Sifat Tumor :
1. Maligna
2. Benigna
Lokasi :
1. Sistem Saraf Pusat - 1.1. Otak
- 1.2. Med.
Spinalis
2. Sistem Saraf Tepi
Asal Tumor :
1. Primer
2. Metastasis
Persentase
20
10
6
4
5
15
7
7
6
4
4
4
5
3
100
Mechanism
1. Space occupying lesion
2. Ventricle compression
3. Destruction
Cerebral oedem
Vasogenic
Sitotoksik
Interstitial
BRAIN SWELLING
HYPODENSE SWELLING
VASOGENIC
OEDEMA
ISODENSE SWELLING
DYSAUTOREGULATION
Destruksiatau
atau
--Destruksi
kompresilangsung
langsung
kompresi
Kompresiakibat
akibat
--Kompresi
massa,edema
edema
massa,
Nyerikepala
kepala
Nyeri
(>50%)
(>50%)
Memburukdidi
Memburuk
pagihari
hari
pagi
Invasiatau
ataukompresi
kompresi
--Invasi
TIKtinggi
tinggi
--TIK
Sekunderatau
atau
--Sekunder
psikogenik
psikogenik
Kejang(15(15Kejang
20%)
20%)
Gangguan
Gangguan
eksitabilitasneural
neural
eksitabilitas
- Demensia
- Ggn mood
- Ggn perilaku
- Inkontinensia
- disfungsi olfaktorius
- Disfungsi opticus
Hemianopsia
Homonim
Kontralateral
- Ggn bahasa
- Ggn memori
- Ggn mood
- Ggn perilaku
- Hearing & vision
pathways
Nistagmus
Disartria
Ataksia
(Wilkinson, 1997)
Gejala saat px
Defisit neurologis
Persentase
pasien
Persentase
Hemiparesis
61 - 83 %
Papiledema
32 - 66 %
Gangguan kesadaran
18 - 40 %
Afasia
25 - 32 %
Headache
Increased ICP : tumor mass effect,
hydrocephalus, mass effect from associated
edema or hemorrhage
Invasion or compression of pain sensitive
structures : dura, blood vessels, periosteum
Secondary to difficulty with vision : diplopia,
difficulty focusing
Greenberg (2001)
Environmental
Irradiation
Severe head trauma
Chronic exposure of the petrochemicals
2. Ras Protein
Activated by mutations in 20 to 30 percent of cancers
3. Abl Kinase
Activatied by abnormal chromosomes in chronic myelogenous leukemia
4. Src Kinase
Activated by mutations in 2 to 5 percent of cancers
5. pRB Protein
Mutated or deleted in 40 percent of cancers
6. p53 Protein
Mutated or deleted in 50 percent of cancers
Treatment
Supportive
Corticosteroid
Anticonvulsant
Definitive
Surgery
Radiation
Radionecrosis
Chemotherapy
Corticosteroids
These agents reduce edema around tumor, frequently leading to
symptomatic and objective improvement in symptoms
Drug Name
Adult Dose
Pediatric Dose
Contraindications
Estrogen antagonists
Inhibit effects of estrogen by competitively binding to estrogen
receptor
Drug Name
Adult Dose
Pediatric Dose
Contraindications
Not established
Progesterone antagonists
RU-486 has been used experimentally in the treatment of this
medical condition
Drug Name
Adult Dose
200 mg PO bid
Pediatric Dose
Not established
Contraindications
Documented hypersensitivity
Approach to Treatment
Medical treatment
Surgery
Radiation
Chemotherapy
Palliative treatment
Approach to Treatment
Number of metastases
Control of the primary tumor
Extent of the extracranial metastases
Age
Performance Status (Karnovsky)
Medical treatment
Anticonvulsants
When seizures are a symptom of disease
Little role as prophylaxis
Steroids
Important in treatment, help relieve symptoms of mass effect
Minimize long term use given side effects
Surgical treatment
Biopsy:
Open brain biopsy
Stereotactic biopsy
Frame-based: BRW, CRW, Leksell
Frameless
Advantage:
Diagnosis:
No known primary
Known primary Important role for bx
Low morbidity
Surgery
Tumor resection best recommended in:
Surgically accessible lesions, particularly if >3cm
Symptomatic lesions with evidence of mass effect
Posterior fossa lesions
single, accesible brain met with no LM dissemination
life expectancy > 3mths
Karnofsky >70
not a radiosensitive tumour (e.g., small cell)
Biopsy or Resection?
