Brain Tumours- Treatment op0ons and outcomes. Mr. Yagnesh Vellore FRACS Neurosurgeon and Spine Surgeon
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1 Brain Tumours- Treatment op0ons and outcomes Mr. Yagnesh Vellore FRACS Neurosurgeon and Spine Surgeon
2 WHO Classifica0on Neuroepithelial 0ssue Cranial and paraspinal nerves Meninges Lymphomas and haematopoe0c Germ cell Sellar region Metasta0c
3 Primary brain tumours Incidence 24.6/ adults in US One third malignant Less in children but more malignant Ranked 19 th in incidence for cancer in Australia, but 4 th in person years lost to 75
4 Adults (11/12) Children (1/12) Supratentorial 80-85% Infratentorial 60% Gliomas 50% Meningiomas 15% Metastases 15% Pituitary 8% Acous0c neuroma 8% Pilocy0c astrocytomas 27% Medulloblastomas 27% Brain stem gliomas 28% Ependymoma
5 Presenta0on Raised ICP Progressive neurological deficit e.g. motor weakness Headache Seizure Mental state change TIA like sx Endocrinopathies
6 Ae0ology Familial syndromes eg NF 1 op0c glioma Gene0cs eg. p53 loss in glioblastoma Radia0on eg. meningioma, Glioblastoma Immuosuppression eg. Lymphoma Weak evidence: trauma & meningioma Unproven: power lines/mobile phones
7 Glioma Half of brain tumours are gliomas 2/3 are high grade astrocytomas (ie GBM) Types Astrocytomas Oligodendroglial tumours Mixed gliomas Ependymomal tumours Choroid plexus tumours Glial tumours of uncertain origin
8 Astrocytoma WHO grade I: Pilocy0c astrocytoma WHO grade II: Diffuse astrocytoma WHO grade III: Anaplas0c astrocytoma WHO grade IV: Glioblastoma mul0forme Diffusely infiltra0ng astrocytomas = WHO grade II, III & IV
9 Pilocy0c astrocytoma Children, young adult 1/3 PCA have NF1 Preferred sites: Op0c nerve Chiasmal/hypothalamic Thalamus/basal ganglia Cerebellar hemisphere Brainstem Spinal cord
10 Pilocy0c astrocytoma Occasionally seed the neuraxis Surgical cure if total removal Beeer prognosis: 10 yr survival 94% May recur later in life May undergo malignant degenera0on?rtx RTX for inoperable recurrence Chemo preferred over RTX in children
11 Difusely infiltra0ng astrocytoma >60% primary brain tumours Adults Cerebral hemisphere
12 Diffusely infiltra0ng astrocytoma Diffuse astrocytoma (DA) Anaplas0c astrocytoma (AA) Glioblastoma (GBM) Increasing degrees of malignancy
13 Diffusely infiltra0ng astrocytoma WHO designation DA AA GBM WHO grading II III IV Mean age % of astrocytomas 10-15% 35-40% 50-60% Incidence 1.4/million/yr 2-3/100,000/yr Clinical Seizures Deficits Increased ICP Subtle deficits Seizures Deficits Increased ICP Seizures Imaging CT: low density no enhancement complex enhancement ring enhancement Median survival (optimal Rx) 7-10 years 3 years months
14 LGG WHO 2 astrocytoma Oligodendroglioma Oligoastrocytoma 15% of all primary brain tumours Younger age Seizures in 80% Predilec0on for insula and supplementary motor area
15
16 Management of LGG Controversial Op0ons: Serial exams & imaging inves0ga0ons Surgery Biopsy Par0al resec0on Total resec0on Radiotherapy (early vs late) Chemotherapy Diffuse vs focal Extent of resec0on 1p19q status (oligo)
17 AA/GBM (HGG) Older age Mental state changes more common Poor prognosis
18 Treatment of HGG Issues: Age (70) Histology Karnofsky score (70) Loca0on: deep/lobar Pa0ent s wishes Presen0ng features Good evidence for extent of resec0on Stupp protocol: concurrent temozolamide + RTX
19 Treatment (AA & GBM) Biopsy versus cytoreduc0ve surgery NOT cure Aim: prolong quality survival Options Biopsy 3-4 Resection 6 Biopsy + RadioRx 6-8 Resection + RadioRx 9-10 Resection + RTx + chemo Median survival (months)
