Disclaimer Metro-Detroit Oncology Nursing Society PRACTICE PEARLS UPDATE IN CNS MALIGNANCY Gayle Groshko RN BSN OCN Beaumont Health Radiation Oncology Nurse Case Manager I have no conflicts of interest. Scope Cancer Stat Facts: Brain and other nervous system cancers (NCI SEER data) Estimate new cases in 2016: 23, 770 % of all new cancer cases: 1.4% Estimated deaths in 2016: 16, 050 % of all cancer deaths: 2.7% The Brain 3 Main Areas: Cerebrum, Cerebellum, Brain Stem Cerebrum Large, outer part of the brain 2 hemispheres Controls reasoning, thought, emotion, language Responsible for voluntary movement, talking and interpreting sensory information Symptoms of tumors of the cerebral hemisphere Seizure Trouble speaking Change in mood Change in personality Weakness, paralysis on one side of the body Change in senses, vision, hearing 1
Cerebellum Under the cerebrum, at the back of the brain Helps coordinate movement Symptoms of tumors of the cerebellum Problems with coordination Trouble walking Trouble with precise movements of arms, hands, legs, and feet Trouble swallowing Trouble synchronizing eye movements Changes in speech Brain Stem Lower part of the brain that connect to the spinal cord Contains bundles of nerves that carry the signals to control muscles and sensation Special centers in brain also control breathing and heart beat Most cranial nerves start in brain stem Symptoms of tumors of the brain stem Weakness Stiff muscles Trouble with sensation Trouble with facial or eye movement Double vision Loss of coordination Spinal Cord Long nerves that carry signals to/from brain to control muscles, sensation, bladder and bowel Symptoms of tumors of the spinal cord Numbness Weakness Paralysis Symptoms usually bilateral 2
Blood Brain Barrier Gliomas The inner lining of small blood vessels in the brain and spinal cord Create a selective barrier between blood and the tissues of the central nervous system Purpose is to maintain metabolic balance and prevent toxins from getting in to the brain General term to describe tumors that arise from the supportive tissues of the brain Glia helps keep neurons in place and functioning 3 types of glial cells that produce tumors: Astrocytes, Oligodendrocytes, Ependymal cells Astrocytoma Arise from astrocytes-star shaped cells that make up the glue-like supportive tissues of the brain Graded on a scale of I-IV Most astrocytomas in adults are high grade They can appear in the cerebrum, cerebellum, brain stem and spinal cord Symptoms include headache, seizures, memory loss, behavior changes More frequent in males; more frequent over age 45 Cause is unknown Treatment is surgery to remove as much tumor as possible and Radiation with or without chemotherapy; most likely Temozolomide Oligodendroglioma Oligodendrocytes make up the supportive tissue of the brain Can arise anywhere in the cerebral hemispheres but most often occur in the frontal and temporal lobes Often contain calcifications, areas of hemorrhage and cysts They can be slow growing Most common symptoms are seizures, headaches, personality changes, difficulty with short term memory Cause is unknown but chromosomal abnormalities are being investigated Treatment is surgical resection followed by chemotherapy + Radiation Ependymoma Ependymal cells line the ventricles and the center of the spinal cord Symptoms depend on location and size Nausea, vomiting and headache most common Cause is unknown Treatment is surgical resection CNS Lymphoma Arise in the cells of the lymphatic system, usually B- lymphocytes Occur most often in the cerebral hemispheres May involve cerebral spinal fluid, the eyes or the spinal cord Most often presents as personality or behavior changes, confusion, headache, nausea, vomiting, drowsiness, vision change Can occur in healthy as well as immunocompromised Steroids given for cerebral edema Treated with radiation and chemotherapy 3
Meningioma Pituitary Tumors Represent about 1/3 of all brain tumors Often benign Arise from the coverings of the brain and spinal cord Because they grow inward they can put pressure on the brain and spine. They can also grow outward causing the skull to thicken Because of slow growth they can reach large size before causing symptoms Incidence increases with age Between 40% to 80% contain an abnormal chromosome 22 They have been found to have extra copies of platelet derived growth factor (PDGFR) and epidermal growth factor (EGFR) receptors Previous Radiation to the head and neck or neurofibromatosis II may be risk factors Surgery and Radiation are the common treatments Tumors arising from the pituitary gland Adenomas are slow growing and benign Carcinomas are rare Account for about 10% of brain tumors Most grow in the front 2/3 of the gland Tumors are classified as secreting or non-secreting depending on hormones produced Symptoms include