do you know what ’ s in people ’ s head?
DESCRIPTION
Do you know what ’ s in people ’ s head?. Brain tumors. 72 male HPI: presents to E.R. with history of confusion, change of personality, left sided H/A P/E: disorientation and aggressiveness, no focal signs Labs: WNL Imaging:. Brain tumors. Brain tumors. anatomy. Brain tumors. - PowerPoint PPT PresentationTRANSCRIPT
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Do you know what’s in people’s Do you know what’s in people’s head?head?
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Brain tumorsBrain tumors 72 male72 male HPI: presents to E.R. with history of HPI: presents to E.R. with history of
confusion, change of personality, left confusion, change of personality, left sided H/Asided H/A
P/E: disorientation and P/E: disorientation and aggressiveness, no focal signsaggressiveness, no focal signs
Labs: WNLLabs: WNL Imaging:Imaging:
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Brain tumorsBrain tumors
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Brain tumorsBrain tumors anatomyanatomy
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Brain tumorsBrain tumors
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Brain tumorsBrain tumors
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Brain tumorsBrain tumors
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Brain tumorsBrain tumors DDx:DDx:
BenignBenign CongenitalCongenital
AVM/aneurismAVM/aneurism Acquired Acquired
Infectious (toxoplasmosis, cyst)Infectious (toxoplasmosis, cyst) strokestroke
MalignantMalignant PrimaryPrimary metastaticmetastatic
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Brain tumorsBrain tumors Glioblastoma Glioblastoma
multiformemultiforme AstrocytomaAstrocytoma OligodendrogliomaOligodendroglioma MeningiomaMeningioma Brain stem tumorsBrain stem tumors MedulloblastomaMedulloblastoma Ependymoma Ependymoma
SarcomaSarcoma LymphomaLymphoma CraniopharyngiomaCraniopharyngioma NeurofibromaNeurofibroma Germ cell tumorsGerm cell tumors SchwannomaSchwannoma Pituitary tumorsPituitary tumors meningiomameningioma
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Brain tumorsBrain tumors MetastasesMetastases
SingleSingle Multiple Multiple
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Brain tumorsBrain tumors
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Brain tumorBrain tumor
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Brain tumorsBrain tumors
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Brain tumorsBrain tumors Management:Management:
Medical support (steroids + PPI)Medical support (steroids + PPI) Staging Staging Surgical resection if indicatedSurgical resection if indicated Adjuvant therapiesAdjuvant therapies
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Brain tumorsBrain tumors
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Brain tumorsBrain tumors
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GBMGBM Radiation therapyRadiation therapy
Standard dose: 60 Gy / 30 fractionsStandard dose: 60 Gy / 30 fractions O.S. = 42 weeks (1979 study)O.S. = 42 weeks (1979 study)
Radiation therapy + chemotherapyRadiation therapy + chemotherapy Meta analysis shows improvement in Meta analysis shows improvement in
generalgeneral
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GBMGBM Best results to Best results to
date:date: Combination with Combination with
temozolomidetemozolomide 75 mg/m2 po od x 6 75 mg/m2 po od x 6
weeks (concurrent weeks (concurrent with xrt), then 150 with xrt), then 150 mg/m2 po od on d1-mg/m2 po od on d1-5 every 28 days x 6 5 every 28 days x 6 cyclescycles
RTRT RT/TMZRT/TMZ
Median Median OS OS (months(months))
12.112.1 14.614.6
2 yr 2 yr survivalsurvival
10%10% 26%26%
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GBMGBM If poor performance statusIf poor performance status
Hypofractionated xrt:Hypofractionated xrt: 40/1540/15 35/1035/10
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Brain tumorsBrain tumors 57 male 57 male HPI: known lung cancer; developped HPI: known lung cancer; developped
gait instabilitygait instability P/E: cerebellar exam abnormalP/E: cerebellar exam abnormal ImagingImaging
