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Republic of the Philippines

University of Northern Philippines


Tamag, Vigan City

College of Nursing

CASE STUDY

ON

PRIMITIVE NEUROECTODERMAL
TUMOR

Presented to

Raul Raguindin RN
Clinical Instructor

Presented by

Nimrod A. Bacroya
BSN III
I. Introduction

Primitive Neuroectodermal Tumors (PNET) are neoplasms of which medulloblastoma is


the prototype. These are small cell, malignant embryonal tumors showing divergent
differentiation of variable degree along neuronal, glial, or rarely mesenchymal lines. Only
tumors of the CNS are discussed here. Peripheral primitive neuroectodermal tumors are regarded
as distinct entities. PNET of the CNS can be divided grossly into infratentorial tumors
(medulloblastoma or iPNET) and supratentorial tumors (sPNET). One of a remarkable group of
tumors that originate in cells from the primitive neural crest and share the same reciprocal
translocation between chromosomes 11 and 22 and the same patterns of biochemical and
oncogene expression. Some primitive neuroectodermal tumors (PNETs) occur in the brain while
others (the peripheral PNETs) occur in sites outside the brain such as in the extremities, pelvis,
and the chest wall.
These tumors are discussed as infratentorial (medulloblastoma) and supratentorial. The
latter occur rarely (25:1) and are more common in young adults than infratentorial tumors.

Spinal dissemination via the cerebrospinal fluid (CSF) is the most common form of
metastatic spread of PNETs. No pathognomonic signs or symptoms exist. The onset at
presentation is insidious.The observed symptoms are due to the neuroanatomical location of the
tumor or are a consequence of increased intracranial pressure. They include the following:

o Irritability, lethargy, and decreased social interaction (60%)


o Intermittent vomiting (40%)
o Headache (40%) (usually worse in the morning)
o Visual blurring/change (30%)
o Nausea - Unusual as a distinct symptom, unless the tumor infiltrates the floor of
the fourth ventricle (5%)
o Imbalance (40%)
o Papilledema (60%)
o Ataxia (50%)
o Nystagmus with or without gaze palsy (40%)
o Lower cranial nerve palsy (20%)
o Dysdiadochokinesia, hypotonia, dysmetria, particularly in lateralized lesions of
the cerebellum (20%)
o Increased head circumference in children younger than 2 years (30%)

Isolated PNET is sporadic in nature, and only 14 familial cases have been reported in the
literature.Loss of the short arm of chromosome 17 (17p13.3) is the most frequent abnormality
(particularly with medulloblastoma, in which it is found in 30-40% of cases), the presence of
which also affects prognosis. This site is, however, distinct from the common tumor suppressor
gene, TP53. Other genetic loci of interest in the pathogenesis of medulloblastoma include PAX
genes and sonic hedgehog (SHH) genes, the roles of which are under intense
investigation.Certain conditions have increased associations with PNETs.
Lab tests are not helpful in the diagnosis of PNET. Diagnosis of these clinical entities is
confirmed or excluded by lumbar puncture and CT scan and/or MRI. Presence of a mass lesion
on an imaging study precludes lumbar puncture because of the risk of herniation. Clinical
diagnosis of these tumors is not possible. Radiologic features unique to each type of tumor may
be helpful, but the only possible absolute confirmation is by pathologic examination of the
surgical specimen. Primitive cells are observed growing in sheets or cords of dense cellularity
with increased mitotic index and increased nuclear-cytoplasmic ratio. Formation of Homer-
Wright rosettes (ie, neuroblastic rosettes consisting of tumor cell nuclei disposed in a circular
fashion about tangled cytoplasmic processes) is typical but not always seen and is not essential
for diagnosis. When present, it is frequently associated with marked nuclear pleomorphism and
high mitotic activity. Associated gross pathologic findings may include cystic changes, although
the tumors are usually solid. They may vary from soft to firm in consistency. Geographic areas
of necrosis, vascular proliferation, or calcification are less common, while hemorrhage is rare.