headache, visual impairment, behavior changes. Visual field testing performed. Hormones most commonly affected are growth hormone (regulates body height and structure), prolactin (controls lactation), sex hormones, thyroid hormones, adrenal gland hormones, vasopressin Treatment is surgery and radiation, medication Post radiation patients monitored for gland function and may need replacement thyroid hormones, testosterone for men, estrogen for women, adrenal hormones, growth hormones. Medicines Prolactin: Bromocriptine (Parlodel), Cabergoline (Destinex) Growth Hormone: Octreotide (Sandostatin) Pegvisomant (Somavert) Thyroid Stimulating Hormone: Octreotide (Sandostatin) Acoustic Neuroma Non-cancerous tumor Develops on 8 th cranial nerve which connects the inner ear to the brain Early symptoms are subtle hearing loss Tinnitus Feeling of fullness in the ear Balance disturbance Vertigo Facial numbness, tingling Facial weakness Some are associated with neurofibromatosis type II Treatment is surgery and radiation. They type of surgery may result in permanent hearing loss Brain Metastasis Spread of cancer from a tumor outside the brain Lung cancers account for the highest number of brain metastasis Other frequent cancers include melanoma, breast, colon, and renal cell If the met is solitary may be resected, or Gamma Knife, for multiple mets treatement is whole brain radiation Leptomeningeal Metastasis Spread of tumor cells to meninges Occurs in about 5% of cancer patients Usually fatal Untreated, median survival 4-6 weeks Treated, median survival 2-3 months Pain and seizures most common presentation Other symptoms include headache, ataxia, memory loss, sensory abnormalities, lethargy If there is cranial nerve involvement patient may have impaired vision, diplopia, hearing loss, cranial nerve palsy Diagnosis is made with imaging and lumbar puncture Positive cytology found in 50%-70% of patients. Elevated CSF pressure and elevated CSF protein also common Treatment is radiation to bulky sites and intrathecal chemotherapy 4
Diagnosis History and physical, performance status Symptom profile, onset and severity Neurologic exam: reflexes, muscle strength, sensation, vision, eye movements, coordination and balance, cognition Cognitive Assessment Brain and Spine Tumor Diagnosis Consultation with Neurosurgery, Neurology, Endocrinology, Medical Oncology, ENT, Radiation Oncology MRI with and without contrast the gold standard CT lacks MRI s resolution; used in patient who cannot have MRI MR Spectroscopy: assess metabolites with in tumors and normal tissue; useful in differentiating tumor from radiation necrosis. MR Perfusion: measures cerebral blood volume in tumors. May be useful in differentiating grade of tumor and determining tumor vs. radiation necrosis Brain PET scanning: Assesses metabolism within tumor and normal tissue Principles of Brain Tumor Surgery Gross total resection when possible Minimal surgical morbidity Adequate specimen to determine diagnosis and molecular markers Chemotherapy implants if indicated; Gliadel wafer (carmustine)-placed in resection cavity, wafer degrades releasing the drug. (Used in high-grade glioma) Biopsy/resection Diagnosis Removal of tumor Craniotomy 5
Nursing Management Assist in assessment Coordinate between disciplines, assist with scheduling Medication management; steroids, anticonvulsants, endocrine therapies Pre-op teaching Post-op incision care, treatment planning, MRI Nursing Care Following Craniotomy Immediate post-op phase q30-60 minute neuro checks: level of consciousness, weakness, mobility, aphasia, cognition, visual changes, pupils, nausea and vomiting Keep head of bed elevated to reduce pressure; unless infratentorial approach, then bed flat Monitor dressing and drains; normal drainage in hemovac or jackson-pratt about 30-50 ml Administer medications Continued assessment for signs of increased intracranial pressure: headache, seizure, nausea and vomiting, unusual pupil size and reactivity Pathology Tissue diagnosis Histologic sub groups, molecular hallmarks WHO Meningioma Pathology Radiation Atoms form the basic building blocks of all matter Atoms consist of a nucleus: made of positively charged protons and neutrally charged neutrons; and an outer cloud of electron which are negatively charged The positive charge of a single proton is equal to the negative charge of a single electron; so equal at net zero If an atom loses or gains an electron it becomes an ion and carries a charge Ionizing radiation caused by unstable atoms giving off energy In ionizing radiation the target is cellular DNA Ionizing Radiation Caused by unstable atoms giving off energy to reach a stable state Target is cellular DNA 6
