Oncology Neurooncology

FOCUS BRAIN MENINGIOMA

Rizal Tumewah
 Oncology - Neurooncology

The rising public and medical problem in

Indonesia

Usually have a poor outcome and effects in

pessimistic in the patient and family, and also
in the doctors.

Direct and indirect high medical cost.

 Neuro-oncology
PRIMARY BRAIN TUMOR (BT I)
Prognosis of patient with primary brain tumor are
determinate by :
Histological type
Grade
Post operative size
Extent of the tumor
Patient age
Performance status of patient
Duration of symptoms
 Neuro-oncology
SECONDARY BRAIN TUMOR (BT II)
Secondary brain tumor > primary brain tumor
Metastases to brain :
Lung cancer, breast cancer, melanoma and kidney

Secondary brain tumor :

Usually multiple, solitary metastases may also occur

Brain involvement can occur with cancer on the nasopharyngeal region by

direct extension along the cranial nerves or through the foramina at the
base of skull.

Metastases meningeal involvement can also occur especially with

leukemia, lymphoma, small cell lung cancer, breast cancer and primary
CNS tumors such as medulloblastoma & ependymal gliomas.
 Meningioma
Tumor extra axial (supra/ infra temtorial)
Ditemukan dimana ada sel arachnoid
Lokasi yg sering (sub frontal, sphenoid wing, supra sellar
dan sekitar foramen magnum)
Ciri:
batas tegas
dengan atau tanpa fokal edema.
Prekontrast tampak isodens
Dengen kontras penyegatan yang homogen
Bisa dengan kalsifikasi
Sering terjadi osteoblastik pada tulang di dekatnya
Bisa ditemukan dural tail
 Gambaran umur tumor CNS
Tipe tumor usia Location Clinical Survival RT kemo
astrocytoma dew>anak sptentorial lambat, berthn 5 th MS ya at recur
anaplas-astro dewasa sptentorial cepat 2,5 th MS Ya Ya
GBM dewasa/tua sptentorial cepat, > ganas 1 thn MS Ya at recur
Oligodendro Any sp, tu front sering kejang 5 thn MS Ya Ya
BO glioma anak> dew BO tu pons def. n. cranial 1 thn MS Ya Kdg
Pilocyst astro Idem bellu, hipo cure w/reseksi 80% 10 th Ya Ya
Ependymoma Anak, dew Vent 4, ce cure w/reseksi 70% 5 th Ya Kdg
Meduloblast anak>dew Serebelum Tdp di LCS 55% 5 th Ya Ya
Meningioma Dewasa konvek,cli- Wanita>pria Lama Ya Jarang
vus, thorak cure w/reseksi
PCNSL Dewasa Multifokal LCS/ocular 2 thn MS Ya Ya
Germinoma 2nd-3th dek pineal Peka dgn 80% 5 th Ya Ya
supra sella kemo dan RT
nonger germ Idem Pineal camp, marker 25% 5 th Ya ya
 persentase dari
yang sering
jenis tumor asal status keganasan semua
terkena
tumor otak
sel saraf dari
jinak tetapi
kordoma kolumna < 1% dewasa
invasif
spinalis
tumor sel germ sel-sel embrionik ganas atau jinak 1% anak-anak
glioma
(glioblastoma sel-sel penyokong
multiformis, otak, termasuk ganas atau relatif anak-anak &
65%
astrositoma, astrosit & jinak dewasa
oligodendtrosit oligodendrosit
oma)
anak-anak &
hemangioblastoma pembuluh darah jinak 1-2%
dewasa
meduloblastoma sel-sel embrionik ganas anak-anak
sel-sel dari selaput
yg
meningioma jinak 20% dewasa
membungkus
otak
Etiology
1. Trauma
Brain absces
2. Virus
Papova virus (simian virus 40, BK, simian 40 - like virus), adeno virus.
Viral protein, DNA, RNA
3. Radiation
1.6% higherdose, younger patiens.
4. Genetics & molecular biology
Neurofibromatosis type II (chromosome 22 partial loss tumor
suppressor gene)
Tipe I (von Recklinghausens disease) less frequent
oncogen
5. Hormone & Growth Factor receptors
 CLINICAL SYMPTOMS AND SIGN

1. HEADACHES ( 35 % )
2. SEIZURES ( 30 % )
3. ALTERED MENTAL STATUS ( 15-20 % )
4. PAPILLEDEMA ( 50-70 % )
5. FOCAL NEUROLOGIC DEFICIT
 RADIOLOGIC DIAGNOSIS

1. SKULL X-rays
2. CT SCAN
3. MRI/MRA
4. ANGIOGRAPHY
5. PET
6. SPECT
 LABORATORY DIAGNOSIS
1. PERIMETRY
2. EEG
3. BSAEP
4. AUDIOMETRY
5. CSF ANALYSIS
6. ENDOCRINE EVALUATION
7. BASIC-FGF ( FIBROBLAST GROWTH FACTOR )
 Neuro-oncology

Medical Anticipate for new case of brain tumor with

complication/ symptom control :
Corticosteroid Intracranial Hypertension
Mannitol Intracranial Hypertension
Diazepam Seizure
Difenilhydantoin Seizure
Carbamazepim Seizure
Gabapentine Seizure
Valvoratic Acid Seizure
 Symptom Control: Seizure

Anticonvulsants
When do we start AEDs?
When patient has seizures
In absence of seizures, prophylactic AEDs
DO NOT reduce frequency of first seizures
[4][5]

ASNA July 2005 Jakarta

 Symptom Control: Seizure
Anticonvulsants
When do we start AEDs?
When patient has seizures
In absence of seizures, prophylactic AEDs DO NOT reduce frequency of first
seizures [4][5]

ASNA July 2005 Jakarta

 Symptom Control: Seizure
Which AED?
Preferably non-enzyme inducers
Induction of cytochrome P450 enzyme system can lead to increased
metabolism of chemotherapeutic agents and new agents.

