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CNS Tumors

Megan Comer
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General Patient Info

 56 y/o

 Male

 WHO grade IV glioblastoma multiforme

 ATRX intact, IDH1 intact, EGFR amplified, Ki-67 25%, MGMT

not methylated
 What does this mean? Immunohistorychemistry
 Vascular proliferation, necrosis

 Centered in right thalamus

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Epidemiology of CNS tumors

 Brain tumors account for 1.5-2% of all newly diagnosed

tumors each year
 80% of these are brain tumors
 50% of primary brain tumors are Gliomas

 Peak ages are 3-12 and 40-80 years old

 Approximately 24,000 new malignant CNS tumors are

diagnosed each year, and approximately 16,000 deaths occur
each year from CNS tumors, according to the National Brain
Tumor Society
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Etiology

 Mostly unknown

 Possible genetic link?

 Caucasian or Asian ethnicities have an increased risk

 Possible rubber compounds, polyvinyl chloride, N-nitroso

compounds and polycyclic hydrocarbons.

 Radiation exposure
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Anatomy
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Anatomy

 Diencephalon: located between cerebrum and midbrain.

 Made up of thalamus, hypothalamus, optic chiasm and pineal
body

 Thalamus: responsible for sensations of pain, temperature,

touch. Also for emotions, sensory impulses.
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Lymphatics/Distant Mets

 There are no lymphatics associated with the brain!

 Can GBMs metastasize?

 Only to other parts of the brain
 Commonly the cerebellum
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Grading System

 Provides information about aggressiveness of tumor

 G1 – Well differentiated, closely resemble normal cells. Low

proliferative potential

 G2 – Moderately differentiated. Low in mitotic activity,

generally infiltrating lesions

 G3 – Poorly differentiated. Clear infiltrative capabilities,

anaplasia, clear mitotic activity

 G4 – Undifferentiated, do not resemble normal cells.

Necrosis-prone, rapid evolution
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Gliomas

 Lowest grade:
 Pilocytic Astrocytoma, Glanglioglioma, Subependymoma, etc

 Lower grade:
 Ependymoma, Oligodendroglioma, Optic Nerve Glioma, etc

 Higher grade:
 Anaplastic astrocytoma, anaplastic oligodendroglioma, etc

 Highest grade:
 Glioblastoma multiforme, Gliosarcoma, Gliomatosis cerebri
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Pathology

 GBMs can develop directly or evolve from lower grade

astrocytomas

 Develop from star-shaped glial cells

 Glial cells surround neurons and provide support and insulation
for them
 Most abundant type of cell in CNS
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Social History

 Single

 Worked at humanitarian society

 20 pack/year
 Cigarettes

 “Quit drinking mostly”

 Drug use: yes

 Opiates
 Marijuana

 Lives with disabled sister and nephew, their primary care taker
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Family History

 Mother: deceased
 Aneurysm
 Lung cancer
 Heart disease

 Father: deceased
 Heart disease
 Skin cancer

 Sister:
 Undocumented disability
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Medical/Surgical History

 GSW at 14, right eye blind, extorted, numbness of face. Eye surgery

 Hypertension

 Diabetes mellitus

 GERD

 COPD

 Meds before admission:

 Albuterol: (2.5 mg/3 mL) 2.5 mg by nebulizaation route every 6 hrs or as
needed for wheezig
 Budesonide formoterol. 2 puffs every 12 hours for wheezing
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Possible presenting signs and
symptoms
 Headache – 70% of patients

 Seizure – 55% of patients

 Unilateral weakness

 Mental changes/altered mental state

 Visual field problems

 Hydrocephalus (if CSF flow is obstructed)

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Presentation
 2-3 weeks before CT, patient began experiencing left sided numbness
and weakness to the point he started walking with a cane.
 Around this time, he stopped using illegally purchased narcotics, and assumed
his symptoms were from opioid withdrawal.

 Symptoms progressed, he eventually felt unsafe driving home from his

job. Younger brother picked him up and took him to local ED.
 Lab work here only remarkable for mild hypernatremia (147).
 CXR was done because history of smoking, unremarkable.

 Head CT performed, discovered 4x4 cm mass in right thalamus. Given

dexamethasone, transferred to OSU.
 What is dexamethasone?
 Why not an MRI?

 Patient also then noted inexplicable weight loss since September,

around 20 lbs.

 Family also noted personality changes, including increased anxiety

and irritability.
 Hard to discern if this was from tumor or lack of narcotics.
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CT from local ED
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Treatment

 Surgery
 Right craniotomy
 Partial resection

 Chemotherapy

 Radiation Therapy
 Standard treatment: 5000-7000 cGy total, 150-200 cGy/fx
 Possible cone down?
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Post Treatment CT
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Chemotherapy

 Temozolomide

 Alkylating agent

 75 mg/m2 for 42 days during RT

 Then 4 weeks of rest
 Then 150 mg/m2/day for 5 days for the first 28 day cycle,
followed by 200 mg/m2/day for 5 days to continue for up to 12
cycles
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Other meds

 Dexamethasone daily

 Famotidine, while on dexamethasone

 Docusate, Senna, Polyethylene Glycol Pack (for stool

problems)

 Enoxaparin – blood thinner

 Oxycodone

 Zofran
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RT Treatment Plan

 6000 cGy total

 30 fractions

 200 cGy/fx

 VMAT 3 arcs total

 181-0 71.8 cGy
 359-182 73 cGy
 T270 190-330 55.1 cGy

 6 DOF
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Set up

 Q2+custom head rest

 Aquaplast

 Right hand on peg

 Left hand on chest

 Knee sponge

 Arms secured with safety strap

 Set up problems: pull shoulders left, nose right daily

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Axial
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Coronal
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Sagittal
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Organs at Risk
TD5/5 Normal Tissue Tolerances (GY)
1.8 – 2.0 Gy/fraction
Organ 1/3 2/3 3/3 End Point
Lens 10 10 10 Cataract
Lacimal Gland 26 26 26 Dry eye
Optic Chiasm 50 50 50 Blindness

Optic Nerve 50 50 50 Blindness

Brain 58 51 47 Necrosis/Infarc
(Temporal Lobe) tion

Brain Stem 60 53 50 Necrosis/Infarc

tion

Spinal Cord 50 (5 CM) 50(10 CM) 47 (20CM) Myelitis/necrosi

s
Ear 30 30 30 Acute serous
otitis
Ear 55 55 55 Chronic serous
otitis
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Dose Volume Histogram
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Dose Volume Histogram
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Potential Side Effects

 Acute  Late
 Fatigue – Rest!  Radiation necrosis
 Alopecia  Visual changes, cataracts
 Edema  Endocrine abnormalities
 Nausea/vomiting - Zofran  Decreased cognitive ability
 Skin reactions – Non-alcohol  Memory loss
lotions
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Prognosis and Survival

 Prognosis depends on:

 Age of diagnosis
 Histology
 Proliferation Index
 Karnofsky performance score
 Indications functional impairment status

 Survival:
 WHO states Grade IV GBMs have a median survival of about 17
months after RT/Chemo
 National Brain Tumor Society states a 5.1% 5 year survival rate for
GBMs
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References

1. Brain Tumor Facts. National Brain Tumor Society.

http://braintumor.org/brain-tumor-information/brain-tumor-
facts/

2. Understanding Glioblastoma (GBM). www.mdanderson.org.

https://www.mdanderson.org/publications/cancerwise/2013/0
4/understanding-glioblastoma.html

3. Hackworth, R. CNS Tumors Presentation. 2016.

4. Hackworth, R. Adult CNS Tumors Presentation. 2016.