neuro-oncology Flashcards
cancer
tumour
Cancer = a group of diseases caused when cells divide and grow in an uncontrolled manner
Tumour = a mass of cancerous cells
Intracranial tumours are classified based on pathology and
site and these dictate the clinical presentation
neuroepithelial
Astrocytoma Oligodendroglioma Ependymoma Glioblastoma muliforme (GBM) Medulloblastoma
meninges
meningioma
nerve sheath cells
neuroma / schwannoma
neurofibroma
blood vessels
Haemangioblastoma
cerebellar tumours
infratentorial
supratentorial
Infratentorial brain tumours are more common in children (medulloblastoma, cerebellar astrocytoma)
Supratentorial = 85% adult brain tumours (most common astrocytoma, meningioma and metastases)
primary secondary brain tumour intrinsic extrinsic
Primary Brain Tumour: Mass of abnormal cells that arises from within the brain parenchyma
Secondary Brain Tumour / Brain Metastasis: Spread of cancer cells from a primary tumour outside the brain
Intrinsic: Tumour cells within the brain tissue
Extrinsic : Tumour cells located outside the brain tissue
Histology: composition of cells and their organization
Mass Effect: compression caused by increased intracranial pressure from a space-occupying lesion
Space Occupying Lesion (SOL): Describes a mass of unknown
histology on MRI
clinical features
Insidious, gradual onset
Depends on site and degree of malignancy
Raised intracranial pressure – headache, papilloedema
Mass effect with brain shift – vomiting, deteriorating consciousness, pupillary dilatation
Epilepsy in 30% - initial or later
Neurological deficits depend on site of tumour, usually not the first presenting symptom or sign
brain tumour work up
Imaging: CT / MRI / MR or CT angiography
Surgical intervention: biopsy ± debulking / decompression / excision
Histopathology: frozen section (in surgery) and histology of biopsy (5- 7 days)Medical or radio- oncology management depending on pathological classification
brain tumour management
steroid therapy Reduce mass effect and oedema
Do not affect
tumour growth
Dexamethasone
surgery Craniotomy
Subsequent procedure depends on findings
May be awake if tumour approaches “eloquent brain”
radiotherapy Destruction of cancer cells with XRay beams
Stereotactic
Gamma knife
chemotherapy Limited value in “gliomas”
Used in lymphomas
Metastases may
respond
astrocytoma and glioblastoma multiforme
Most common (40% of all intracranial tumours in adults)
Peak incidence 40-60y, M:F 2:1
Site: equal incidence in frontal, temporal, parietal and thalamic regions, rare in occipital lobe
Graded 1 to 4
Classification depends on biopsy obtained at surgery
meningioma
Arises from the arachnoid granulations Tends to compress rather than invade tissue Generally low grade Can also occur in the skull base, orbit and spinal canal
nerve sheath cells
Schwannoma
Non-invasive / “benign”
Slow growing (2mm / y, but may not grow)
Usually occur in middle age 40-50 years
More frequent in females
Most common location: vestibular portion of CNVIII (vestibular schwannoma) and cerebellopontine angle (CP angle)
Management depends on disability from compression of surrounding structures
Haemangioblastoma
Vascular origin
Generally low grade lesion
Mainly occurs in the middle aged
Most common primary brain tumour of the cerebellum in adults
70% association with presence of a cyst
Characteristic of Von Hippel Lindau Syndrome
metastatic lesions
Any malignant tumour can metastasise to the brain
Highest frequency is malignant melanoma (66%)
Most common primary site is bronchus and the breast
25% of patients with this primary diagnosis develop brain mets
50% have multiple metastases
Intracranial sites: ¾ hemispheres, ¼ cerebellum
Characteristics: surrounding oedema, well defined tumour margins, necrotic areas that may break down to form cystic cavities
Mets are the commonest tumours of the cerebellar hemisphere
steroids
Reduce oedema
Do not affect tumour growth
Loading dose of 12mg of Dexamethasone followed by 4mg can reverse clinical deterioration within a few hours
Need gradual reduction to prevent side effects
Steroid Psychosis
surgery
Burrhole Biopsy Craniotomy Craniectomy Debulking / decompression Gross Total Resection Trans-sphenoidal approach for pituitary tumours
radiotherapy
Radiotherapy uses high-energy rays to target and destroy cancer cells
Modern methods produce greater tissue penetration and avoid radiation damage to the skins surface
Beams are shaped to conform with the with the shape of the tumour thus eliminating adverse effects on normal tissue
Particularly useful in treating high grade lesions
Risk factors include: Oedema Radionecrosis; can occur over months Cognitive impairment; Can cause dementia Radiation induced tumours eg. Meningioma can occur several years post treatment
chemotherapy
Cytotoxic drugs to kill cancer cells
Temozolomide commonly used due to its ability to cross the
blood brain barrier and low level of toxicity
Associated side effects of alopecia, nausea, lethargy, toxicity
assessment
Presenting Complaint Symptom duration Neurological deficits Mobility / falls Response to steroids Seizures
ICF: personal / environmental factors
MRI
surgery
extent
pathology
MDT
Assessment
Full neurological examination (T/P/C/S/R)
Mobility (to highest functional
level – compare with baseline)
Can include:
Falls risk assessment Balance assessment Function: upper limb
MDT – cognitive assessment (OT / neuropsych), SLT (speech deficits), clinical nurse specialists
Family meeting
GOals
short term and long term
Short term goals depend on immediate treatment, prognosis and discharge plan.
Long term goals depend on response to treatment.
physio management
Thorough clinical assessment – identify main neurological deficits
Goals depend on tumour grading and prognosis
Factors to consider: Impact of ongoing treatment Steroid dependency Extent of surgical removal Discharge planning
physio for brain tumours
High prevalence of neurological impairment in people with primary brain tumours:
Limb weakness 37%
Ataxia / coordination difficulties 32%
Sensory-perceptual deficit 24%
Significant symptom burden for patients and their families.
These deficits should be amenable to neurorehabilitation similar to other neurological conditions, but the evidence base is not well established.
No current best practice is defined (Hansen et al, 2020).
safety and feasibility
Safety and feasibility:
Intensive, supervised physiotherapy exercise is safe
Unsupervised training has a high drop-out rate and poor adherence
Complex symptoms are a barrier to self management
Efficacy:
Reduced short- and long-term motor disability in patients who participated in high-intensity ambulatory rehabilitation (non-randomised trial, Khan et al, 2014)
RCT evidence of improved aerobic power and strength after intensive 6-weeks, 3x weekly rehabilitation for newly-diagnosed glioma, despite concurrent anti-cancer treatment (Hansen et al, 2020)
No improvements detected in quality of life or participation
physio management
Goal setting will be informed by factors similar to brain tumours (extent of resection, pathology, prognosis)
Rehabilitation: refer to spinal cord injury lecture
Differences with traumatic SCI:
Tumours usually cause an incomplete SCI (initially) Tumours may grow
Cancer treatment impacts heavily on rehabilitation progress
