12/10/2004
Dear Mr. Doe,
Thank you for your recent request for a second opinion consultation from The Cleveland Clinic Foundation. Please find below the second opinion consultation written by Dr. Gene Barnett, Department of Neurological Surgery. A registered nurse from the e-Cleveland Clinic office will call you within the next 1-2 days to ensure that you have received your second opinion and that any questions you may have are answered.

Feel free to contact the e-Cleveland Clinic nurse at 216.444.3223 or 800.223.2273 ext 43223, 8 a.m.- 5 p.m., EST, Monday through Friday, should you have additional questions or concerns.

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Second Opinion Consultation

Summary:

Date: 12/10/2004
Patient Name: John Doe
Physician's name: Gene H. Barnett, M.D.
Department: Neurological Surgery
CCF#: (MRN) 0-111-222-3
Date of Birth: 10/01/1949
Patient Address:
123 Main Street
Phoenix, Arizona 85012

Diagnosis / Reason for Consultation:

Meningioma

Mr. Doe was evaluated for headache and an intracranial mass was found. He has sought the opinion of a Cleveland Clinic specialist through e-Cleveland Clinic in order to determine his "next step" and, in particular, the role of noninvasive treatment of the tumor.

Diagnostic Summary:

Review of his medical records, which he has forwarded to e-Cleveland Clinic, demonstrates a right sphenoid wing meningioma 2.0 x 2.5 x 3.0 cm (as well as small vessel disease and sinusitis). His past medical history is notable for hypertension, history of colonic polyps, diverticulosis, lumbar spinal stenosis, and a remote history of atrial fibrillation. His present medications include Allegra 60 mg bid, Maxzide 75-50 Qd, Celebrex 200 mg Qd, Clonazepam 1 mg Qhs and methylprednisolone 4 mg Qd. According to a history by his PCP from 9/00 he is manager in technology company, he does not use cigarettes and drinks wine occasionally. There is no family history of brain tumor or cancer.

Treatment Summary:

This 52 year-old man was treated for sinusitis in May/June of this year with resolution of that headache, but a persistent right-sided dull pain. It was not exacerbated by light or sound and he distinguished it as being something other than migraine headache. They were improved by reclining. The headaches worsened, and his wife noted a change in behavior such that he would come home from work at lunch and not return to work thereafter. An MRI of the brain was performed on 11/12/04 showing a right sphenoid wing meningioma 2.0 x 2.5 x 3.0 cm (as well as small vessel disease and sinusitis). When seen by his primary care physician, his weight was 250 pounds, BP 148/70, pulse 72 and respirations 16. Some right lateral deviation and puffiness were observed of the right eye. He was begun on a tapering schedule of low dose Medrol. Use of this steroid is associated with improved symptoms and a return to more normal behavior.

An opinion from a neurosurgeon in Phoenix was reportedly that his options were to monitor the tumor, surgically remove it, get a second opinion, or treat with radiosurgery / radiotherapy.

I personally reviewed his MRI scan. This shows a durally based, avidly enhancing lesion in the region of the medial right sphenoid wing. There is hyperostosis of the underlying bone. There is surrounding brain edema and mild shift of the midline. The tumor is adjacent to the middle cerebral artery and right optic nerve. It is most consistent with meningioma. There are also small vessel changes in the brain and brainstem.

Second Opinion Recommendations:

Mr. Doe has various options. These include observation, surgical resection, radiosurgery, fractionated radiosurgery and radiotherapy. I do not believe that medical therapy would be effective or indicated at this time other than symptomatic treatment with steroids - these should be tapered off as soon as symptoms allow.

Of these options, I believe that conformal radiosurgery (where the delivered radiation conforms to the shape of the tumor -- such as delivered with the Gamma Knife) or fractionated conformal radiosurgery (such as delivered with the CyberKnife) are the best management options. Although observation is clearly an option, his headaches are likely to worsen and chronic steroid treatment is not a good alternative. Surgery on this lesion is certainly feasible, but its proximity to the middle cerebral artery and nerves to and from the right orbit (eye) mean there is real risk of disabling stroke or visual impairment in the right eye (it is unclear if he has any vision problems at this time - this should be assessed with formal visual testing and peripheral vision testing). Also, surgery of this lesion is not likely to be curative.

The extended control rate from radiosurgery of meningioma is upwards of 80%. The principal risk in this case would be a small risk of visual loss in the right eye or delayed brain edema (swelling). The risk of visual loss could be further lessened by fractionating the radiation (delivering lower doses in several sessions) but would require about two weeks of treatment. The Gamma Knife requires one day for treatment. There is no convincing evidence that Proton Beam radiosurgery is superior to Gamma Knife radiosurgery for meningioma - in fact, results of the Gamma Knife are generally held as the "gold standard" for radiosurgery. The Lexar system may also be able to provide single or multiple fraction conformal radiosurgery although there is much less published information on it than for Gamma Knife or CyberKnife.

In short, my recommendations are: 1) Get visual acuity and field testing, 2) taper off steroid (Medrol) as soon as symptoms allow, 3) Treat with either conformal radiosurgery or fractionated conformal radiosurgery in the near future.

References:

I am forwarding with this consultation written literature on the Gamma Knife. In addition, should the patient have additional questions regarding these recommendations as he prepares to make his decision regarding future care, he should not hesitate to contact the nursing staff at e-Cleveland Clinic, who are in contact with my clinical nurse specialist.

Physician Signature:
Gene H. Barnett, M.D./sp

D: 12/10/04
T: 12/10/04

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