Preoperative administration of steroids can help to alleviate some of the signs and
symptoms by reducing peritumoral edema. Radiation therapy, usually given adjuvantly, should
be performed under the direction of a radiation oncologist. Adjuvant radiotherapy alone, with
posterior fossa doses of 5000 cGy and neuraxis doses of 3000 cGy, results in a 5-year event-free
survival rate of 50-70%. Lower than standard doses of radiation therapy, at least without
chemotherapy, are less effective. Another is chemotherapy, varying combinations of drugs used
in these tumors include, but are not limited to, lomustine (CCNU), vincristine, cisplatin,
etoposide (VP-16), and cyclophosphamide. The following factors worsen the prognosis:

o Presence of metastases at diagnosis


o Infiltrative nature, evidence of glial differentiation, and presence of TP53
mutation
o Unfavorable location that prevents complete resection: Failure at the primary site
continues to be the predominant barrier to cure in patients with medulloblastoma.
o Younger age at presentation: Age older than 4 years at the time of initial diagnosis
is associated with more favorable prognosis than age younger than 4 years.

In recent series of low-risk cases, the 5-year survival rate has been reported to be 60-80% (or
even higher).
II. PERSONAL DATA:

Name: John Michael Bitan

Present Address: 161 kaybagal Central, Tagaytay City

Home Address: 161 kaybagal Central, Tagaytay City

Age: 4 years old

Birthday: April 23, 2002

Religion: Roman Catholic

Gender: Male

Nationality: Filipino

Name of Mother: Maria Theresa Bitan

Age: 30y/o

Occupation: housewife

Name of Father: Rowel Bitan

Age: 32y/o

Occupation: Butcher

Date o Admission: March 13, 2007

Time: 7pm

Service/Department National Children’s Hospital

Ward: NeuroSurgery

Admitting Physician: Dr. Torre

Date Discharge:

Time:

Admitting Diagnosis: Primitive Neuroectoderma Tumor s/p craniotomy oct 2006


III. Nursing History of Past and Present Illness

Present Illness

7 days prior to admission patient experiences weakness associated with vomiting,


decrease appetite was noted. 1 day prior to admission vomiting was continues and the mother
was forced to confine his son to National Children’s Hospital where the patient was admitted to
the neuro-surgery ward.

Past Illness
Last july 2006 the patient was rush to tagaytay city health center to seek consultation
because of intermittent vomiting, the patient was reffered to Philippine Orthopedic Center. There
he was diagnosed that there is a mass found in his brain, he was then reffered to NCH for surgery
and removal of the tumor. The patient was recently diagnosed with Primitive Neuroectodermal
Tumor last 2006. After the surgery the patient didn’t undergone any chemotherapy or
radiotherapy to completely remove the left tumor. Last February 2007 the patient experience
vomiting and weakness. He was then rush to NCH for further consultation. The patient family
has a history of having cancer at his father’s side. The patient has no history of any illness and
has completed his vaccination.
IV. PEARSON ASSESSMENT

April 10, 2007 Tuesday April 10, 2007


Wednesday
John Michael Bitan 4y/o male child from 161 Weak in appearance.

P
kaybagal Central, Tagaytay City, Roman Catholic.
He is living with his parents Ma. Theresa & Rowel Weakness and muscular
Bitan. atrophy on lower
extremities is noted, r
He is weak in appearance. Unable to properly arm is also paralyze
communicate with people because he has difficulty
in speech.

Hx of Past illness:
Last june 2006 he experienced vomiting and seek
for medical consultations & he was diagnosed to
have a tumor in his brain. He undergone
craniotomy at NCH and was diagnosed with
Primitive Neuroectodermal Tumor.He was
discharge on November 20, 2006.
Hx of present illness:
1 week PTA patient was noted to have body
weakness due to vomiting. A day PTA patient is
still weak and had decrease appetite. Patient was
brought to NCH for consultation and further
treatment. CT scan revealed that tumor had re
occurred and disseminated much of his brain. The
condition is getting worse day by day.

“lagi siyang irritable” as verbalized by the mother.

