Brain Tumours – what should I know?

Dr Hannah LordConsultant Clinical Oncologist

Causes of brain tumours

Causes:

DNA damage Radiation Genetics

NF- 1 (acoustic neuromas)

Li Fraumeni syndrome

Tuberous sclerosis ( astrocytomas)

multiple endocrine neoplasia type 1(pituitary

macroadenoma) Infection

HIV

Diagnosis

So – how do you suspect a brain tumour?

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

Investigations

What would you do?

Ix?

CT brain

MRI brain/spine – to exclude multiple metastaic deposits; to better characterise tumour

How would you classify brain tumours?

Types of Brain Tumours

Primary: benign or malignant (rare)

Secondary: malignant (majority)

Primary brain tumour

Primary brain tumour

Radiology - brain mets

Questions:

Where do brain metastases come from?

Secondary Brain Tumours

Lung

Breast

GI

Any primary potentially

Questions:

How will you initially treat brain secondaries?

How to treat?

Oedema – steroids

Pain – analgaesia

Nausea - antiemetics

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#)

Primary brain tumours

Types of primary brain tumours?

BENIGN

Primary brain tumours

I Benign

Pituitary – adenoma, cranio-pharyngioma Meningioma Acoustic neuroma Dermoid tumour

Benign brain tumours

Treatment?

Observation Surgery Radiotherapy BSC

Can behave in a malignant fashion due to location and recurrent nature

Primary brain tumours

Types of primary brain tumours?

MALIGNANT

Malignant brain tumours

II Malignant:

Glioma Primary Cerebral Lymphoma Germinoma Pineoblastoma Medulloblastoma

Primary Brain Tumours

GLIOMA

Malignant: Gliomata

Glioma Commonest Primary Brain Tumours

WHO Grades:

I: Fibrillary astrocytoma

II: Astroctytoma or Oligodendroglioma

III: Anaplastic Astrocytoma /oligodendrglioma

IV: Glioblastoma multiforme

GBM – radiology

Treatment of gliomata

Observation – low grade Surgery

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)

Benefits of Temozolamide

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%

Gliadel Wafers

Gliadel wafers at time of surgery (carmustine soaked) in completely resected high grade glioma (3 or 4)

Pathology - GBM

High Ki 67NecrosisPleomorphismAbnormal vasculatureGFAP +ve

Primary CNS Tumours

Ependymoma

Ependymoma

Ependymoma

Grade I- III

Location?

Treatment?

Surgery +/- radiotherapy 54Gy in 30# over 6 weeks

Primary CNS Lymphoma

Primary Cerebral Lymphoma

Primary cerebral lymphoma – HIV related Steroids Chemo (methotrexate based)+/- XRT Cognitive impairment Poor outcomes

Primary CNS Lymphoma

Pathology

Blue cellsB CellsPerivascular cuffing

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

Effects on patient and family

Effects of treatment – steroids, anti epileptics, surgery and XRT

Invasion of space by supportive teams Death Genetic consequences

Multidisciplinary teams

Need GP, neurosurgeon, oncologist, endocrinologist, neurologist, specialist CNS nurse, palliative care team, pathologist, radiologist

Community Macmillan, DNs Social work, OT, physiotherapy input

??

Research