Biopsy indicated for:
Deep lesions
Multiple lesions
Patients otherwise too debilitated, medically unfit
Poor Karnofsky performance score
Advantages:
Diagnosis
Relief of mass effect
Improved outcomes over biopsy alone, and when used in conjuction with
radiation
Disadvantages:
Morbidity of procedure
Morbidity minimized with the use of intraoperative aids:
Intraoperative image guidance
Awake craniotomi
Radiation
Whole Brain radiation
Radiosurgery
Side Effects
Exposure of radiation to the whole brain
Acute:
Transient worsening of neurological symptoms
Nausea, vomiting
Dry desquamation, hair loss, otitis
Thought to be due to distorted cerebrovascular autoregulation and increased
capillary permeability
Chemotherapy
Effectiveness of chemotherapeutic agents depends on
Ability to treat specific tumor
Ability to cross the BBB
Timozolamide
Alkylating agents with better BBB penetration
Additive/synergistic activity in combination with other chemo
agents
Recurrent Metastases
Further CNS progression often accompanied by decline in KPS
More limited therapeutic options
Surgery
Radiation
Single lesion
Surgically
accessible
Surgery
WBRT
Deep lesion
>3cm, multiple lesions,
poor KPS
WBRT
Deep lesion
<3 cm
Radiosurgery
+/- WBRT
Imaging
Low-grade astrocytoma
T2-weighted image shows a
high-signal-intensity lesion
with well-defined margins,
no surrounding edema, and
little mass effect
Metastases
Axial T2-weighted scan
demonstrates three large
masses (arrows) surrounded
by extensive high-signal
edema
Imaging
Glioblastoma multiforme
Thick irregular ringenhancing lesion
associated with a large amount of
surrounding low-attenuation edema
Cystic astrocytoma
Hypodense mass with a thin rim of contrast
enhancement
Summary
Prognosis for patients with brain metastases remains poor
Single lesions in patients with good prognostic factors should
preferably be treated surgically, followed by Rx
Surgically inaccessible lesions benefit from radiosurgery
Multiple controversies remain, for which adequate randomized
controls are necessary
Upcoming role for new chemotherapeutic agents (Timozolamide)
Metastatic Tumor of
Spine
Metastasis
Cancer metastasis: lung, liver, bone
bone metastasis origin: lung, breast, prostate, renal,
thyroid
Spine is the most common site of bone metastasis
L-spine: most common
Batsons plexus
Metastasis
Pathway of Metastasis:
arterial, direct extension, lymphatic, venous
epidural venous plexus--Batsons plexus
cancellous bone micro-environmental necessary
cortical bone invasion secondarily
Diagnosis
Bone scan:
nonspecific, identify for biopsy position
Biopsy:
suspecious x-ray; tissue for hormonal evaluation
95% accuracy; 75% success rate
complication:
pneumo- / hemo- throax
excessive bleeding
neurologic injury
Diagnosis
Non-Operative Treatment
Steroid:
reduce edema, pain relief; not motor recovery
dexamethasone IV bolus 100mg
followed by 96mg/day in four divided doses for 3
days
tapered over 2 weeks; > 3 weeks, steroid toxicity
Operative Treatment
Indications and Goals:
intractable pain unresponsive to nonoperative
progressive neurologic change
radioresistant tumor
specimen for histologic diagnosis
decompression with debulking of tumor mass
spinal instability, body major destruction
collapse > 50%, body involve > 50%, posterior element
Kemoterapi Temozolomide
Farmakokinetik
Semoga Bermanfaat
Jazakumulloh Khoiron