Right: Antonia Reyes with her husband, Billy, and her son, Anthony.
Antonia Reyes was 39 years old and 18 weeks pregnant when, on July 24, 2006, she was admitted to Hackensack University Medical Center (HUMC) in New Jersey after a sudden-onset severe headache and apparent seizure followed by disorientation and left-sided weakness. Had she not been pregnant, Antonia would have undergone magnetic resonance imaging (MRI) with contrast and, depending upon the results, been treated with immediate surgical resection followed by chemotherapy and radiation.
Instead, she had an MRI without contrast that revealed an apparent glioma (suspected to be an astrocytoma) in the right temporal-parietal lobe region. After 1 week, Antonia was discharged home on anti-seizure medication, returning for twice-monthly neurological evaluations and fetal monitoring until her November 15 C-section. Despite being moderately aggressive, astrocytomas are relatively slow-growing; the decision to postpone treatment was based on best evidence that such a delay would not place her at risk.
Resection and Reoperation
The day after Antonia’s C-section, an MRI with contrast produced findings highly suspicious for a glioma, while more clearly delineating its right temporal-parietal location. Surgical resection was done on December 18. When postoperative MRI indicated that most, but not all, of the tumor had been resected, the decision was made to reoperate. Astrocytomas grow by infiltrating the brain, and residual astrocytoma cells remain even with a “clean” postoperative MRI; consequently, complete resection, as indicated by MRI, was Antonia’s best chance for survival and optimal quality of life.
After her second surgery, a repeat MRI showed that all visible signs of the tumor were gone. She was discharged on Christmas Eve, after which she experienced mild pain, fatigue, and headaches. Two weeks later, pathology results confirmed the diagnosis of anaplastic (grade III) astrocytoma.
On February 5, Antonia started the following combined temozolomide (Temodar)-radiation regimen:
- Low-dose (75 mg/m2), once-nightly oral temozolomide for 6 weeks in conjunction with daily radiation therapy, followed by a 4-week rest period, and
- Full-dose (150 mg/m2), followed by 200 mg/m2 once-nightly temozolomide, 5 days/week every 28 days for 19 weeks.
Adverse effects included mild nausea, constipation, and stomach pain. Fatigue (primarily from the radiation) was sometimes extreme and, as is typical, worsened later in the day and during the latter portion of the radiotherapy regimen. Platelets and white blood cells were checked each week throughout treatment.
The use of temozolomide for grade III astrocytomas was controversial in 2007 and remains so today, as all of the data on the drug are from studies of patients with grade IV tumors (glioblastomas). While some oncologists would opt to treat such patients with radiation alone, using temozolomide only in the event of a recurrence, gross resection followed by this relatively aggressive but well-tolerated combined modality is, today, considered prudent by most neuro-oncologists, especially since patients with anaplastic astrocytomas almost always relapse 2 to 5 years post-treatment.
5 Years of Remission
Antonia has now been in remission for over 5 years and her MRIs remain completely clean. Seizure-free since her first hospital admission, she is now off all medication and is doing her best to cope with hot flashes from medically induced menopause, which began shortly after treatment. Her occasional right-sided “ice cream headaches,” loss of balance, and minor episodes of forgetfulness are likely late post-radiation complications of vasculopathy, seen in a number of patients years after treatment, and may plateau or become slowly progressive. Most recently, Antonia was told that her MRIs, obtained every 3 months since surgery, will now be needed only twice yearly.
Antonia’s pregnancy added layers of complexity to the already dire situation of a young woman with an infiltrative brain tumor. While in some cases, pregnant women can begin chemotherapy without risk to the fetus, it is unclear whether temozolomide adversely affects fetal brain development; therefore, Antonia’s preoperative nursing care consisted of close neurological monitoring along with developmental monitoring of the fetus.
Antonia greatly appreciated the encouragement she received from her surgical intensive care unit (SICU) nursing team and, in particular, Jennifer Lee, RN. In an interview with OncLive Nursing, Lee said, “The unknown is frightening, and a nurse’s explanation of what’s happening and why puts patients at ease.” She added that Antonia’s steady stream of visitors—thanks to the SICU’s open visitation policy—undoubtedly had a positive impact on her recovery.
Lee described her nursing duties as primarily standard-of-care neurologic monitoring (eg, pupil reaction, signs of weakness, orientation, ability to follow commands), initially performed every 2 hours, and then every 4. Antonia’s C-section 1 month prior did not alter her nursing care; adjustments in medications might have been needed had she been breast-feeding.
While significant from Antonia’s perspective, Lee explains that it is not unusual for a patient to undergo a second surgical procedure so quickly, and that postoperative care tends to remain essentially unchanged. Once neurologically and clinically stable, patients like Antonia are typically transferred from the SICU, where the patient-to-nurse ratio is 2:1, to the immediate care unit, where this ratio more closely resembles that on a regular medical-surgical unit. At this point, patients are reassured and prepared for the change in their care routine.