Eliminates through diaper, an average of 2 per day. Eliminates through

E
Usual bowel pattern. diaper, an average of 2
per day. Usual bowel
pattern.

Sleeps fairly Sleeps fairly.

R
Activity: mostly lying on bed and sitting on Activity: mostly lying on
wheelchair. bed and sitting on
Cannot move w/o assistance thus having difficulty wheelchair.
performing ADL.

He has difficulty in

S
He has difficulty in speech speech.
Weakness at booth lower extremities and R arm is
noted Weakness at booth lower
extremities and R arm is
Seat strap on wheelchair is put on and side rails are noted.
raised for safety.
Seat strap on wheelchair
(+) facial edema is put on and side rails
are raised for safety
Weak in appearance

No known allergies to any foods

Medications:
Gentamicin 75mg IV OD
Dexamethasone 5mg IV q 6
With initial V/S as follows: With initial V/S as

O
BT 36.8C follows:
PR: 100bpm BT 37.1C
RR: 18cpm PR: 98bpm
c HL @ R forearm intact RR: 18cpm
(-) DOB c HL @ R forearm intact
Hgb 146 not in distress
Hct 44%
WBC 11.2
Neutrophils 0.92
Lymphocytes 0.08
Platelet count: 295
Diet appropriate for age Diet appropriate for age

N
Good appetite. Good appetite.

V. Diagnostic Procedures

A. Ideal
CBC(Complete Blood Count) – A complete blood count is a lab test performed on sample
of your blood, includes a determination of your hematocrit, the percentage of the blood that
consist RBC. The CBC also measures the amount of Hgb in your blood.

WBC (5,000-10,000/mm3) – These are cells that usually fight infection. If this count is
elevated it may indicate presence of infection or steroid treatment. If the count is low, it is
usually from medications, infections, autoimmune diseases, or blood disease among many
other causes.

Neutrophils (55-70%) – may be elevated with bacterial infections, burns, stress, or


inflammation,. A decrease may be caused by radiation, certain drugs, vit. B12 deficiency or
systemic lupus erythematosus.

Eusinophils(1-4%) – may be elevated due to allergies, parasitic infections, autoimmune


disease or adrenal insufficiency. A low eosinophil count could be caused by Cushing’s
syndrome, certain drugs, or stress.

Lymphocytes (20-40%) – May be elevated in viral infections, immune diseases, and sime
leukemia. Low numbers may be seen in prolonged, severe illness, during chemotherapy, and
when high levels of steroids are present.
Monocyte (2-8%) – may be elevated from viral or fungal infections, tuberculosis, some
leukemia and other chronic diseases. Low levels are rarely seen.

Basophiles (1/2 – 1%) – Elevations in basophiles may be seen in allergic responses,


leukemia’s, cancers, and hypothyroidism. A decrease may occur during pregnancy,
ovulation, stress, and hyperthyroidism.

Hemoglobin (14-48g/dl) – It’s the iron-containing pigment of red bloo cells, which carries
oxygen from the lungs to the tissues.

Hematocrit (42-52%) – it is the ratio of RBC to the total blood volume. These tests usually
indicate the presence of anemia when they are below normal range. An elevated hemoglobin
and hematocrit may occur in smokers and in polycythemia, a blood disease where there is too
many red blood cells.

Platelet count – involved in clotting and prevention of bleeding. An increased platelet count
is usually seen with malignancy, certain blood diseases, or rheumatoid arthritis. A low
platelet count may be seen in certain blood diseases, infections and with some medications.

CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the
body, taken from different angles. The pictures are made by a computer linked to an x-ray
machine. A dye may be injected into a vein or swallowed to help the organs or tissues show
up more clearly. This procedure is also called computed tomography, computerized
tomography, or computerized axial tomography.

MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a
computer to make a series of detailed pictures of areas inside the brain and spinal cord. A
substance called gadolinium is injected into the patient through a vein. The gadolinium
collects around the cancer cells so they show up brighter in the picture. This procedure is also
called nuclear magnetic resonance imaging (NMRI).

