Neurologic Complications of Cancer. Dr. Kathryn Giles MD, MSc, FRCPC Cambridge Ontario
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1 Neurologic Complications of Cancer Dr. Kathryn Giles MD, MSc, FRCPC Cambridge Ontario
2 Copyright 2017 by Sea Courses Inc. All rights reserved. No part of this document may be reproduced, copied, stored, or transmitted in any form or by any means graphic, electronic, or mechanical, including photocopying, recording, or information storage and retrieval systems without prior written permission of Sea Courses Inc. except where permitted by law. Sea Courses is not responsible for any speaker or participant s statements, materials, acts or omissions.
3 Faculty/Presenter Disclosure Faculty: Dr. Kathryn Giles Relationships with commercial interests: o Grants/Research Support: Biogen Idec, Genzyme o Speakers Bureau/Honoraria: Bayer, Biogen Idec, EMDSerono o Consulting Fees: Biogen Idec, EMDSerono, Genzyme o Other: none
4 Disclosure of Commercial Support Potential for conflicts of interest: o none
5 Neurological Effects of Cancer Direct Primary Metastatic Indirect Paraneoplastic Treatment
6 Primary Malignancy BRAIN o When in hemispheres usually present with seizures, personality or cognitive change, visual change or headache o Cerebellar present with raised ICP, balance o Brainstem multifocal SPINAL CORD o Cord syndrome o Acute/subacute o Often bladder and bowel o Often painless o Usually multiple segments
7 Neurological Effects of Cancer Direct Primary Metastatic Indirect Paraneoplastic Treatment
8 Direct Effects of Metastatic Cancer Localization CNS o Brain o Spinal Cord PNS o Root o Plexus o Nerve
9 CNS Brain o Focal Symptoms/Deficit o Cognitive/Personality Change o Headache o Diagnosis o CT with contrast o MRI o CSF (meningeal involvement)
10 CNS Spinal Cord o Focal/cord deficit o Pain o Diagnosis X-ray MRI
11 PNS Root o Radicular Symptoms o Often multiple o +/- Spinal cord o Pain o Diagnosis MRI EMG CSF
12 PNS Plexus o Multiple root/nerves o Pain o Diagnosis MRI + gadolinium EMG CSF
13 PNS Peripheral Nerve o Rare o Usually indirect
14 Treatment of Secondary Cancer in the Nervous System Diagnosis Referral Pain o Narcotics/Opioids o Pregabalin (Lyrica) o Cannabinoids (Sativex, Cesamet/Nabilone, medical marijauna) Treatment of the Tumor
15 Neurological Effects of Cancer Direct Primary Metastatic Indirect Paraneoplastic Treatment
16 Paraneoplastic Syndromes Immune mediated/onconeuronal antigens Cytotoxic T-cell responses (CD8+/CD4+) Precede tumor diagnosis in 60% Check CSF + blood for antibody (Anti-Hu, Anti- Ri, Anti-Yo) Occult neoplasm presumed
17 Paraneoplastic Syndromes Most common in: o SCLC o Breast o Ovary o Neuroblastoma o Plasma cell tumors Acute/subacute onset Blood/CSF/MRI/PET
18 Paraneoplastic Syndromes in CNS o Cerebellar degeneration SCLC, Breast, Ovary, Lymphoma Anti-Yo o Encephalomyelitis (Limbic encephalitis) Lung Anti-Hu o Opsoclonus Myoclonus Neuroblastoma, SCLC, Breast Anti-Hu, Anti-Ri
19 Paraneoplastic Syndromes in PNS o Sensory neuronopathy (dorsal root ganglion) Lung Anti-Hu o Subacute or chronic sensorimotor peripheral neuropathy Plasma cell dyscrasias, B-cell lymphoma
20 Paraneoplastic Syndromes of the Neuromuscular Junction o Lambert-Eaton myasthenic syndrome Fatigue, weakness, myalgia, paresthesias Cholinergic dysautonomia dry mouth Characteristic EMG SCLC Anti VGCC Treat with 3,4-diaminopyridine
21 Paraneoplastic Syndromes of Muscle Dermatomyositis o Subacute muscle weakness, elevated CK o dysphagia o Skin changes o Breast, lung, ovarian, gastric o Anti-Jo Acute Necrotizing Myopathy o Solid tumors
22 Paraneoplastic Syndromes Treatment Steroids IVIg Plasma Exchange Treatment of underlying tumor
23 Indirect Paraneoplastic Treatment Chemo Radiation
24 Chemotheraphy Neuropathy Encephalopathy Acute cerebellar syndrome/ataxia Myelopathy Cerebral Vasculopathy
25 Radiation Brain o Acute (hours to days) ICP vasogenic edema o Early Delayed (weeks) Diffuse (somnolence), or focal demyelination o Delayed (months to years) Diffuse (dementia), or focal glial and vascular destruction
26 Radiation Spinal Cord o Early delayed (weeks) L hermittes sign demyelination o Delayed (months to years) Necrosis MND Arachnoiditis Glial and vascular destruction
27 Radiation Cranial Nerves o Visual loss (retina, optic nerve, central artery occlusion) o Hearing loss ( radiation otitis) o 12th nerve (hypoglossal)
28 Radiation Plexopathy (brachial/lumbosacral) o Delayed o Fibrosis o No pain
29 Radiation Radiogenic tumours Vascular abnormalities Endocrinopathies
30 Summary Neurologic complications of cancer are common Think of them Refer
31 QUESTIONS?
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