Brain Tumours – what should I know? Dr Hannah Lord Consultant Clinical Oncologist

Causes of brain tumours

Causes: DNA - damage Radiation Genetics NF- 1 (acoustic neuromas) Li Fraumeni syndrome Tuberous sclerosis ( astrocytomas) multiple endocrine neoplasia type 1(pituitary macroadenoma) Infection HIV

Diagnosis So – how do you suspect a brain tumour?

What makes you suspect a brain tumour in patient? Morning headache, n+v, confusion New onset of seizures Motor deficit Sensory deficit Personality change Dyshasia Ataxia

Investigations What would you do?

Ix? CT brain MRI brain/spine – to exclude multiple metastaic deposits; to better characterise tumour If cerebral lymphoma – other Ix to exclude HIV and systemic disease – (where especially in men?)

Primary brain tumour

Primary brain tumour

Radiology - multiple brain mets

Outcomes Depends on pathology– weeks to non life threatening

Types of Brain Tumours Primary (rare) benign or malignant Secondary (majority) malignant

Secondary Brain Tumours Lung Breast GI Any primary potentially

How to treat? Oedema – steroids Pain – analgaesia Nausea - antiemetics

Investigations CT / MRI Brain If appropriate Solitary / multiple Surgical candidate? If appropriate CT Chest Abdo Pelvis Tumour markers Neurosurgical Biopsy

How to treat Depends on Primary cancer and its extent / control Depends on patient fitness and wishes Can occasionally debulk and give post op XRT

Primary brain tumours Types of primary brain tumours?

Primary brain tumours I Benign Pituitary – adenoma, cranio-pharyngioma Meningioma Acoustic neuroma Dermoid tumour

Malignant brain tumours II Malignant: Glioma Primary Cerebral Lymphoma Germinoma Pineoblastoma Medulloblastoma

Benign brain tumours Treatment? Observation Surgery Radiotherapy BSC Can behave in a malignant fashion due to location and recurrent nature

Malignant: Gliomata Commonest Primary Brain Tumours Grades: I: Fibrillary astrocytoma II: Astroctytoma or Oligodendroglioma III: Anaplastic Astrocytoma / Oligodendroglioma IV: Glioblastoma multiforme

GBM – radiology

Treatment of gliomata Observation Surgery

Treatment of gliomata Radiotherapy 60Gy in 30# over 6 weeks +/- Temozolamide chemotherapy (25% alive at 2 years) Or 30Gy in 6# over 2 weeks (months) Gliadel wafers Or BSC ( weeks)

Pathology - GBM High Ki 67 Necrosis Pleomorphism Abnormal vasculature GFAP +ve

Ependymoma Grade I- III Location? Treatment? Surgery +/- radiotherapy 54Gy in 30# over 6 weeks

Imaging of ependymoma

Primary Cerebral Lymphoma Primary cerebral lymphoma – HIV related Steroids Chemo (methotrexate based)+/- XRT Cognitive impairment Poor outcomes

Pathology Blue cells B Cells Perivascular cuffing

Effects on patient and family Loss of autonomy Can not drive Neurological deficit Confusion and personality change Family lose the person they knew Financial loss Social loss

Effects on patient and family Effects of treatment – steroids, anti epileptics, surgery and XRT Invasion of space by supportive teams Death Genetic consequences

Multidisciplinary teams Need GP, neurosurgeon, oncologist, endocrinologist, neurologist, specialist CNS nurse, palliative care team, patholgist, radiologist Community Macmillan, DNs Social work, OT, physiotherapy input

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Research