B. Actual

Name of Actual Normal Values Implication to the Nursing


procedure Values disease condition Responsibilities
Hematology:  Assess the
condition of
Hgb 146g/l 140-180 Level is w/in normal the patient.
range  Explain the
Hct 0.44 0.4-0.54 procedure to
the patient
WBC 14.4x10/L 5-10 Value is higher than with in the
normal
Higher than normal Indicates educational
Neutro 0.9 0.4-0.75 bacterial infection background of
the patient
Lympho 0.09 0.20-0.45 Lower than normal

Mono 0.01 0.02-0.06 Lower than normal value

Platelet 295 150-450x10/L Within normal value

Urinalysis &
Urine Culture
Color Yellow Yellow
Transparency Clear
Reaction Acidic Usually acidic The presence of pus cells  Assess the
bacteria and mucous threds
Sp gravity 1.046 1.010-1.025 (causing turbid appearance) condition of
Sugar (-) (-) indicates infection. the patient.
Bacteria Few Rare  Explain the
Pus cells 6-10 none procedure to
Epithelial cells Few Rare the patient
Macrophage Occasional with in the
RBC 2-3 0-3 educational
background of
Gram staining (4-8-
07)
the patient
Gram + Occasional (-) for pathogenic
Gram - Occasional gram

BUN /Creatinin
(4-3-07)
3.77 1.7-8.3
BUN
40.6 80-11.5
Crea
w/in normal range

CT scan 4-04-07
Interpretation:
- plain and contrast scan of the head shows
- there is an enhancing mass noted on the frontal lobe w/ cystic compartment on the
left
- The lesion measures 10x11.0x12.0 cm. there is an old bone defect noted on the
left
- The ventricles are dilated w/ deformity noted along the horns of the lateral
ventricles
- The posterior fosse unremarkable.

Impression: Intracranial Tumor Re occurrence on Both Frontal Lobes


Obstructive Hydrocephalus s/p craniotomy, left frontal area
VI Anatomy and Physiology of Organ Involve

The Brain

Brain, portion of the central nervous system contained within the skull. The brain is the
control center for movement, sleep, hunger, thirst, and virtually every other vital activity
necessary to survival. All human emotions including love, hate, fear, anger, elation, and sadness
are controlled by the brain. It also receives and interprets the countless signals that are sent to it
from other parts of the body and from the external environment. The brain makes us conscious,
emotional, and intelligent.

The adult human brain is a 1.3-kg (3-lb) mass of pinkish-gray jellylike tissue made up of
approximately 100 billion nerve cells, or neurons; neuroglia (supporting-tissue) cells; and
vascular (blood-carrying) and other tissues.

Between the brain and the cranium the part of the skull that directly covers the brain are
three protective membranes, or meninges. The outermost membrane, the dura mater, is the
toughest and thickest. Below the dura mater is a middle membrane, called the arachnoid layer.
The innermost membrane, the pia mater, consists mainly of small blood vessels and follows the
contours of the surface of the brain.

A clear liquid, the cerebrospinal fluid, bathes the entire brain and fills a series of four
cavities, called ventricles, near the center of the brain. The cerebrospinal fluid protects the
internal portion of the brain from varying pressures and transports chemical substances within
the nervous system.

From the outside, the brain appears as three distinct but connected parts: the cerebrum
(the Latin word for brain) two large, almost symmetrical hemispheres; the cerebellum (“little
brain”) two smaller hemispheres located at the back of the cerebrum; and the brain stem, a
central core that gradually becomes the spinal cord, exiting the skull through an opening at its
base called the foramen magnum. Two other major parts of the brain, the thalamus and the
hypothalamus, lie in the midline above the brain stem underneath the cerebellum.

The brain and the spinal cord together make up the central nervous system, which
communicates with the rest of the body through the peripheral nervous system. The peripheral
nervous system consists of 12 pairs of cranial nerves extending from the cerebrum and brain
stem; a system of other nerves branching throughout the body from the spinal cord; and the
autonomic nervous system, which regulates vital functions not under conscious control, such as
the activity of the heart muscle, smooth muscle (involuntary muscle found in the skin, blood
vessels, and internal organs), and glands.