Enzyme inducers Non-enzyme inducers

Phenytoin Valproic acid
Phenobarbitone Levetiracetam
Primidone Lamotrigine
Carbamazepine Gabapentin

ASNA July 2005 Jakarta

 Symptom Control: Cerebral Oedema

Corticosteroids
Reduce BBB permeability within hours Chumas P et al. JNNP
1997;62:590. Ostergaard L et al. J Neurosurg 1999;90:300

Reduction of oedema

Reduction of mass effect, focal deficits, raised ICP

ASNA July 2005 Jakarta

 Symptom Control: Cerebral Oedema
When is steroids used?
To lower raised ICP
To reduce significant focal neurologic deficit resulting from oedema

Which steroid agent?

Dexamethasone
Long half-life
No mineralocorticoid activity

What dose?
Lowest effective dose. E.g. 2 mg twice/ day
Raised ICP: 24 mg/ day

Caution
Significant long term side effects affecting QOL
Alters histologic features of primary CNS lymphoma, resulting in false negative
biopsies & delayed diagnosis.
Alters imaging findings Watling CJ et al. J Clin Oncol 1994;12:1886

ASNA July 2005 Jakarta

BASIC PRINCIPLES MANAGEMENT OF BRAIN
TUMOR
1. SURGICAL
2. STEREOTAXIS
a. CYST ASPIRATION / DRAINAGE
b. STEREOTACTIC CRANIOTOMY
c. INTRALESIONAL THERAPY
c.1. CHEMOTHERAPY
c.2. HYPERTHERMIA
c.3. PHOTODYNAMIC THERAPY
c.4. BRACHYTHERAPY
3. RADIOSURGERY
a. GAMMA
b. LINAC
c. CONVENTIONAL
4. CHEMOTHERAPY
 New Case of Brain
Tumor

GP; Neurologist; Non Neurologist

Clinical- Neuro Medical
Neurologic
Emergency anticipation
Examination

- Ro, CT Scan, MRI, MRA, MRS, PET-

SPECT
- Laboratory
- ECG, Doppler, Evoked Potensial
Non Brain Stop ???
Tumor No Budget

Primary Brain Tumor Positive Brain Tumor: Secondary Brain Tumor

- IICP VP Shunt - IICP
- PA Biopsy - Soliter
- Total Removal - Stereo tactic
- To Reduce Tumor Size - Open
- Resection
- Residual tumor

Histologic Finding (PA)

3 cm Radiosurgery ?

Definitive Radio Tx Radiotherapy Palliative

3 Modalities Treatment Chemotherapy Depend on Primary Cancer

Out come
Quality of life & life expectancy
 CONVENTIONAL RADIATION THERAPY FOR
INTRACRANIAL TUMORS
MENINGIOMA

TOTAL RESECTION PARTIAL RESECTION

BENIGN MALIGNANT

RADIATION RADIATION
(-) - 5000 5500 Rad
- DOSE : 180 200 Rad
- 5 6 Weeks
Radiation Therapi for Intracranial tumor
Baron L. Guhrie
Steven C Carabell
Ednase R. Law JR
 BRAIN TUMOR SURGERY
GOALS IN BRAIN TUMOR SURGERY :
1. TO MAXIMALLY DECREASE THE MACHANICAL INFLUENCE OF
BRAIN TUMOR

2. TO RELIEF THE EFFECT OF INCREASED INTRACRANIAL

PRESSURE ( ICP ) AS QUICKLY AS POSSIBLE

3. TO TAKEN THE EXACT TUMOR TISSUE IN ORDER TO

IDENTIFICATION OF TUMOR TYPE WITH HISTOPATHOLOGIC
EXAMINATION

4. TUMOR TYPE IDENTIFICATION AND HISTOPATHOLOGIC

EXAMINATION CAN BE USED FOR FURTHER TREATMENT
WITH RADIOTHERAPY AND CHEMOTHERAPY.
 BASIC PRINCIPLES IN
BRAIN TUMOR SURGERY
1. IF SIGNS OF HYDROCEPHALUS ARE PRESENT INITIAL
TREATMENT IS DRAINAGE THE CSF INTO OTHER BODY
CAVITY
2. CARE SHOULD BE TAKEN TO PREVENT DAMAGING THE
BRAIN TISSUE AND OTHER IMPORTANT STRUCTURES OF
THE BRAIN
3. MINIMALLY RETRACTION AND REMOVAL OF NORMAL
BRAIN TISSUE
4. PREVENT DAMAGING THE BRAIN VASCULAR
5. IN CAPSULATED TUMORS, DONT MAKE THE SURROUNDING
TISSUE DAMAGE IN ATTEMPT TO RELEASE THE CAPSULE.
 Management: Radiation Therapy
1. External beam radiation therapy
1. Classic
Old age
Deep positioned tumor: cavernous sinus, petrosal, tentorial, clival etc
2. Malignant meningioma, hemangiopericytoma
3. Recurrence of tumor

2. Stereotactic Radiosurgery linear accelerator (LINAC-

based-Syetems = X-knife), Gamma knife, proton beam,
cyber knife

3. Interstitial brachytherapy recurrent & malignant, Iodine

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