brain tumors neurosurgical treatment including gamma knife

8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife

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Brain Tumors:Neurosurgic al treatment(inc luding Gamma Knife)

An Introduction

The LSU-Shreveport Department of Neurosurgery

Presenting Authors: Neurosurgery Residents & Faculty


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Brain Tumors: Classification

Categorized & Considered by c ell layer of origin

World Health Organization (WHO) Classification:

Tumors of Neuroepithelial tissue

Tumors of Meninges

Tumors of Craniospinal Nerves

Hematopoietic Neop lasms Germ Cell Tumors

Sellar Tumors

Metastatic Tumors


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Common Intrac ranial Tumors

Metastatic tumors to brain (lung, breast, rena l, GI mostfreqeuent; melanoma has highest affinity for brain)

Gliomas (astroc ytoma, anaplastic astroc ytoma,gliob lastoma multiforme)

Meningioma & Hemangiopericytoma

Pituitary adenoma Craniopharyngioma

Vestibular schwannoma (a.k.a. acoustic neuroma) &Neurofibroma

Lymphoma

Pinea l region tumors

Cystic lesions which mimic intrac ranial tumors

Inflammatory lesions which mimic intrac ranial tumors

Infec tious lesions which mimic intrac ranial tumors


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Brain Tumors in General

Presentation

Headac he, seizure, neurolog ical defic it

History Progressive onset of sym ptoms (weeks to months)

Physical Exam Depends upon brain reg ion affec ted

Diagnostic Imaging Studies CT, MRI, PET (if r/ o nec rosis)

Diag nostic Laboratory Studies

Important for systemic tumors, e.g. leukem ia Treatment

Varies per histology of spec ific tumors

Prognosis Varies per histology of spec ific tumors

http://www.neurobc.com/conditions/Brain_metastases.htm


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Metastatic Brain Tumor History

Rapid ly p rog ressive o nset of symp tom s (weeks vs. months)

Mo st c ommon sources a re LUNG, BREAST (in women), RENAL, & G.I. trac t

Diag nostic Imaging Stud ies MRI: Tumor a t g rey-white ma tter junc tion, usually assoc ia ted with edema

Systemic work-up inc ludes CT sc an o f chest and a bd omen

Diagnostic Labora tory Stud ies Liver func tion tests, CBC w / d iff

Trea tment For solita ry lesion or less tha n 4 lesions a ll < 3 cm. b iop sy

if undiagnosed, plus Gamma Knife

For > 3 cm. tumor, surge ry followed by WBRT

For > 4 lesions, biop sy for diag nosis, plus whole b ra in

rad ia tion therapy

Prognosis: 7 12 mos.http://www.neurobc.com/conditions/Brain_metastases.htm


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Gliomas Presenta tion

Depends upon b rain loc ation, usually H/ A over

severa l mos., seizure, wo rd finding d ifficulty

Physic al Exam Depends upon brain region affected

Diag nostic Imaging Studies CT, MRI

Trea tment Surge ry, Radiation, Chemo (varies/ age group &

type)

Survival dep ends on pa thology: Piloc ytic astroc ytoma: resec tion cure; Grad e 1 Astroc ytoma (nuclear atypia) 8-10 yrs;

Grade 2 Anaplast ic astrocytoma (+endothelia lp rolifera tion) 2 yrs.

Grade 3 (+nec rosis) GBM 11 monthshttp://www.neurobc.com/conditions/

Astrocytoma Note absence of edema

GBM Note crossing of corpus callosum

http://sprojects.mmi.mcgill.ca/braintumor/section2/subsection1/Default.htm


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Meningioma &Hemangiopericytoma

Presenta tion Meningioma s oc c ur in midd le ag ed fema les more frequently

Hemangioperic ytomas oc c ur in younger pa tients

History Mening iomas are usually slow-growing (months to yea rs) vs.

hemangioperictyomas(months)

CT/ MRI: Show meninges-based tumor (usua lly), withvariab le a mount of edema

Trea tment Meninigioma s: Gross tota l resec tion cure;

Hemangiope ric ytoma s: Surgica l resec tion + XRT

Prognosis Meningioma s: Can be c ured with gross tota l resec tion

Hemang iop eric ytomas: Variab le, depends upon rec urrenc e

http://sprojects.mmi.mcgill.ca/braintumor/section2/subsection1/Default.htm


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Pituitary adenoma Presenta tion

Hea dac he, visual defec t (c lassic ally bitempo ra l hemianopsia),end oc rine abnorma lities (depend ent upon hormone sec reted )

Cushings d isease is life-threa tening (w / hypertension, stria , buffa lohump, morbid obesity); Prolac tin, GH, TSH, FSH/LH a lso p resent

History Slow-grow ing, over months to years

Diagnostic Labo ra tory Stud ies Endoc rine panel (with hormones noted ab ove); c an test IGF-1 for

GH-sec ret ing tumor; use d examethasone suppression test forCushing s d isea se vs. ec top ic Cushing s syndrome

Trea tment Surg ic a l exc ision usua lly initial trea tment (usua lly transnasa l

approa c h), with GK for rec urrenc e vs. loc a l foc used rad ia tion

Prognosis Genera lly benign, so p rop ortiona l to g ross tota l resec tion &

c ontrol of endoc rine effec ts; Cushing s d isea se is life-threa tening,so remove p ituitary g land if nec essary

http://www.clevelandclinic.org/neuroscience/treat/brain/neuroendocrine.htm

http://www.medschool.lsumc.edu/Nsurgery/case23.html


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Craniopharyngioma Presenta tion

More co mmon in younger c hildren and olde r ad ults

History Endoc rinolog ic abo rma lity, often diabetes insipidus

Skull X-ray/CT: Often c a lc ified mass nea r

hypotha lamic a rea Diagnostic Labora tory Stud ies

R/ O D.I.: Serum sod ium > 145, Urine spec ific g ravity< 1.005, with c lea r d ilute urine up to 10,000 c c / day!

