Case Study

Central Nervous System

David Lloyd

Patient5

MRN: 907972614
61 Y/O
Caucasian
Male
Treated on the MXE
Consult was September 2013
Treatment soon after.

General Medical Hx 5
Overall healthy individual
Prior to CA had no major medical Hx
NKDA
Some surgeries through out his life
Hernia (at age 4)
Ankle surgery (2005)
Brain Surgery for GBM (Resection @ RMH 9/2013)
No Hx of Previous Radiation or Chemotherapy

Presenting Symptoms 5
Pt goes to RMH ED with:

Headache x10 days

Fatigue
Loss of vision in left eye
1-2 months of increasing confusion
Getting lost
Could not put things together
Running into things / tripping
Driving Accidents
Diagnosed R-Parietal Lobe Grade IV Glioma, GBM

Typical Presentation of CNS

Tumors1
Often the location of the tumor dictates the
presenting symptoms.

Headache (worse in am difference in CSF drainage)

Seizures
Fatigue
Nausea / Vomiting
Difficulties with balance and gate - (tripping)
Ocular Symptoms - (Left eye vision loss)
Expressive Aphasia
Personality Changes

Etiology1
Origin of primary CNS Tumors are mostly
unknown:
Environmental Factors - Chemicals, Pesticides, Ionizing
radiation and electromagnetic fields.
Life Style Factors cell phones, nitrates, hair dyes and
smoking.
Medical Conditions drugs, viral infections, AIDS
Family Hx indicates none of these factors directly relate
to him.

Epidemiology3
The National Cancer Institute estimates 22,910
adults will be diagnosed with brain and other CNS
tumors in 2012.
(60%) 13,700 of these diagnoses will result in
death.
GBM = 15% of all brain tumors
primarily occurs in adults 45 to 70 years old.

Prognosis1,2,5

Senator Ted Kennedy was diagnosed with GBM in

May 2008 Surgery June Died August 25, 2009.4

Basic Brain Anatomy

Axial CT of R-Parietal GBM 8

Axial CT of R-Parietal GBM 8

Mid-line shift
to the left

Images Defining Location of

Disease
Imaging prior to surgery was outside of OSU
(RMH)
Post-Op - MRI on 09/21/2013
***See Aria at this time***

Images Defining Location of

Disease
Outside (RMH) imaging prior to surgery
Post-Op - MRI on 09/21/2013
Surgical defect in the right parietal
lobe.
Postsurgical reactive change.
Unclear what is primary brain neoplasm versus
edematous changes post-op.
Report - Midline shift improved from 7mm to 2mm postop.

Lymphatics of the Brain 1,2

There are no lymphatic channels in the brain.
Gliomas primarily spread through local invasion
along pre-existing pathways in the white matter
Invasive they have no natural capsule to inhibit growth

Anaplastic Astrocytomas and GBM may seed the

CSF in the sub-arachnoid space.
The brain is also protected by the BBB in lack of
lymphatics.

Classification of CNS Tumors 1

Staging and Grading 1,7

There is no universal staging system currently in use

Staging and Grading 1

The American Joint Committee on Cancer uses a system
based on (GTM):
Grade has prognostic significance
G1, well differentiated, better outcome
G3, poorly differentiated, worse outcome

Tumor
Metastasis

Staging and Grading 7

WHO Grade System
(1993 the WHO ratified a new comprehensive
classification)
tumor classification dictates the choice of therapy and
predicts prognosis.

Grade
G1, well differentiated, better outcome
G2, moderately differentiated
G3, poorly differentiated
G4, undifferentiated, worse outcome
All GBMs = Grade IV

Possible Treatments 1,2

Complete resection
or debulking if larger
tumor volume

Must be agents that can

penetrate the BBB.
Temozolomide and
Nitrosoureas have this
ability.

Used to be whole
brain, now with CT
and MRI limited
radiation fields
covering the lesion
and a margin is
advocated. If it is
brain mets from
another site wholebrain is then prefered.

Overview of Treatment Plan 5

Pt Treatment Plan

Field Design5
Field

Gantry
Angle

Segments

MUs per
Angle

180

40

220

37

260

33

300

30

340

57

20

47

90

30

46

45

145

40
330 Total
Mus

Couch

Critical Structures 5

Patient Positioning 5

Axial Isodose Curves

IMRT
treatment
collimators
define field
size to
match
isodose
curves

Sagital Isodose Curves

IMRT
treatment
collimators
define
field size
to match
isodose
curves

Sagital Treatment DRR

Coronal Isodose Curves

IMRT
treatmen
t
collimato
rs define
field size
to match
isodose
curves

Coronal Treatment DRR

Acute Side Effects5

Skin irritation
Hair loss
Brain swelling (steroids)
Fatigue rest PRN
Vomiting
Nausea Tx with anti-emetics
Decreased Appetite observe
Abnormal Taste and Smell some irritation from
radiation in oral cavity, this should subside in 1-2
months.

Late Side Effects 5

Hearing Loss
Vision Changes
Short Term Memory Loss
Cognitive Dysfunction
Secondary cancer Formation
As of the patients follow-up visit in 12/2013, he was not
experiencing any late side effects.

In Conclusion
This patient has been thru a lot. He remains in
good spirits but fatigued most of the time. He has
not seen much improvement in his symptoms, but
also has not demonstrated new symptoms or
problems. Most recent MRI shows no
enhancement suggestive of progressive disease.
He celebrates his 62nd birthday on February 18th.

References
1. Reviews CT. e-Study Guide for: Principles and Practice of Radiation
Therapy by Charles Washington, ISBN 9780323053624. Cram101; 2012.
2. Vann AM, Dasher B, Wiggers N. Portal Design in Radiation Therapy, 3rd
Edition. 2013.
3. Available at: http://www.aans.org/Patient Information/Conditions and
Treatments/Glioblastoma Multiforme.aspx. Accessed January 26, 2014.
4. Available at: http://emedicine.com. Accessed January 26, 2014.
5. IHIS
6. Carter CE, Veal BL. Digital Radiography and Pacs. Mosby Incorporated;
2010. Might not use this one it is PACS book.
7. Available at: http://neurosurgery.mgh.harvard.edu/newwhobt.htm.
Accessed January 28, 2014.
8. Available at: http://www.mypacs.net/cases/62178343.html. Accessed
February 1, 2014.