Cerebrum

Most high-level brain functions take place in the cerebrum. Its two large hemispheres
make up approximately 85 percent of the brain's weight. The exterior surface of the cerebrum,
the cerebral cortex, is a convoluted, or folded, grayish layer of cell bodies known as the gray
matter. The gray matter covers an underlying mass of fibers called the white matter. The
convolutions are made up of ridgelike bulges, known as gyri, separated by small grooves called
sulci and larger grooves called fissures. Approximately two-thirds of the cortical surface is
hidden in the folds of the sulci. The extensive convolutions enable a very large surface area of
brain cortex—about 1.5 m2 (16 ft2) in an adult—to fit within the cranium. The pattern of these
convolutions is similar, although not identical, in all humans.

The two cerebral hemispheres are partially separated from each other by a deep fold
known as the longitudinal fissure. Communication between the two hemispheres is through
several concentrated bundles of axons, called commissures, the largest of which is the corpus
callosum.

Several major sulci divide the cortex into distinguishable regions. The central sulcus, or
Rolandic fissure, runs from the middle of the top of each hemisphere downward, forward, and
toward another major sulcus, the lateral (“side”), or Sylvian, sulcus. These and other sulci and
gyri divide the cerebrum into five lobes: the frontal, parietal, temporal, and occipital lobes and
the insula.

The frontal lobe is the largest of the five and consists of all the cortex in front of the
central sulcus. Broca's area, a part of the cortex related to speech, is located in the frontal lobe.
The parietal lobe consists of the cortex behind the central sulcus to a sulcus near the back of the
cerebrum known as the parieto-occipital sulcus. The parieto-occipital sulcus, in turn, forms the
front border of the occipital lobe, which is the rearmost part of the cerebrum. The temporal lobe
is to the side of and below the lateral sulcus. Wernicke's area, a part of the cortex related to the
understanding of language, is located in the temporal lobe. The insula lies deep within the folds
of the lateral sulcus.

The cerebrum receives information from all the sense organs and sends motor commands
(signals that result in activity in the muscles or glands) to other parts of the brain and the rest of
the body. Motor commands are transmitted by the motor cortex, a strip of cerebral cortex
extending from side to side across the top of the cerebrum just in front of the central sulcus. The
sensory cortex, a parallel strip of cerebral cortex just in back of the central sulcus, receives input
from the sense organs.

Many other areas of the cerebral cortex have also been mapped according to their specific
functions, such as vision, hearing, speech, emotions, language, and other aspects of perceiving,
thinking, and remembering. Cortical regions known as associative cortex are responsible for
integrating multiple inputs, processing the information, and carrying out complex responses.

Cerebellum

The cerebellum coordinates body movements. Located at the lower back of the brain
beneath the occipital lobes, the cerebellum is divided into two lateral (side-by-side) lobes
connected by a fingerlike bundle of white fibers called the vermis. The outer layer, or cortex, of
the cerebellum consists of fine folds called folia. As in the cerebrum, the outer layer of cortical
gray matter surrounds a deeper layer of white matter and nuclei (groups of nerve cells). Three
fiber bundles called cerebellar peduncles connect the cerebellum to the three parts of the brain
stem—the midbrain, the pons, and the medulla oblongata.

The cerebellum coordinates voluntary movements by fine-tuning commands from the


motor cortex in the cerebrum. The cerebellum also maintains posture and balance by controlling
muscle tone and sensing the position of the limbs. All motor activity, from hitting a baseball to
fingering a violin, depends on the cerebellum.

Thalamus and the Hypothalamus

The thalamus and the hypothalamus lie underneath the cerebrum and connect it to the
brain stem. The thalamus consists of two rounded masses of gray tissue lying within the middle
of the brain, between the two cerebral hemispheres. The thalamus is the main relay station for
incoming sensory signals to the cerebral cortex and for outgoing motor signals from it. All
sensory input to the brain, except that of the sense of smell, connects to individual nuclei of the
thalamus.