Trea tment Surgica l resec tion and / or focused rad ia tion

Prognosis 5-yea r survival 55%; morta lity 10% usua lly from

hypotha lamic injury

http://www.rbrs.org/database/82-3/page130.html


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Vestibular sc hwannoma

Presenta tion Hea ring diffic ulty in a ffec ted ea r, vertigo ,

hea dac he/ fac ia l wea kness/ fac ia l numbness if la rgetumor

Physic al Exam Evaluate fac ia l weakness & hea ring ability

Diag nostic Imaging Stud ies MRI Brain

Trea tment Surg ic a l resec tion if >3 c m. or c ausing excessive

mass effec t bra instem c ompression; GK for sma llerlesions (


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Lymphoma

Presenta tion Sporad ic , more c ommon in immunosuppresed or

immunocompromised patients (e.g . HIV+); ma y or ma y notbe systemic @ presentation.

Spinal co rd (epidural) compression or c arc inoma tousmeningitis multip le c rania l nerve deficits

Diag nostic Imaging Stud ies CT and / or MRI Brain

Trea tment Biop sy for estab lishing d iagnosis, follow ed by rad ia tion;

c hemotherap y (methotrexate ) has shown inc rea sed surviva l

Prognosis No tx 2.5 mos.; XRT 10 m os.; IntraVENTRICULAR

methotrexate 41 months. Prog nosis worse in AIDS p ts. (4months)

http://www.uhrad.com/mriarc/mri001.htm


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Pineal Region Tumors Presenta tion

Heada c he, Hydroc epha lus (if large)

Physica l Exam May develop Perinauds syndrome (upgaze pa lsy,

c onvergenc e, and ac c omod ation impairment) ifla rge tumor

Diag nostic Ima ging Studies MRI

Diagnostic Labo ra tory Stud ies CSF can be sent for ma rkers AFP, HCG, PLAP

Trea tment Depend s upon histology: Germinoma biopsy &

irrad ia te; Pineob lastoma : resec t & irrad ia te

Prognosis

Depend s upon histology: Pineocytoma better thange rminoma, pineob lastoma

Some tumors, particularly germinoma,can concomitantly present in the pinealand parasellar regions, as shown here.

http://home.earthlink.net/~radiologist/tf/100200.htm


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Pediatric tumors

Will be c overed in lec ture on Ped ia tric Neurosurgery

Inc lude medulloblastoma,ependymoma, p iloc ytic astroc ytoma ,

c horoid p lexus pap illoma &c arc inoma, and DNET


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Cystic lesions that can mimican intrac ranial tumor on MRI

Example: ARACHNOID CYST vs. EPIDERMOID TUMOR

History: AC may be p resent from b irth; ET is benign, ma ybe a ssoc ia ted with H/ A a nd oc c asiona lly enla rge ve ryslowly

Diagnostic Ima ging Stud ies: MRI shows fluid -c onta iningc yst (use d iffusion ima g ing to r/ o ep idermo id tumor)

Patholog y: ET inc lusion of stra tified squamous ep ithelium(+/ - ha ir follic les/ swea t g lands = Dermoid ); AC = simp learachnoid

Trea tment: Exc ision of wa ll, with remova l of lesion; forarac hnoid c ysts, fenestra tion of a rac hnoid memb rane,ra rely shunt p lac ement

Prog nosis: Usually good with resec tion/ fenestra tion, aslong as no rec urrenc e

http://www.uchsc.edu/sm/neuroimaging/P0432/P0432_frameset.htm


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Example: SARCOID

History

May be a ssoc iated with pulmonarysa rc oid, but NOT ALWAYS!

Diagnost ic Imaging Studies

MRI

Diagnostic Lab oratory Studies

ACE leve ls (CSF, b lood helpful)

Trea tment

Steroids (ma y need b iop sy to estab lishdx show s non-ca sea ting granuloma)

Prog nosis

Dependent upon respo nse to steroids

Inflammatory lesions that canmimic an intrac ranial tumor

www.uiowa.edu/~c064s01/nr088.htmhttp://www.uiowa.edu/~c064s01/nr088.htm


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Infec tious lesions canmimic an intrac ranial tumor

Disc ussed under sec tion of Vasc ula r, Critic a l

Care, & CNS Infec tions


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Care of the Brain Tumor Patient

Steroid s Help resolve ed ema and symptoms assoc ia ted with it

Can confuse the issue of lymphoma , bec ause rap id d isappea rance is seen for lymphoma , followed byrecurrence

Anti-c onvulsants Rec ommended p artic ula rly for ep ilep togenic areas, e.g.

mesia l tempora l lob e, and with pa st h/ o seizures


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Treatment Options in generalfor Intrac ranial Tumors

Sometimes need Biop sy for identific a tion then one orc omb ination o f:

Surgery

Rad ia tion Therapy

Whole b ra in

Focused beam

Ga mma Knife Stereota c tic Radiosurgery

Chemotherapy

Systemic

Loc a l


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Gamma Knife Radiosurgery

Ind ic a tions Tumors (Benign & Ma lignant, Primary & Metasta tic ) Arteriovenous ma lforma tions

Trigemina l neura lg ia Func tiona l neurosurgery, to c rea te lesions (controversia l)

Suc c ess Rate Comp arab le succ ess ra te for tumors vs. surgery/c onventiona lrad ia tion, with few er side effec ts/ morb id ity/ morta lity

Lim ita tions

Tumors must be sma ller (


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The End

brain tumors neurosurgical treatment including gamma knife

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