Brain Tumors. Andrew J. Fabiano, MD FAANS. Associate Professor of Neurosurgery Roswell Park Cancer Institute SUNY at Buffalo School of Medicine

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1 Brain Tumors Andrew J. Fabiano, MD FAANS Associate Professor of Neurosurgery Roswell Park Cancer Institute SUNY at Buffalo School of Medicine

2 Brain Tumors Brain Tumor Basics Types of Tumors Cases

3 Brain Tumors Skull is a fixed space Symptoms develop due to compression of normal brain

4 Brain Tumors

5 Brain Tumors Inflammation/Edema occurs in the surrounding normal brain

6 Brain Tumors Tumors cause edema and irritation of normal brain Breakdown of BBB Corticosteroids for edema Anti-epileptics to prevent seizures

7 Corticosteroids Dexamethasone traditionally used Reduces vasogenic edema GI prophylaxis

8 Steroids Multiple side effects: Diabetes Myopathy Infection LE edema Weight gain Wound issues

9 Anti-Epileptic Drugs Used for cortical lesions Not required for cerebellar lesions Dilantin requires monitoring Keppra

10 Tumor Types Gliomas Meningiomas Metastatic Tumors Pituitary Tumors

11 Gliomas Arise from native cells within the brain

12 Gliomas WHO I Pilocytic Astrocytoma WHO II Diffuse Astrocytoma WHO III Anaplastic Astrocytoma WHO IV Glioblastoma

13 2016 WHO Changes Mitosis, microvascular proliferation, nuclear atypia, necrosis Ki-67 proliferation index IDH-1 mutant vs. wild-type 1p19q co-deletion

14 Gliomas WHO I

15 Gliomas WHO II & III

16 WHO IV - GBM

17 Glioblastoma Multiforme Most common primary brain tumor in adults Incidence 3 per 100,000 Average survival from diagnosis ~ 13 months Young age, High Karnofsky score associated with increased survival

18 Glioblastoma Start steroids and anti-epileptics

19 Glioblastoma

20 Gliomas - Treatment Surgery Biopsy External Beam XRT Chemotherapy (Temodar)

21 Glioblastoma Survival Related to Extent of Resection

22 Glioblastoma Typical IMRT course is Monday-Friday for 6 weeks.

23 Glioblastoma Standard Diagnosis Therapy Surgery if resectable RT and Oral Chemotherapy (Temazolamide)

24 Glioblastoma Standard Therapy

25 Glioblastoma Standard Therapy Optune alternating electrical field therapy

26 Gliobastoma Monitor for recurrence If recurrence, assess for possible reresection May add additional chemotherapy

27 GBM Additional Therapies Gliadel wafers can be inserted

28 GBM Additional Therapies Vaccines

29 GBM Additional Therapies Laser-Interstitial Thermal Therapy (LITT)

30 GBM Additional Therapies Stereotactic Radiosurgery

31 Meningiomas

32 Meningiomas Develop from arachnoid cap cells More common in females Most are WHO I WHO II, III, IV malignant meningiomas

33 Meningiomas

34 Meningiomas - Treatment Anti-epileptics, steroids in some instances Observation Gamma Knife (<3 cm) Open Surgery

35 Meningiomas 62 yo female presented with gait instability On PE, had an ataxic gait and lower extremity hyperreflexia

36 Meningiomas

37

38 Meningiomas 60 yo female presents with change of personality Over the past 6 months 1 year, patient has been confused and has poor shortterm memory Always pleasant, which is unusual Diagnosed with Depression with psychotic features

39 Meningiomas Exam: Awake and pleasant Obese Confused, poor recall No sense of smell Some difficulty moving legs

40 Meningiomas

41 Meningiomas

42 Meningiomas Patient started on steroids and antiepileptics Underwent bifrontal craniotomy for tumor removal

43 Meningiomas

44 Meningiomas Patient has had slow recovery over 6 months Edema slowly resolving Now doing crosswords, but still a shortterm memory deficit

45 Metastatic Tumors

46 Metastatic Tumors Single lesion < 3 cm Gamma Knife Single lesion > 3 cm Open Surgery Multiple lesions: Gamma Knife vs. XRT

47 Gamma Knife Radiosurgery

48 Gamma Knife Radiosurgery

49 Gamma Knife Radiosurgery

50 Gamma Knife Radiosurgery

51 Gamma Knife Radiosurgery

52 Leptomeningeal Disease Poor prognosis Patients may develop cranial nerve palsies

53 Leptomeningeal Disease Intrathecal chemotherapy

54 Leptomeningeal Disease

55 Leptomeningeal Disease Ref:

56 Hydrocephalus Cerebrospinal fluid build-up resulting in an increased intracranial pressure

57 Hydrocephalus Patients develop symptoms from increased intracranial pressure Headaches, N/V, confusion, lethargy, coma

58 Hydrocephalus Can be communicating or obstructive

59 Hydrocephalus Treatments include VP Shunt and Endoscopic Third Ventriculostomy (ETV)

60 Hydrocephalus 58 yo man with a history of colon cancer with worsening headaches and confusion Patient had just completed external beam radiation tx for multiple brain metastases On PE he was confused and sleepy

61

62

63 ETV

64 Pituitary Tumors

65 Pituitary Tumors Pituitary gland is a marble-sized gland at the base of the brain that controls hormone regulation in the body

66 Pituitary Tumors Most common Pituitary Adenomas (nonsecreting) Cushing s Disease Acromegaly Prolactinomas

67 Pituitary Adenoma Benign Tumor Seen in ~5% of normal population Microadenoma < 1 cm Macroadenoma > 1 cm Treat with observation

68 Pituitary Adenoma If it is growing, or putting pressure on surrounding structures should be treated Endocrine function Visual field testing

69 Pituitary Adenoma Transsphenoidal Resection

70

71 Cushing s Disease ACTH-secreting tumor Treat with surgical resection

72 Acromegaly Excess growth hormone secretion Enlarging hands and feet Bilateral carpal tunnel syndrome Diabetes mellitus Dilated cardiomyopathy

73 Acromegaly Measure IGF-1 Can try somatostatin analogs Oftentimes requires surgical resection

74 Prolactinoma Patient may have nipple discharge Elevated Prolactin Usually greater than > 200 ng/ml Can be treated with Bromocriptine

75 Learning Points High Grade glioma = Glioblastoma Factors in Grading Gliomas Standard GBM Therapy Alternating electric field therapy for glioblastoma Meningioma Hydrocephalus Intrathecal Chemotherapy Pituitary Tumor Effects

76 Thank you!

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