The hypothalamus lies beneath the thalamus on the midline at the base of the brain. It
regulates or is involved directly in the control of many of the body's vital drives and activities,
such as eating, drinking, temperature regulation, sleep, emotional behavior, and sexual activity. It
also controls the function of internal body organs by means of the autonomic nervous system,
interacts closely with the pituitary gland, and helps coordinate activities of the brain stem.

Brain Stem
The brain stem is evolutionarily the most primitive part of the brain and is responsible for
sustaining the basic functions of life, such as breathing and blood pressure. It includes three main
structures lying between and below the two cerebral hemispheres—the midbrain, pons, and
medulla oblongata.

A. Midbrain

The topmost structure of the brain stem is the midbrain. It contains major relay
stations for neurons transmitting signals to the cerebral cortex, as well as many reflex
centers—pathways carrying sensory (input) information and motor (output) commands.
Relay and reflex centers for visual and auditory (hearing) functions are located in the top
portion of the midbrain. A pair of nuclei called the superior colliculus control reflex
actions of the eye, such as blinking, opening and closing the pupil, and focusing the lens.
A second pair of nuclei, called the inferior colliculus, control auditory reflexes, such as
adjusting the ear to the volume of sound. At the bottom of the midbrain are reflex and
relay centers relating to pain, temperature, and touch, as well as several regions
associated with the control of movement, such as the red nucleus and the substantia nigra.

B. Pons
Continuous with and below the midbrain and directly in front of the cerebellum is
a prominent bulge in the brain stem called the pons. The pons consists of large bundles of
nerve fibers that connect the two halves of the cerebellum and also connect each side of
the cerebellum with the opposite-side cerebral hemisphere. The pons serves mainly as a
relay station linking the cerebral cortex and the medulla oblongata.

C. medulla oblongata
The long, stalklike lowermost portion of the brain stem is called the medulla
oblongata. At the top, it is continuous with the pons and the midbrain; at the bottom, it
makes a gradual transition into the spinal cord at the foramen magnum. Sensory and
motor nerve fibers connecting the brain and the rest of the body cross over to the opposite
side as they pass through the medulla. Thus, the left half of the brain communicates with
the right half of the body, and the right half of the brain with the left half of the body.

D. Reticular Formation

Running up the brain stem from the medulla oblongata through the pons and the
midbrain is a netlike formation of nuclei known as the reticular formation. The reticular
formation controls respiration, cardiovascular function (see Heart), digestion, levels of
alertness, and patterns of sleep. It also determines which parts of the constant flow of
sensory information into the body are received by the cerebrum.

Brain Cells

There are two main types of brain cells: neurons and neuroglia. Neurons are responsible for the
transmission and analysis of all electrochemical communication within the brain and other parts
of the nervous system. Each neuron is composed of a cell body called a soma, a major fiber
called an axon, and a system of branches called dendrites. Axons, also called nerve fibers,
convey electrical signals away from the soma and can be up to 1 m (3.3 ft) in length. Most axons
are covered with a protective sheath of myelin, a substance made of fats and protein, which
insulates the axon. Myelinated axons conduct neuronal signals faster than do unmyelinated
axons. Dendrites convey electrical signals toward the soma, are shorter than axons, and are
usually multiple and branching.

Neuroglial cells are twice as numerous as neurons and account for half of the brain's weight.
Neuroglia (from glia, Greek for “glue”) provide structural support to the neurons. Neuroglial
cells also form myelin, guide developing neurons, take up chemicals involved in cell-to-cell
communication, and contribute to the maintenance of the environment around neurons.

