Pseudo Progression

Reader's alert:  Technical content ahead. Reward to follow.

Brain cancer is...

Not Darrell's brain.  Source:  Understanding and Managing Pseudo Progression

...NOT growing.  It's pseudo progressing.

Here's a vocabulary lesson in confusing and counter-intuitive cancer terms.  Ready?

• When a brain cancer tumor grows, it is called progression. (Most of us don't think of cancer growth as "progress," right?)
• In GBM world, then, people talk in terms of PFS (Progression Free Survival).  That's how long it takes before the tumor grows, or "progresses," if it does grow. So far Darrell is almost 6 months PFS...looking for many more months PFS! 
• They also talk about OS (Overall Survival).  That's how long people live in total after diagnosis, after the tumor recurs (if it recurs).

 Now to recent events in Darrell's case.  No bad news, don't worry.

•  As you know,  Dr. Cloughesy don't need no stinkin' radiologist report.  He always reads the scans himself, as the GBM expert.  He found no evidence of progression on Monday, 8/01.  In fact, he concluded that the tumor cavity appears to be collapsing.
•  The St. Jude radiologist read the recent scans and filed a report yesterday.  Although the result said, "normal," the radiologist also noted, "There is increased nodular enhancement particularly along the lateral margin of the resection cavity, suspicious for residual/recurrent tumor."  (Recall that "enhancement" is where we find bright spots on the scan.)  Here's Darrell's recent scan again, to show you the bright spots that outline the tumor cavity.

 

• Alex says that radiologists are known as the kings and queens of "hedge," meaning that they are very cautious in their reports, using phrases like "suspicious for recurrent tumor." But of course we were thinking of this radiologist's report as a bit of a wet blanket after our good news at UCLA Monday.
• Today the same radiologist filed an addendum to his report.  In the addendum, he notes, "Given the time frame, however, pseudoprogression remains a differential consideration..."
  

Pseudoprogression is a good thing, and it's a recent thing.

The standard of care for GBM that Darrell is receiving is surgical resection, followed by radiation and concurrent chemotherapy (temozolomide), followed by 5 days each month of maintenance dose temozolomide.  Named after the physician who led the trials with temozolomide combined with radiation, this standard of care is called the Stupp Protocol.  (The Stupp Protocol!  Now playing at a theater near you!)

This standard of care has been in place for fewer than 10 years.  Previously patients didn't receive chemo with the radiation.  (Side note:  Professor Stupp recently advocated for Optune to be added to the standard of care for newly diagnosed GBM, based on promising results to date.)
Apparently, combining radiation with chemotherapy--the very thing that makes it more effective than radiation alone--also causes something called pseudoprogression.  In pseudoprogression, it appears that the tumor is progressing, but it actually isn't.  For a while, the tumor cavity lights up in MRI scans as if there is progression, but then the enhancement dims away a few months later.

The first image, above, shows that the bright spots in panel c diminish over time in pseudoprogression, in panels e, f, and g.  

The bright spots, or enhancements, in pseudoprogression appear to be signs of tissue necrosis (cell death), an indicator that the treatment is working.

In conclusion, we find optimism in the likelihood of pseudoprogression: another of life's VGT (Very Good Things).
   

Alternate Hypothesis:  Brain Pokemon

No radiologist can rule out the possibility that Darrell has tiny Pokemon wreaking havoc in the posterior left frontal lobe of his brain.

Evidence:  Darrell's backyard battles. 

Darrell starts his morning with Pikachu and Charmander.

Darrell vs Gyroados

Darrell vs. Hitomanlee

Magnemites charge Darrell's Optune.

[Brain] Pokemon!  Gotta Catch 'em All!

 (Photos credit:  Pokemon support:  Summer Yoast.)