20 Newer Technologies Func0onal MRI DTI fibre tracking 5- ALA assisted resec0on
21 Meningioma 14-19% primary brain tumour Extrinsic Origin : arachnoid cap cells Peak age 45 F>M=1.8:1 Excellent prognosis
22 Meningioma Mostly benign, slow growing (WHO grade I) Greater likelihood of recurrence and aggressive behaviour Atypical meningioma (WHO grade II) Anaplas0c meningioma (WHO grade III)
23 Convexity Parafalcine/parasagieal Olfactory groove Sphenoidal ridge Parasellar Op0c sheath Tentorium cerebelli CPA Intraventricular Foramen magnum Spinal Sites
24 CT/MRI Well- circumscribed, extrinsic, durally- based Homogenous enhancement Dural tail +/- oedema +/- hyperostosis +/- calcifica0on Occa en- plaque
25 Management Surgery Aim for complete removal of tumour and its dural origin Simpson grading Sinus involvement Radiotherapy: Unhelpful For grade III meningioma 5 year survival 92%
26 Pituitary adenoma 10% intracranial tumours Anterior lobe of pituitary gland Usually benign 20-40s M=F MEN Microadenoma, <1cm Macroadenoma, 1cm
27 Classifica0on (Histology) Histology Chromophobe, acidophil, basophil Endocrine func0on Endocrine- ac0ve tumours Prolac0noma ACTH- secre0ng tumours GH- secre0ng tumours Thyrotropin- secre0ng tumours Gonadotropin- secre0ng tumours Endocrine- inac0ve tumours Null- cell adenoma Oncocytoma others
28 Presenta0on Endocrinological disturbance: over or underproduc0on of hormones Mass effect (more common with non- func0oning tumours): op0c chiasm 3 rd ventricle (hydrocephalus) cavernous sinus (cranial nerves) Apoplexy CSF rhinorrhea Headache incidental
29 Clinical- Local mass effect Headache Visual field defects Sup temp quadrantanopia Bitemporal hemianopia Cavernous sinus compession CNIII, IV, V1, V2, VI palsies Proptosis, chemosis ICA encasement Ver0cal extension Hydrocephalus Hypothalamic compression Inferior extension CSF rhinorrhoea
30 Evalua0on: Hx & O/E Signs/symptoms of endocrine hyperfunc0on prolac'n: amenorrhea, nipple discharge, impotence thyroid: heat intolerance, anxiety,palpita0ons GH: acromegaly/gigan0sm cor'sol: hyperpigmenta0on, Cushing s syndrome
31 Evalua0on: Hx & O/E Endocrine deficits (in order of likelihood): GH: growth delay, metabolic syndrome LH/FSH: hypogonadism, amenorrhea, low libido, infer0lity Thyroid: myxedema, cold intolerance, weight gain ACTH: orthosta0c hypotension, easy fa0gability DI: almost never seen pre- opera0vely
32 Pituitary apoplexy Acute H/A Rapid progressive visual loss Extraocular nerve palsies Acute pituitary insufficiency Mx: Steroid Urgent decompression
33 Endocrine screening 8am cor0sol & 24 hr urine free cor0sol Free T4, TSH PRL FSH, LH, sex steroids IGF- 1 Fas0ng BSL
34 Imaging MRI CT (stereotaxis)
35 Treatment If prolac0noma, medical treatment with bromocrip0ne, cabergolide Opera0ve aproaches: Transsphenoidal Craniotomy (Radiotherapy)
36 When to operate: hormonally inac0ve macroadenomas Apoplexy: rapid visual/neurological deteriora0on: an emergency Tumours causing mass effect: visual field deficit / panhypopituitarism Tumours eleva0ng chiasm even without signs/symptoms To obtain 0ssue in ques0onable cases Nelson s syndrome (hyperpigmenta0on, raised ACTH, progression of pituitary tumour aper bilateral adrenalectomies)
37 Outcomes Generally good, especially Endocrinological cure in 25% PRL and 20% GH tumours ACTH tumour: 85% cure for microadenomas Recurrence rate : 12%
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