike, Max and Renn:

Your opinion on this case of recurrent hemangioblastoma would be greatly appreciated.

September 1, 2004 - Dr. Max Findlay, Neurosurgeon, Edmonton

Dear Chris,

Funny case, although I am sure you are not laughing. I gather the pathology has been checked--this isn't a hemangiopericytoma or atypical meningioma. At any rate I don't think there is any right answer here. Seeing this 63 year old has had two operations in a year and this small residuum is asymptomatic, another image in 3 to 6 months would be reasonable to me, with action to be taken only if it grew, then or on further follow-up. In that event surgery or radiosurgery would be reasonable, but its pretty accessible to a microsurgical approach (of course it was the last two times too and look what happened!) and that would be my personal preference, having not operated on her twice already. The patient could have a good say in this, and getting Mike West's ideas is certainly smart. Does she have any relatives here in Alberta I can get in touch with? My only recurrences have

been with Lindau's disease.

Let me know what you do.

Yours,

Max

September 1, 2004 - Dr. Renn Holness, Neurosurgeon, Halifax

Hi Chris

We are all influenced by our most recent case. I have been fortunate to have had only one like this, a young physician - also 2 trys both "complete" excisions. The 3rd time he had a good result eventually but a stormy course & hasn't really returned to normal activity.

I would have your pathologist reexamine the tissue 2nd opinions looking for increased mitotic activity in which case I'd opt for stereotactic radiation therapy, SRT. If this is the 'usual' Hemangio and in view of the age I'd give Winnipeg a call re gamma knife, SRS.

I am closer to her age than you and that would be my preference (recognizing that there are no large series such as exists with acoustics etc.)

Renn

September 2, 2004 - Dr. Mike Tymianski, Neurosurgeon, Toronto

Unless there are medical contra-indications, I'd take it out.. I think that it's achievable with minimal morbidity, and there may be opportunity for a cure.

Mike

September 2, 2004 - Dr. Michael Schwartz, Neurosurgeon, Toronto

Dear Chris,

I agree with Mike Tymianski. The tumor is circumscribed, accessible and usually cured by excision. If there is no contraindication, excision would be my preferred treatment. If the tumor recurred a second time, I would then recommend radiosurgery.

Mike

October 13, 2004 - Progress

Stereotaxic craniotomy and excision of recurrent tumour done. She has done well.

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