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Brain Tumours – what should I know?
Dr Hannah LordConsultant Clinical Oncologist
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Causes of brain tumours
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Causes:
DNA damage Radiation Genetics
NF- 1 (acoustic neuromas)
Li Fraumeni syndrome
Tuberous sclerosis ( astrocytomas)
multiple endocrine neoplasia type 1(pituitary
macroadenoma) Infection
HIV
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Diagnosis
So – how do you suspect a brain tumour?
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What makes you suspect a brain tumour in patient?
Morning headache, n+v, confusion New onset of seizures Motor deficit Sensory deficit Personality change Dyshasia Ataxia
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Investigations
What would you do?
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Ix?
CT brain
MRI brain/spine – to exclude multiple metastaic deposits; to better characterise tumour
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How would you classify brain tumours?
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Types of Brain Tumours
Primary: benign or malignant (rare)
Secondary: malignant (majority)
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Primary brain tumour
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Primary brain tumour
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Radiology - brain mets
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Questions:
Where do brain metastases come from?
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Secondary Brain Tumours
Lung
Breast
GI
Any primary potentially
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Questions:
How will you initially treat brain secondaries?
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How to treat?
Oedema – steroids
Pain – analgaesia
Nausea - antiemetics
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How to treat - secondaries
Depends on Primary cancer and its extent / control
Depends on patient fitness and wishes
Can occasionally debulk and give post op XRT, or XRT alone (20Gy in 5#)
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Primary brain tumours
Types of primary brain tumours?
BENIGN
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Primary brain tumours
I Benign
Pituitary – adenoma, cranio-pharyngioma Meningioma Acoustic neuroma Dermoid tumour
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Benign brain tumours
Treatment?
Observation Surgery Radiotherapy BSC
Can behave in a malignant fashion due to location and recurrent nature
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Primary brain tumours
Types of primary brain tumours?
MALIGNANT
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Malignant brain tumours
II Malignant:
Glioma Primary Cerebral Lymphoma Germinoma Pineoblastoma Medulloblastoma
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Primary Brain Tumours
GLIOMA
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Malignant: Gliomata
Glioma Commonest Primary Brain Tumours
WHO Grades:
I: Fibrillary astrocytoma
II: Astroctytoma or Oligodendroglioma
III: Anaplastic Astrocytoma /oligodendrglioma
IV: Glioblastoma multiforme
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GBM – radiology
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Treatment of gliomata
Observation – low grade Surgery
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Treatment of gliomata
Radiotherapy 60Gy in 30# over 6 weeks +/- Temozolamide chemotherapy
(25% alive at 2 years)
Or 30Gy in 6# over 2 weeks (months)
Gliadel wafers
Or BSC ( weeks)
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Benefits of Temozolamide
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Survival with TMZ
OS(Years)
TMZ + XRT XRT
2 27.2% 10.9%
3 16.0% 4.4%
4 12.1% 3.0%
5 9.8% 1.9%
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Gliadel Wafers
Gliadel wafers at time of surgery (carmustine soaked) in completely resected high grade glioma (3 or 4)
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Pathology - GBM
High Ki 67NecrosisPleomorphismAbnormal vasculatureGFAP +ve
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Primary CNS Tumours
Ependymoma
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Ependymoma
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Ependymoma
Grade I- III
Location?
Treatment?
Surgery +/- radiotherapy 54Gy in 30# over 6 weeks
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Primary CNS Lymphoma
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Primary Cerebral Lymphoma
Primary cerebral lymphoma – HIV related Steroids Chemo (methotrexate based)+/- XRT Cognitive impairment Poor outcomes
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Primary CNS Lymphoma
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Pathology
Blue cellsB CellsPerivascular cuffing
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Effects on patient and family
Loss of autonomy Can not drive Neurological deficit Confusion and personality change Family lose the person they knew Financial loss Social loss
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Effects on patient and family
Effects of treatment – steroids, anti epileptics, surgery and XRT
Invasion of space by supportive teams Death Genetic consequences
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Multidisciplinary teams
Need GP, neurosurgeon, oncologist, endocrinologist, neurologist, specialist CNS nurse, palliative care team, pathologist, radiologist
Community Macmillan, DNs Social work, OT, physiotherapy input
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??
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Research