BACKGROUND:High-grade gliomas are the most frequent primary brain tumors. Despite improvement in diagnostics and treatment, survival is still poor and quality-of-life issues are of major importance. Little is known regarding the clinical signs and symptoms of dying patients with glioblastoma.OBJECTIVE:The aim of this study was to investigate signs and symptoms as well as therapeutic strategies in patients with glioblastoma in the end-of-life phase in order to improve end-of-life care.METHODS:In this prospective single-center study, clinical data were obtained using a standardized protocol. We descriptively analyzed signs, symptoms, and therapeutic strategies on a daily basis.RESULTS:A total of 57 patients, who died due to glioblastoma in a hospital setting, were included. The most frequent signs and symptoms in the last 10 days before death were decrease in level of consciousness (95%), fever (88%), dysphagia (65%), seizures (65%), and headache (33%). Concerning medication, 95% received opioids. There was a high need for nonsteroidal anti-inflammatory drugs (77%) and anticonvulsants (75%). Steroids were given to 56%.CONCLUSION:Due to a decrease in level of consciousness and cognitive impairment, assessment of clinical signs and symptoms such as headache at the end of life is difficult. Based on the signs and symptoms in the last days before death in patients with glioblastoma, supportive drug treatment remains challenging. Our study emphasizes the importance of standardized guidelines for end-of-life care in patients with glioblastoma.

INTRODUCTION: Primary melanocytic tumours of the leptomeninges are rare diseases. The WHO classification of 2007 described four entities: diffuse melanocytosis, melanocytoma, malignant melanoma and meningeal melanomatosis. Meningeal melanocytosis is a benign proliferation of melanocytes with a risk of malignant transformation and is often associated with neurocutaneos melanosis. CASE REPORT: A 65-year-old male patient presented with low back pain and disturbed micturition. Neurological examination revealed left sided S1- sensory radiculopathy. His medical history was unremarkable. MRI of the lumbar spine showed a contrast-enhancing intrathecal tumour of the conus medullaris and MRI of the brain was suspicious of neoplastic meningitis. Spinal surgery exhibited a brown tumour mass with diffuse spreading of pigmented lesions along the arachnoidea. Histological, immunohistochemical, and molecular analyses showed an intrathecal melanoma with a wild-type BRAF genotype. Dermatological examination was unremarkable. Lumbar stereotactic radiotherapy was applied. Subsequently, 3 cycles of temozolomide (150mg/m2 on 5 days out of 28) and bi-weekly intrathecal liposomal cytarabine were administered. Despite the poor prognosis of neoplastic meningitis in melanoma, the patient survived without clinical for more than one year. 15 months after the initial diagnosis spinal MRI showed a local relapse and a second surgery was performed. This time molecular analysis of the tumor revealed the presence of the BRAF V600E mutation. Due to the initially slow tumor progression treatment with B-Raf inhibitors was withheld and immunotherapy with the anti-CTLA-4 antibody ipilimumab was initiated together with stereotactic radiotherapy of the conus medullaris. Three months later, the patient complained about diplopia and dizziness. Neurological examination revealed oculomotor nerve palsy. MRI of the brain showed a meningeal contrast-enhancement in the brainstem area. The B-Raf inhibitor vemurafenib was initiated in combination with intrathecally administered liposomal cytarabine and whole brain radiotherapy. Despite this the patient's condition deteriorated and he died two weeks later. Considering the long progression-free interval and the diffuse intrathecal melanocytic spread, the initial diagnosis of neoplastic meningitis was re-evaluated. Differential diagnoses include neoplastic meningitis from an unknown primary melanoma and malignant transformation of leptomeningeal melanocytosis. Retrospectively, we speculate that the patient had a leptomeningeal melanocytosis and consecutive malignant transformation. Treatment options are palliative and include intrathecal and systemic chemotherapy, radiotherapy, immunotherapy, as well as kinase inhibitors. Since evidence based guidelines are lacking therapy has to be selected on an individual basis.

INTRODUCTION: High grade gliomas are the most frequent primary brain tumours. Despite improvement of novel targeted therapies survival is still poor. In the last years the importance of quality of life came to the fore. It is well known that patients who suffer from a primary malignant brain tumour differ in the end of life phase from other oncological patients. The aim of this study is to survey sign and symptoms as well as therapeutic strategies in patients with malignant gliomas in an end of life hospital setting. METHODS: The end of life of 57 consecutive patients, who died due to a malignant glioma in a hospital setting, was analysed prospectively using a standardized protocol. Clinical signs and symptoms and supportive therapy were analysed within the last 10 days before death. RESULTS: Sixty-eight percent of patients (n = 39/57) were male, 32% (n= 18/57) were female with a mean age of 59 years (Standard deviation [SD] ±11) and an overall survival of 48 weeks (SD ±47). Most frequent symptoms were decrease of vigilance (95%, n = 54/57), fever (88%, n = 50/54), dysphagia (65%, n = 37/54), seizures (65%, n = 37/57) and headache (33%, n = 19/57). Eighteen patients (32%) sustained pneumonia. In 13 patients (23%) a urinary tract infection was diagnosed. With respect to treatment, 95% (n = 54/57) needed opioids. In 77% (n = 44/57) NSAIDs were administered additively. 86% (n = 49/57) received gastric protection, 88% (n = 50/57) LMWH and 91% (n= 52/57) intravenous fluids. In 75% (n = 43/57) anticonvulsant medication was needed. Steroids were administered in 56% (n = 32/57) of patients and only 26% (n = 15/57) received antibiotics. DISCUSSION: Due to a decrease of vigilance and cognitive impairment, assessment of clinical signs and symptoms such as pain in the end of life is often difficult. As reported signs and symptoms such as headache, dysphagia, seizures and fever are the most common ones, interventions and treatment strategies should be focused on these symptoms. Our study emphasizes the importance of standardized guidelines for end of life care in patients with malignant gliomas.

Background: In areas endemic for Borrelia burgdorferi, facial palsy is a possible manifestation of neuroborreliosis. According to this all adult patients admitted with facial palsy to our hospital, are investigated for Lyme neuroborreliosis including CSF analysis.