Cranial Nerves

Twelve pairs of cranial nerves arise symmetrically from the base of the brain and are numbered,
from front to back, in the order in which they arise. They connect mainly with structures of the
head and neck, such as the eyes, ears, nose, mouth, tongue, and throat. Some are motor nerves,
controlling muscle movement; some are sensory nerves, conveying information from the sense
organs; and others contain fibers for both sensory and motor impulses. The first and second pairs
of cranial nerves—the olfactory (smell) nerve and the optic (vision) nerve—carry sensory
information from the nose and eyes, respectively, to the undersurface of the cerebral
hemispheres. The other ten pairs of cranial nerves originate in or end in the brain stem.
THE BRAIN
Genetic Factor Unknown Etiology

Originates in cells
from the
primitive neural
crest

VII. Pathophysiology
Onset is insidious no
A. algorithm pathognomonic s/sx
Tumor Growth
compressed content
of cranium

IICP Intermittent Vomiting


Headache

No Chemotherapy or Surgical
Intervention to Portion of
radiotherapy done tumor still left
remove tumor

Reoccurrence
of the Tumor

Sx on left frontal lobe Hydrocephalus


affects the ® hand

Surgery was
contraindicated
Lower cranial because of poor
nerve palsy prognosis

Complications

Paralysis of the
lower extremities

↓ Social interaction Irritability


B. Explanation

Tumors particularly Primitive Neuroectodermal Tumor are unknown in origin. Tumors in


children are difficult to diagnose than in adults. The risk is greater in boys. Genetic tendency
in developing tumors w/ family history of cancer cases increases risk. There I no
pathognomonic signs and symptoms because it depends on the location of the tumor. All
tumors of the brain are potentially harmful because of the location near the vital structures
and critical amount of mass effect that eventually destroys neuronal functions. Within the
confined space of the skull, a growing tumor alters the normally stable volume of brain,
blood and CSF, leading to focal disturbances and IICP, it eventually results to hydrocephalus
by CSF obstruction from the lateral ventricle. The most common symptom I vomiting. When
diagnosed it is remove by surgical intervention, but not all of the mass is remove. With out
follow up treatment like radiation therapy, it increases the risk of re occurrence. When this
happened to the patient the condition became worst and it spreads to the brain affecting
some important functions such as motor and speech which was noted on the patient.
Compression of the neural tissues and decrease Blood supply also leads to altered behavior
and even cause seizures.

VII. Management

A. Medical and Surgical Management

Medical Management:

• Preoperative administration of steroids can help to alleviate some of the signs and
symptoms by reducing peritumoral edema.
• Radiation therapy is indicated for radioseneitive tumor such as medulloblastoma, some
cerenellar astrocytomas, and ependymomas. It it may also be indicated for tumors
considered unoperable, such as brain stem gliomas. The goal of radioactive therapy is to
prevent malignant spread.

o Radiation therapy, usually given adjuvantly, should be performed under the


direction of a radiation oncologist.
o Many series report a clear, dose-dependent relationship between postoperative
radiation and local tumor control.
o Adjuvant radiotherapy alone, with posterior fossa doses of 5000 cGy and neuraxis
doses of 3000 cGy, results in a 5-year event-free survival rate of 50-70%. Lower
than standard doses of radiation therapy, at least without chemotherapy, are less
effective.
o Craniospinal axis radiation is employed for patients with spinal dissemination.
o Newer methods, including stereotactic radiosurgery and high fractionation
radiotherapy, are being evaluated. These methods limit the dose of radiation to the
local sites and avoid potential adverse effects in children, including cognitive
dysfunction or delay in growth, that are seen frequently with conventional
radiotherapy.

• Chemotherapy is used to assist in control of metastatic process. Until recently,


chemotherapy was not a principal treatment for brain tumors. The blood brain barrier is a
physical barrier that may block the flow of chemotherapeutic agents from the blood to the
brain.

o Chemotherapy should be administered under the direction of a medical


oncologist.
o Varying combinations of drugs used in these tumors include, but are not limited
to, lomustine (CCNU), vincristine, cisplatin, etoposide (VP-16), and
cyclophosphamide. Several trials, including those from the Pediatric Oncology
Group (POG) and Children's Cancer Group (CCG), are underway, evaluating
varying combinations of chemotherapy with and without radiotherapy. The best
results, so far, have come from the Children's Hospital of Pennsylvania study,
reporting a 5-year event-free survival rate of 80% among 51 patients.

o CCNU has been shown to be of limited benefit, particularly in high-risk cases.


o High-dose chemotherapy with stem cell rescue is being tried to improve survival
and outcome.

