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Case study by: Morgan

Jostpille
Patient History

 31 year old male


 Born in Bangladesh and moved to US in 2006
 Race: Bengalis
 Treated on Vault 7
Past Medical History

 Diabetes mellitus (Type II)


 Arthritis
 Hypertension
 H. pylori infection
 Head trauma – motorcycle accident skull fracture without complications
 Low testosterone
 Meningioma
 Microhematuria
 No know allergies
Past Surgical History

8/20/2014
 Esophagogastroduodenoscopy (Egd diagnostic)
11/2/2016
 Craniotomy (bilateral)
Social and Family History

 Married with no kids


 Occupation – business
 Former smoker for 10 years (.25 packs/day)
 No smokeless tobacco, alcohol, or drug use
 Mother - hypertension, diabetes, and stroke
 Father - diabetes and myocardial infraction
 Brother - diabetes
Presenting Signs

10/31/16
 Patient had been having memory loss and loss of appetite for 3-4 months.
Patient presented to ED after episodes of nausea and vomiting.
10/31/16
 MRI brain shows 6.6 x 7.6 large enhancing, hypervascular, with significant
mass effect.
11/2/16
 Bifrontal resection of tumor. Pathology was diagnosed.
11/3/16
 MRI showed the new post surgical changes involving the anterior frontal
region and the large mass has been resected.
11/15/16
 Recommended to rad onc due to high Ki-67 proliferation rate of 16%.
Common Presenting Signs of Meningioma

 Localized headache (70% of patients)


 Seizure (55% of patients)

Symptoms of all primary brain tumors:


 Mental status changes, double vision, nausea/vomiting, dizziness, visual
disturbances, difficulty with balancing, weakness & stiffness in side or extremity,
facial weakness, speech & personality changes.
 Intellectual functions – orientation, speech, memory, and logical thought
process.
 Visual fields may decrease and blind spots increase as disease progresses.
 Hydrocephalus on CT if CSF flow is obstructed.
Detection and Diagnosis

 Mental changes, personality changes and changes in behavior are often 1st
noticed by family or friends.
 Sudden onset of symptoms may indicate a tumor of higher grade and size.
Symptoms of long duration may indicate a slow growing tumor.
 Invasion, irritation, and compression of the brain by the tumor cause these
symptoms.
Epidemiology

 Approximately 23,130 new CNS tumors (brain and spinal cord) are diagnosed
annually in the US and result in approximately 14,080 deaths in 2013.
 Brain tumors account for 1.5-2% of the newly diagnosed tumors/year.
 Meningioma’s occur around 60 years old.
 2:1 women to men ratio
Common Etiology

 Mostly unknown what causes CNS tumors.


 A genetic link is thought to exist with different types of CNS tumors but there
is no absolute proof.
 Sister was found to also have CNS tumor.
 Possible rubber compounds, polyvinyl chloride, N-nitroso compounds and
polycyclic hydrocarbons
Anatomy
 There are three meninges that are intracranial: Dura mater,
arachnoid, and pia mater.
 Epidural (potential) space, subdural (potential) space, and
subarachnoid (real) space
 The tumors arise from the meninges spreading outward, not
arising from the brain tissue.
Histopathology

 WHO Grade I
 Meningioma of bifrontal region
 Spindle cell neoplasm with frequent macronucleoli with no brain invasion
 Mesenchymal neoplasm with focal necrosis
 Mass of tumor was 6.6 x 7.6

 Consistent with findings of a fibroblastic meningioma


Primary Brain Tumor: Meningioma

 Benign (90%)
 Meningothelial, fibrous (fibroblastic), transitional, psammomatous, and angioblastic

 Atypical (7%)
 Chordoid, clear cell, atypical

 Anaplastic/Malignant (2%)
 Papillary, rhabdoid, and anaplastic
WHO Grading Scale
 Grade I
• These tumors are regarded as benign, or non-cancerous, though they may slowly grow. Their
cells appear close to normal under a microscope. The borders of the tumor are distinct. Benign
tumors can cause problems when they compress the brain. Grade I tumors are rare in adults,
and are associated with long-term survival.
 Grade II
• These slowly-growing tumors may spread to nearby tissue. Their cells appear slightly abnormal
under a microscope. Grade II tumors may return as a more aggressive tumor after therapy.
 Grade III
• These tumors are considered malignant, or cancerous. The cells are abnormal and reproducing, with
spread into healthy brain tissue. Grade III tumors are likely to recur, coming back as a more
aggressive tumor.
 Grade IV
• These aggressive tumors are the most serious because of their rapid growth and spread. The cells
are very abnormal, and the tumor creates new blood vessels as it grows. Grade IV tumors may have
a core of dead cells (necrosis).
Lymphatics

 No lymphatics in the brain


Treatment Options

 Surgery is the most common treatment and most often the only treatment
 Cancerous tumors includes radiation therapy and/or chemotherapy after surgery
 Craniotomy
 Radiation therapy includes methods of VMAT, IMRT, SRS, SRT, conformal,
gamma knife, cyber knife, or proton therapy
 Chemotherapy must use agents that cross the blood brain barrier
 Lipid-soluable
 BCNU, lomustine, streptozocin
 Mylosuppresion
MRI pre surgery MRI post surgery
Treatment Plan

 6mv
 V-mat / 3 arcs
 5400 in 180 cGy
 30 fractions
Primary Brain Treatment Borders

 If surgery is done, there is no gross tumor volume.


 Small margin around the tumor to include for set up error.
 No lymph nodes in the brain so the field is localized to the tumor.
Dose Volume Histogram
Treatment Plans
Treatment Plans
Patient Positioning

 Supine
 Shims: 1mm x 2
 Q2 + custom headrest
 Aquaplast mask shoulder mask
 Hands on chest
 Knee sponge
Critical Structures
Potential Side Effects
 Fatigue
 Skin reaction –dryness, erythema, itchiness, blistering
 Loss of hair
 Possible difficulties in concentration and/or short term memory
 Possible sense of fullness in the ears
 Possible nausea, vomiting, and/or headache
 Possible brain swelling
 Possible hearing loss/loss of vision
 Possible decreased hormone levels needing replacement
 Possible damage to brainstem/spinal cord leading to paralysis/debilitation
 Possible loss of strength of extremities
 Possible cataracts
Disease Prognosis and Survival

 Meningioma 5 year survival rate:

 20-44 years old 92% survival

 45-54 years old 77% survival

 55-64 years old 67% survival


Possible Metastatic Sites

 Local spread, but not to other organs.


References

 Brain Tumor Grading . John Hopkins Medicine .


http://www.hopkinsmedicine.org/healthlibrary/conditions/nervous_system_d
isorders/brain_tumor_grading_22,BrainTumorGrading/. Accessed March 2,
2017.
 Heimer H, Schultz K. Meningioma . Focusing on Tumors.
http://hope.abta.org/site/DocServer/Meningioma.pdf?docID=101. Published
2006. Accessed March 2, 2017.
 Kesari S, Saria M, Lai A. Meningioma . American Brain Tumor Association .
http://www.abta.org/secure/meningioma-brochure.pdf. Published 2005.
Accessed March 2, 2017.
 Ruth’s notes
 Washington CM, Leaver DT. Principles and Practice of Radiation Therapy. St.
Louis, MO: Elsevier, Mosby; 2016.