The Atom Principles of Brain and Spinal Cord Tumor Radiation Radiotherapy is the most effective nonsurgical treatment for brain tumors Tumor volumes are defined using pre-and postoperative imaging and simulation films Clinical target volume and surrounding 1-2 cm margin is drawn Doses are measured in Gy. Radiation-Gliomas Clinical target volume plus 1-2 cm margin delineated on treatment planning Low grade (I/II) treated daily, Monday-Friday, total dose 45-54 Gy, 1.8-2.0 Gy fractions. SRS not indicated in low grade tumors High grade (III/IV) treated daily, Monday-Friday, total dose 60 Gy in 2.0 Gy fractions. Lower dose can be given in grade III tumors Elderly, poor-performance status patients generally treated at a hypofractionated accelerated course; example 34 Gy in 10 fractions-50 Gy in 20 fractions. Radiation-CNS Lymphoma Low-dose whole brain RT following complete response to chemotheray. Doses usually limited to 23.4 Gy. For less than complete response to chemotherapy; whole brain RT plus limited field RT to gross disease If patient does not receive chemotherapy, whole brain RT to dose of 24-36 Gy with boost to gross disease, total RT dose is 45 GY Radiation-Spinal Tumors Primary tumor doses are 45-54 Gy, given in 1.8 Gy fractions. Spine metastasis: dose depends on performance status, spine stability, primary tumor histology. Some cases can be single fraction Stereotactic body radiotherapy. Radiation Treatment Planning Simulation: planning session for radiation therapy. Patient education as to potential treatment side effects: fatigue, headache, weakness, vision changes, nausea and vomiting (generally due to cerebral edema; may exacerbate presenting symptoms) Scalp and hair care: mild shampoo like baby shampoo, no styling products. Wash face with mild soap live Dove, Basis, Neutrogena. No lotions on radiated skin 4 hours prior to treatment. Immobilization device. If patient is claustrophobic, may require premedication with xanax. 7
Aquaplast mask Radiation Therapy Side Effects Headaches Hair loss Nausea Vomiting Extreme fatigue Hearing loss Skin/scalp dryness, itching, sunburn like reaction Trouble with memory and speech Approaches to Neurocognitive Toxicity Hippocampus Block Increased focus on focal therapy; surgery, stereotactic radiotherapy Neurocognitive decline due to microvacular changes, neuroglial loss and damage to the hippocampus Hippocampus located in temporal lobes; responsible for learning and memory. New radiation techniques include treatment plans that block the hippocampus Whole Brain Neurotoxicity Long term decrease in cognition, memory Trial of Memantine published in Neuro Oncology 2013 Oct; 15(10): 1429-37 (RTOG 0614) Brain mets receiving whole brain RT, 508 eligible patients. Patients randomized to Memantine 20mg/day vs. placebo, within 3 days of RT and for 24 weeks. There was less decline in recall in the Memantine arm (not statistically significant, only 149 analyzable patients at 24 weeks). The Memantine arm had better cognitive function over time, reduced rate in decline in memory, executive function, processing speed than the placebo arm. Memantine (Namenda) RTOG 0614 dosing schedule Week 1 5mg AM Week 2 5mg AM 5mg PM Week 2 10mg AM 5 mg PM Week 4-24 10mg AM 10mg PM Generally well tolerated, rare side effects: dizziness, headache, constipation, pain, shortness of breath, high blood pressure, coughing, nervousness, changes in behavior, tremor. 8
Systemic Therapy for CNS Tumor Therapy selection and dosing based on tumor type, patient performance status. NCCN Guidelines NCCN Guidelines NCCN Guidelines Optune Treatment for Glioblastoma Multiforme (GBM) following maximal debulking, RT and concomitant chemotherapy Treatment for recurrent GBM Wearable device, transducer arrays applied to scalp and connected to device and battery When turned on creates low-intensity electric fields called TTFields TTFields travel in waves; designed to interfere with cell division Worn in combination with Temozolomide (Temodar) Clinical trials have shown device to improve progression-free survival from Temodar alone (7.2 months vs. 4 months) and median survival (20.5 months vs. 15.6 months) Device should be attached/worn for at least 18 hours a day Optune 9
References NCCN Guidelines Version 1.2016 WWW.cancertherapyadvisor.com/brain-cancer-treatment/218165 http://ro-journal.biomedcentral.com/articles Why and how to spare the hippocampus during brain radiotherapy: the developing role of hippocampal avoidance in cranial radiotherapy http://neurosciencenursing.blogspot.com/2013/12/nursing-carefollowing-craniotomy.html Neuro Oncol. 2013 Oct; 15(10)1429-37. Memantine for the prevention of cognitive dysfunction in patients receiving wholebrain radiotherapy: a randomized, double-blind, placebo-controlled trial. Brown PD, Pugh S, Laak NN, Watkins-Bruner D, RTOG Ca: A cancer journal for clinicians. January/February 2017 Leptomeningeal Metastatis: What Nurses Need to Know. Schweisguth, D Bursine 2015 Dec: 45(12): 32-35 10