Neuro/Psycho-oncology Flashcards
What are the most common types of brain tumour?
What is the neurooncology team composed of?
Neurosurgeon
Neuro-oncologist
Neuro-oncology clinical nurse specialist
Neuro radiologist
Neuro pathologist
Neurologist
Neuropsychologist
Legal requirement for all to be present in case discussion
What is the incidence of brain tumours?
15 per 100,000
11,000 new cases a year (5000 gliomas)
30% increase since 90s
What are primary brain tumours?
In situ
What are the most common brain tumours?
Meningiomas
Gliomas
What are the types of glioma?
Glioblastoma multiforme (grade 4)
Low grade gliomas - Astro Thomas and oligodendrogliomas
What is the WHO grading system for meningioma?
Grade I - benign
Grade II - atypical, often due to radiotherapy for childhood cancer
Grade III - rare, very poor prognosis
What is the WHO grading system for intrinsic tumours?
Grade I - pilocytic astrocytoma (childhood, curable)
Grade II - oligodendroglioma, astrocytoma
Grade III - anaplastic
Grade IV - glioblastoma multiforme (from astrocytoma)
What are the most common presentations of brain tumours?
Asymptomatic (found on investigation)
Seizure
Raised ICP
Focal neurological deficit
Cognitive decline
Change of personality
What are symptoms of raised ICP?
Headache
Vomiting
Double vision (from abducens nerve)
Hiccups
Drowsiness/ confusion
Cushing’s triad (fatal) (raised bp, lowered pulse & respiration)
How has prognosis of high grade glioma changed?
Previously 6 months
Now 2 years +
Improved surgical resection using gliolan and MRI
Stupp protocol (temozolamide/radiotherapy)
Safer radiotherapy
Molecular pathology
What does gliolan do?
Fluorescent tags tumour tissue - improves resection
What techniques are helping safer surgery?
fMRI
Awake craniotomy
Intra-operative neuromonitoring
What is the Stupp protocol?
6 weeks of radiotherapy 5 days a week (30 rounds) + temozolamide every day
6 months of temozolamide twice a month
2.5x more effective than radiotherapy alone
How does methylation status affect treatment?
Methylated genes in the GBM increased response to Stupp protocol
46% 2 year survival vs 14%
What is the significance of IDH in grading?
IDH positive - primary GBM
IDH negative - low grade glioma or secondary GBM
How are low grade gliomas treated?
Radiotherapy + PCV
Median survival increased 5,5 years against watchful waiting
How are seizures managed in tumour associated epilepsy?
Treat after first seizure (60-90% of patients will have seizures)
Avoid enzymatic AEDs
Levetiracetam is being trialled as prophylaxis
Tumour treatment takes precedence
What are commonly found mental health difficulties for cancer patients?
Mood and anxiety symptoms (highest at first recurrence)
Insomnia (starts during treatment)
Cognitive symptoms (particularly during treatment)
Body image issues
Said esteem
Existential distress
What factors increase the likelihood of mental health difficulties during cancer journeys?
Head and neck, pancreas, haematological cancers
Younger age
Lower socioeconomic background
Pain
Fatigue
Comorbidities
Severe illness
Poor prognosis
What is the holistic needs assessment?
Government mandated KPI for oncology services
Addresses psychosocial factors
What were the main emotional concerns expressed by oncology patients?
Worry/anxiety
Tiredness fatigue
Thinking about the future
Sex/intimacy
Sleep/tiredness
Sadness/depression
What are the ways in which a tumour might cause psychiatric effects?
Structural effect of tumour
Systemic depletion of nutrients
Hormone secretion by an active tumour (pituitary, thyroid)
Paraneoplastic hormone secretion (ACTH by lungs)
Onconeuronal antibodies (anti-Hu, anti-Yo)
Cytokine release and inflammatory action
What causes Cushing’s syndrome and how might this be caused by cancer?
Chronic low-level hypercortisolaemia
Corticosteroid treatment for cancer (GBM, haem cancers) - most common
Pituitary tumour may oversecrete ACTH
Paraneoplastic secretion of ACTH (lung cancer)
Thyroid medullary tumour secretion of ACTH
Adrenocortical tumour directly secreting glucocorticoids (rare)
How might steroids cause psychiatric problems?
Depression and anxiety
Insomnia
Agitation
Cognitive difficulties
Exacerbation of underlying mental health issues
Psychosis and mania at higher doses
How might hypothyroidism be caused in cancer patients?
Damage to hypothalamus or pituitary
Thyroid damage from surgery
Thyroid damage from radiation
Monoclonal antibodies targeting thyroid
How might loss of oestrogen in cancer treatment affect psychiatric issues?
Higher depression risk
Higher dementia risk
Oestrogen increases serotonin synthesis and promotes neuroplasticity
What antibodies produced by cancer cells can cause encephalitis?
Anti Hu (small cell lung cancer)
Anti NMDAr (teratomas)
What antibody may cause degeneration?
Anti-Yo causes cerebellar degeneration
May happen in aggressive breast cancer
Coordination problems and CCAS
What chemotherapy might cause folate deficiency?
Methotrexate (folate blocker)
How might b12 deficiency present psychiatrically?
Mimics depression symptoms
What are the neuropsychiatric effects of radiotherapy?
50-90% have cognitive deficits
Up to 10 IQ drop
Worse in a developing brain
Worsened by intrathecal chemotherapy
What are possible underlying causes of chemo brain?
Neurotoxicity
Impaired neurogenesis
Oxidative stress
Immune deregulation
Vascular changes
Hormonal changes
Altered long term potentiation
What immunosuppressants might cause proliferation of JC virus?
Monoclonal antibodies (rituximab)
Chemotherapy
How might PML (from JC virus) present?
Progressive weakness
Speech problems
Cognitive deficit is
Personality change
Seizures
Death
What neuropsychiatric syndrome might CAR T therapy causes
CAR related encephalopathy syndrome
(Caused by systemic cytokines release)
Symptoms similar to anti NMDAr
(Hallucinations, agitation, seizures, motor symptoms)
