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Brain Tumours what should I know?

Dr Hannah Lord Consultant 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 27.2% 16.0% 12.1% 9.8%

XRT 10.9% 4.4% 3.0% 1.9%

2 3 4 5

Gliadel Wafers

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

Pathology - GBM

High Ki 67 Necrosis Pleomorphism Abnormal vasculature GFAP +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 cells B Cells Perivascular 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

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