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Brain tumorsBrain tumors Cerebellar metastasis on CT scanCerebellar metastasis on CT scan
Management: Management: Supportive careSupportive care Decadron (10 mg stat, then 4 mg po Decadron (10 mg stat, then 4 mg po
QID) + PPIQID) + PPI
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Brain metsBrain mets Depends on stability of peripheral Depends on stability of peripheral
disease and extend of intra cerebral disease and extend of intra cerebral disease:disease:
Peripheral disease stable: Peripheral disease stable: confirm solitary status with MRIconfirm solitary status with MRI If solitary: If solitary:
consider surgical resection or stereotactic consider surgical resection or stereotactic radiosurgeryradiosurgery
Whole Brain Radiation Therapy (WBRT)Whole Brain Radiation Therapy (WBRT)
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Brain metsBrain mets SurgerySurgery
DiagnosticDiagnostic Quicker steroid Quicker steroid
tapertaper Quicker symptom Quicker symptom
reliefrelief
Limited by Limited by localisationlocalisation
SRSSRS Non invasiveNon invasive Less riskLess risk Less expensiveLess expensive
Limited by sizeLimited by size RadioresistanceRadioresistance
MelanomaMelanoma Sarcoma Sarcoma
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Brain metsBrain mets peripheral disease stableperipheral disease stable
More than 1 lesionMore than 1 lesion Surgery less of a considerationSurgery less of a consideration WBRT +/- stereotactic radiosurgery boostWBRT +/- stereotactic radiosurgery boost
Criteria:Criteria: < or = 3 lesions< or = 3 lesions Volume: < 4 cmVolume: < 4 cm Prognostic > 3 monthsPrognostic > 3 months KPS >70KPS >70
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Brain metsBrain metsSurvivalSurvival WBRT + WBRT +
SRSSRSWBRTWBRT p valuep value
OverallOverall 6.56.5 5.75.7 0.130.131 met1 met 6.56.5 4.94.9 0.040.041-3, 1-3, age<50age<50
9.99.9 8.38.3 0.040.04
1-3, NSCLC1-3, NSCLC 5.95.9 3.93.9 0.050.051-3, RPA1-3, RPA 11.611.6 9.69.6 0.050.05
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Brain metsBrain mets peripheral disease not stableperipheral disease not stable
Palliative radiation therapyPalliative radiation therapy Re-irradiation on a case by case basisRe-irradiation on a case by case basis
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Brain metsBrain mets
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Brain metsBrain mets Prognostic:Prognostic:
Untreated: 1 monthUntreated: 1 month Steroids: 2 monthsSteroids: 2 months
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Brain metsBrain mets Radiation therapyRadiation therapyKPSKPS >70>70 >70>70 <70<70
AgeAge <65<65 >65>65Primary Primary controlcontrol
YesYes nono
MetsMets Brain Brain onlyonly
Multi Multi organorgan
SurvivalSurvival 7.17.1 4.24.2 2.32.3
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Brain metsBrain mets Side effectsSide effects
AlopeciaAlopecia Skin erythemaSkin erythema Fatigue Fatigue Neurocognitive changesNeurocognitive changes
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Brain metsBrain metsSingle metSingle metSymptomatic,ResectableSymptomatic,ResectableFirst/only metFirst/only met
Surgery + WBRTSurgery + WBRT
Single metSingle metLittle / no symptomLittle / no symptomNon resectable / surgery Non resectable / surgery refusedrefused
SRS + WBRTSRS + WBRT
2-3 mets, KPS>702-3 mets, KPS>70RPA 1, NSCLC, <50 yoRPA 1, NSCLC, <50 yo
SRS + WBRTSRS + WBRT
2-3 mets, KPS>702-3 mets, KPS>70None of favorable Px factorsNone of favorable Px factors
WBRT +/- SRSWBRT +/- SRS
4 mets, KPS>704 mets, KPS>70RPA 1, NSCLC, <50 yoRPA 1, NSCLC, <50 yo
WBRT +/- SRSWBRT +/- SRS
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Brain metsBrain mets Role of WBRTRole of WBRTDecrease rate of new mets Decrease rate of new mets
(50% to 25%)(50% to 25%)Does not increase OSDoes not increase OS
Some histologies have less Some histologies have less distant failures (RCC, distant failures (RCC, melanoma, sarcoma)melanoma, sarcoma)
No increase in toxicity No increase in toxicity (objectively)(objectively)
Subjective increase in Subjective increase in toxicitytoxicity
Case where Dx is in doubt Case where Dx is in doubt (meningioma)(meningioma)