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Do you know what ’ s in people ’ s head?. Brain tumors. 72 male HPI: presents to E.R. with history of confusion, change of personality, left sided H/A P/E: disorientation and aggressiveness, no focal signs Labs: WNL Imaging:. Brain tumors. Brain tumors. anatomy. Brain tumors. - PowerPoint PPT Presentation
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Do you know what’s in people’s Do you know what’s in people’s head?head?
Brain tumorsBrain tumors 72 male72 male HPI: presents to E.R. with history of HPI: presents to E.R. with history of
confusion, change of personality, left confusion, change of personality, left sided H/Asided H/A
P/E: disorientation and P/E: disorientation and aggressiveness, no focal signsaggressiveness, no focal signs
Labs: WNLLabs: WNL Imaging:Imaging:
Brain tumorsBrain tumors
Brain tumorsBrain tumors anatomyanatomy
Brain tumorsBrain tumors
Brain tumorsBrain tumors
Brain tumorsBrain tumors
Brain tumorsBrain tumors DDx:DDx:
BenignBenign CongenitalCongenital
AVM/aneurismAVM/aneurism Acquired Acquired
Infectious (toxoplasmosis, cyst)Infectious (toxoplasmosis, cyst) strokestroke
MalignantMalignant PrimaryPrimary metastaticmetastatic
Brain tumorsBrain tumors Glioblastoma Glioblastoma
multiformemultiforme AstrocytomaAstrocytoma OligodendrogliomaOligodendroglioma MeningiomaMeningioma Brain stem tumorsBrain stem tumors MedulloblastomaMedulloblastoma Ependymoma Ependymoma
SarcomaSarcoma LymphomaLymphoma CraniopharyngiomaCraniopharyngioma NeurofibromaNeurofibroma Germ cell tumorsGerm cell tumors SchwannomaSchwannoma Pituitary tumorsPituitary tumors meningiomameningioma
Brain tumorsBrain tumors MetastasesMetastases
SingleSingle Multiple Multiple
Brain tumorsBrain tumors
Brain tumorBrain tumor
Brain tumorsBrain tumors
Brain tumorsBrain tumors Management:Management:
Medical support (steroids + PPI)Medical support (steroids + PPI) Staging Staging Surgical resection if indicatedSurgical resection if indicated Adjuvant therapiesAdjuvant therapies
Brain tumorsBrain tumors
Brain tumorsBrain tumors
GBMGBM Radiation therapyRadiation therapy
Standard dose: 60 Gy / 30 fractionsStandard dose: 60 Gy / 30 fractions O.S. = 42 weeks (1979 study)O.S. = 42 weeks (1979 study)
Radiation therapy + chemotherapyRadiation therapy + chemotherapy Meta analysis shows improvement in Meta analysis shows improvement in
generalgeneral
GBMGBM Best results to Best results to
date:date: Combination with Combination with
temozolomidetemozolomide 75 mg/m2 po od x 6 75 mg/m2 po od x 6
weeks (concurrent weeks (concurrent with xrt), then 150 with xrt), then 150 mg/m2 po od on d1-mg/m2 po od on d1-5 every 28 days x 6 5 every 28 days x 6 cyclescycles
RTRT RT/TMZRT/TMZ
Median Median OS OS (months(months))
12.112.1 14.614.6
2 yr 2 yr survivalsurvival
10%10% 26%26%
GBMGBM If poor performance statusIf poor performance status
Hypofractionated xrt:Hypofractionated xrt: 40/1540/15 35/1035/10
Brain tumorsBrain tumors 57 male 57 male HPI: known lung cancer; developped HPI: known lung cancer; developped
gait instabilitygait instability P/E: cerebellar exam abnormalP/E: cerebellar exam abnormal ImagingImaging
Brain tumorsBrain tumors Cerebellar metastasis on CT scanCerebellar metastasis on CT scan
Management: Management: Supportive careSupportive care Decadron (10 mg stat, then 4 mg po Decadron (10 mg stat, then 4 mg po