Surgical Management:

Surgery is undertaken to establish a specific diagnosis and if possible to resect the tumor totally.
The extent of the operation depends on the location and size of the tumor mass

• The goals of surgery are to achieve radical tumor resection, when possible, and to restore
normal CSF outflow.
• For persistent lesions, second-look surgery is recommended to remove residual tumor.
• Available studies have failed to show a significant advantage, in terms of event-free
survival, of total resection as compared to near-total and less-aggressive resections.
• Permanent CSF diversion in the form of ventriculoperitoneal shunt is required in as many
as 30% of these cases.

C. PROMOTIVE & PREVENTIVE MANAGEMENT

• Preventing injury
• Reducing fears of seizures
• Improving coping mechanism
• Providing patient and family education
• Monitoring and managing potential complications
• Promoting home and community-based care
• Teaching patients self-care
• Continuing care
IX. PATIENT DISCHARGE PLANNING

Name: John Michael Bitan Age: 4 y/o Ward: Neuro Sx


Address: 161 Kaybagal Central, Tagaytay City Sex: Male
Date & Time Instructed: N/A
Final diagnosis: Primive Neuro Ectodermal Tumor S/P Craniotomy 10/06, UIT,
Hydrocephalus

A. DIET

The diet of the patient may consist of foods which the patient can tolerate and appropriate
for age.

B. TAKE HOME MEDICATIONS (N/A)

NAME DOSAGE and TIME FREQUENCY PRECAUTIONS FOR


THIS IS FOR POSSIBLE REACTION

C. ACTIVITIES AND REHABILITATION (N/A)


ALLOWED NOT ALLOWED

D. SYMPTOMS TO REPORT TO PHYSICIAN IMMEDIATELY


1. fatigue
2. general weakness
3. headache
4. Signs and Symptom of increased intracranial pressure e.g. vomiting
5. altered muscle tone
E. FOLLOW-UP CARE (N/A)

REPORTED TO DATE PHYSICIAN REMARKS

_______________________________
______________________________________
Signature of Parent over Printed Name Signature of Student Nurse over Printed
Name

____________________
Date and Time
XI. SUMMARY & COPY OF UPDATES
XI. BIBLIOGRAPHY

Udan,J.Q.,2002,Medical-Surgical Nursing:Concepts & Clinical Application, First Edition


Royle, J.A. & Walsh M., 1996, Watson’s Medical-Surgical Nursing & Related Physiology, 4th
edn,
Baillieri Tindall, Philadelphia.
Bullock L.B. & Henze R.L., 2000, Focus on Pathophysiology, Lippincott Williams & Wilkins,
Philadelpia.
Johnson J.Y., 2004, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 10th edn,
Lippincott Williams & Wilkins, Baltimore.
Gulanick M.,Klopp A.,Galanes S.,Gradishar D. & Puzas M.K.,1994,Nursing Care Plans,3rd edn
Mosby,St. Louis.
Doenges,M.E.,Moorhouse M.F.,Geissler-Murr A.C., Nursing Care Plans; Guidelines for
Individualizing Patient Care, 10th Edition
Deglin J.H. & Vallerand A.H.,Davis’s Drug Guide for Nurses,3rd edn.F.A.Davis Co.,Philadelphia
Tortora, G.J. & Grabowski, S.R. (1993) Principles of Anatomy and Physiology (7th Edition).
HarperCollins College Publisher, New York. [ISBN0-06-046702-9]
Priscilla Lemone/Karen M. Burke, Medical Surgical Nursing, 1996

INTERNET
http://www.sciencedaily.com
http://www.medicalschemes.com
http://www.bartleby.com
http://www.orthopedic.about.com
http://www.nchi.nlm.nih.gov
http://www.osteoporosis.org