NON MALIGNANT BRAIN TUMOURS Facilitator. Ros Taylor Advanced Neurosurgical Nurse Practitioner Southmead Hospital Bristol

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1 NON MALIGNANT BRAIN TUMOURS Facilitator Ros Taylor Advanced Neurosurgical Nurse Practitioner Southmead Hospital Bristol

2 Neurosurgery

3 What will be covered? Meningioma Vestibular schwannoma (acoustic neuroma) Neurofibromatosis 2 Pituitary tumours How are they diagnosed and treated? Why are some tumours not treated? Who is involved in treatment and support? New treatments?

4 Meningioma Most common low grade tumour in 20% cases Meningiomas grow on the surface of the brain (or spinal cord), and therefore push the brain away rather than growing from within it. Develop from arachnoid cap cells of central nervous system.

5 What do we know about causes? Rising incidence with age More common 60 th and 70 th decade of life 3:2 female bias Risk in deletion of NF2 gene Exposure to ionizing radiation Association with breast cancer

6 Tumour type 90% are benign low grade WHO grade 1 1-3% higher grade ( locally more aggressive and progress more rapidly) Grade 2 atypical WHO grade 3 anaplastic / malignant Age at onset and index of tumour independent prognostic factors of clinical outcome

7 Imaging Recent onset seizures Focal neurological sign Magnetic resonance imaging (MRI) Dural tail sign Size, location and surrounding oedema (swelling) guide treatment options

8 Meningioma symptoms Most often slow growing 1-2 mm per year Small will not cause any symptoms Larger tumour may start to cause obstruction or surrounding tissue, raised intracranial pressure and or oedema lead to symptoms Seizure Headache Weakness in arm or leg Loss of sensation in a limb Personality change Visual deficit

9 Common Location (Types) of Meningiomas

10 Meningioma treatment options Location if the tumour is easily accessible then it is often best for it to be removed if it is causing symptoms. Size if the tumour is less than 3cm in diameter it may alternatively be possible to treat it with stereotactic (targeted) radiosurgery. Asymptomatic remain on surveillance. General health - for example there may be risks with a general anaesthetic in patients with other significant medical conditions such as heart disease. Grade of tumour how quickly it is growing, whether it is invading other structures in the brain. Chemotherapy is rarely used.

11 Team approach Panel of specialists Neurosurgeon ENT Neuro-radiologist Neuro-pathologist Neuro-Oncologist Clinical Nurse Specialist

12 Surgical management Pre operative assessment Managing existing medical conditions Steroids Anti convulsants Neuropsychological assessment Scans for neuro navigation Intraoperative scanning Electrophysiology monitoring Angiogram ITU bed

13 Fatigue Cogntive Physical Telephone SUPPORT Emotional effects Scan results Anxiety

14 Vestibular Schwannoma Incidence cases per million Sporadic Asymmetrical hearing loss Tinnitus Balance disturbance Otalgia Facial numbness and weakness Taste disturbance Compression cranial nerves

15 Treatment Options Low grade slow growing non cancerous VS Watch Radiosurgery Surgery Small ongoing surveillance Monitoring hearing Evidence of growth Large tumours with mass effect require surgical management

16 Stereotactic radiosurgery It does not remove the tumour or lesion, but it distorts the DNA of the tumour cells. The cells then lose their ability to reproduce and retain fluids. Side effects Gamma Knife based SRS is, in general, not suitable for tumours > 3.5 cm in diameter Preserve hearing and avoid trigeminal and facial nerve deficits Ongoing surveillance scans

17 Surgical management MDT approach to early phase post operative recovery Vestibular physiotherapy Occupational therapy Hearing therapy Cross aids Speech therapy Facial rehabilitation Ongoing surveillance imaging

18 Neurofibromatosis 2 ( NF2) Identified by development of acoustic tumours (vestibular schwannomas) on BOTH acoustic nerves A rare genetic condition Caused by a mispelling on chromosome 22 Occurs in 1 in of the population Usually definitively diagnosed by MRI scans Characterised by development of nervous system tumours (lumps) typically in the brain and spine Likely to cause hearing loss, deafness, mobility and balance problem

19 Neurofibromatosis 2 Different management to single Vestibular schwannoma Annual surveillance Neurology, ENT, Ophthalmology, Audiology, Genetics, Psychology, Physiotherapy Family history and screening CNS track condition and coordinate cases Holistic approach Nationally commissioned service

20 Advances in treatment Class of agents known as monoclonal antibodies. Inhibits growth slows blood supply to tumour Side effects Benefit prolonging time with hearing before SRS or surgery is required. Avastin

21 Prolactinoma 40% Medication dopamine agonist Functioning tumour Non functioning Impinging on optic nerve Visual Field defects Surveillance Transphenoidal surgery Radiosurgery Pituitary Tumours

22 Impact of heminopia

23 Following surgery Linked with Endocrinology Assess pituitary function post surgery May require steroids Other pituitary hormone supplementation e.g. testosterone, growth hormone, thyroxine Early telephone support from CNS Joint pituitary follow up. Ongoing surveillance

24 Any Questions?