QID) + PPIQID) + PPI
Brain metsBrain mets Depends on stability of peripheral Depends on stability of peripheral
disease and extend of intra cerebral disease and extend of intra cerebral disease:disease:
Peripheral disease stable: Peripheral disease stable: confirm solitary status with MRIconfirm solitary status with MRI If solitary: If solitary:
consider surgical resection or stereotactic consider surgical resection or stereotactic radiosurgeryradiosurgery
Whole Brain Radiation Therapy (WBRT)Whole Brain Radiation Therapy (WBRT)
Brain metsBrain mets SurgerySurgery
DiagnosticDiagnostic Quicker steroid Quicker steroid
tapertaper Quicker symptom Quicker symptom
reliefrelief
Limited by Limited by localisationlocalisation
SRSSRS Non invasiveNon invasive Less riskLess risk Less expensiveLess expensive
Limited by sizeLimited by size RadioresistanceRadioresistance
MelanomaMelanoma Sarcoma Sarcoma
Brain metsBrain mets peripheral disease stableperipheral disease stable
More than 1 lesionMore than 1 lesion Surgery less of a considerationSurgery less of a consideration WBRT +/- stereotactic radiosurgery boostWBRT +/- stereotactic radiosurgery boost
Criteria:Criteria: < or = 3 lesions< or = 3 lesions Volume: < 4 cmVolume: < 4 cm Prognostic > 3 monthsPrognostic > 3 months KPS >70KPS >70
Brain metsBrain metsSurvivalSurvival WBRT + WBRT +
SRSSRSWBRTWBRT p valuep value
OverallOverall 6.56.5 5.75.7 0.130.131 met1 met 6.56.5 4.94.9 0.040.041-3, 1-3, age<50age<50
9.99.9 8.38.3 0.040.04
1-3, NSCLC1-3, NSCLC 5.95.9 3.93.9 0.050.051-3, RPA1-3, RPA 11.611.6 9.69.6 0.050.05
Brain metsBrain mets peripheral disease not stableperipheral disease not stable
Palliative radiation therapyPalliative radiation therapy Re-irradiation on a case by case basisRe-irradiation on a case by case basis
Brain metsBrain mets
Brain metsBrain mets Prognostic:Prognostic:
Untreated: 1 monthUntreated: 1 month Steroids: 2 monthsSteroids: 2 months
Brain metsBrain mets Radiation therapyRadiation therapyKPSKPS >70>70 >70>70 <70<70
AgeAge <65<65 >65>65Primary Primary controlcontrol
YesYes nono
MetsMets Brain Brain onlyonly
Multi Multi organorgan
SurvivalSurvival 7.17.1 4.24.2 2.32.3
Brain metsBrain mets Side effectsSide effects
AlopeciaAlopecia Skin erythemaSkin erythema Fatigue Fatigue Neurocognitive changesNeurocognitive changes
Brain metsBrain metsSingle metSingle metSymptomatic,ResectableSymptomatic,ResectableFirst/only metFirst/only met
Surgery + WBRTSurgery + WBRT
Single metSingle metLittle / no symptomLittle / no symptomNon resectable / surgery Non resectable / surgery refusedrefused
SRS + WBRTSRS + WBRT
2-3 mets, KPS>702-3 mets, KPS>70RPA 1, NSCLC, <50 yoRPA 1, NSCLC, <50 yo
SRS + WBRTSRS + WBRT
2-3 mets, KPS>702-3 mets, KPS>70None of favorable Px factorsNone of favorable Px factors
WBRT +/- SRSWBRT +/- SRS
4 mets, KPS>704 mets, KPS>70RPA 1, NSCLC, <50 yoRPA 1, NSCLC, <50 yo
WBRT +/- SRSWBRT +/- SRS
Brain metsBrain mets Role of WBRTRole of WBRTDecrease rate of new mets Decrease rate of new mets
(50% to 25%)(50% to 25%)Does not increase OSDoes not increase OS
Some histologies have less Some histologies have less distant failures (RCC, distant failures (RCC, melanoma, sarcoma)melanoma, sarcoma)
No increase in toxicity No increase in toxicity (objectively)(objectively)
Subjective increase in Subjective increase in toxicitytoxicity
Case where Dx is in doubt Case where Dx is in doubt (meningioma)(meningioma)