Lisa Randall, RN, MSN, ACNS-BC RNSG 2432

Classify brain tumors according to type and location Discuss unique characteristics of primary and metastatic brain tumors Recognize common signs and symptoms Discuss nursing care re: management of S/S and treatment interventions

Incidence of primary brain tumors (benign or malignant) 12.8/100,000 10%–15% of cancer patients develop brain metastases Second leading cause of death from a neurological cause after stroke

Primary – unknown Genetic – hereditary Metastatic 35% - lung 20% - breast 10% - kidney 5% - gastrointestinal tract

Often unknown Under investigation: Genetic changes Heredity Errors in fetal development Ionizing radiation Electromagnetic fields (including cellular phones) Environmental hazards (including diet) Viruses Injury or immunosuppression

Tissue of origin Location Primary or secondary (metastatic) Grading

Microscopic appearance Growth rate Different for other types of CA For CNS, per WHO: GX Grade cannot be assessed (Undetermined) G1 Well-differentiated (Low grade) G2 Moderately differentiated (Intermediate grade) G3 Poorly differentiated (High grade) G4 Undifferentiated (High grade)

Depends on location, size, and type of tumor Neurological deficit 68% 45% motor weakness Mental status changes HA 54% Seizures 26%

General Cerebral edema Increased intracranial pressure Focal neurologic deficits Obstruction of flow of CSF Pituitary dysfunction Papilledema (if swelling around optic disk)

Cerebral Tumors Headache Vomiting unrelated to food intake Changes in visual fields and acuity Hemiparesis or hemiplegia Hypokinesia Decreased tactile discrimination Seizures Changes in personality or behavior

Brainstem tumors Hearing loss (acoustic neuroma) Facial pain and weakness Dysphagia, decreased gag reflex Nystagmus Hoarseness Ataxia (loss of muscle coordination) and dysarthria (speech muscle disorder) (cerebellar tumors)

Cerebellar tumors Pituitary tumors Disturbances in coordination and equilibrium Pituitary tumors Endocrine dysfunction Visual deficits Headache

Frontal Lobe Inappropriate behavior Personality changes Inability to concentrate Impaired judgment Memory loss Headache Expressive aphasia Motor dysfunctions

Parietal lobe Temporal lobe Occipital lobe Sensory deficits Paresthesia Loss of 2 pt discrimination Visual field deficits Temporal lobe Psychomotor seizures – temporal lobe-judgment, behavior, hallucinations, visceral symptoms, no convulsions, but loss of consciousness Occipital lobe Visual disturbances

Gliomas Oligodendroglioma Ependymomas Medulloblastoma CNS Lymphoma Astrocytoma (Grades I & II) Anaplastic Astrocytoma Glioblastoma Multiforme Oligodendroglioma Ependymomas Medulloblastoma CNS Lymphoma Intra-axial gliomas originate from glial cells; they affect brain by invasion and infiltration. Gliomas Low Grade Glioma (WHO – grade I) ?? Nonenhancing ?? Benign – 5–7 years – dedifferentiate – more aggressive Astrocytoma (WHO – grade II) ?? Nonenhancing, infiltrative ?? 5–7 years – dedifferentiates – more aggressive Anaplstic Astrocytoma (WHO – grade III) ?? Enhancing ?? Survival 18–24 months Glioblastoma Multiforme (WHO – grade IV) ?? Enhancing, necrotic center ?? Survival 8–10 months Ependymomas ?? Arises from lining of ventricle ?? Benign tumor – causes obstruction of CSF Medulloblastoma ?? Malignant tissue – infra-tentorial ?? May “seed” spinal cord CNS Lymphoma ?? Common in immunocompromised patients (e.g., transplant/AIDS) ?? Radiation/decadron or chemotherapy (radiation & chemo effective) ?? Survival 1–4 years

Grade I Non-infiltrating

Grade II Infiltrating Slow growing

Grade III Infiltrating Aggressive

Grade IV Highly infiltrative Rapidly growing Areas of necrosis

Grades II-IV Mixed astro/glio

Slow growing Benign HCP/ICP Surgery, RT, Chemo

Small cell embryonal neoplasms Malignant HCP/ICP

Primary CNS lymphoma B lymphocytes Increased ICP Brain destruction

Acoustic neuromas (Schwannoma) Pituitary adenoma Neurofibroma Meningioma Metastatic Acoustic neuromas (Schwannoma) Pituitary adenoma Neurofibroma Extra-axial originate from supporting structures of CNS. Meningioma • Slow-growing, attached to meninges • Usually benign Metastatic ?? Usually from lung, breast, kidney and GI ?? Enhancing – necrotic center, peritumoral edema, occurs in gray matter Acoustic neuroma • Cranial nerve VIII • Benign Pituitary adenoma ?? Classification by hormone secretion ?? Classification by location – adenohypophysis – anterior pituitary Prolactin-secreting – serum prolactin >500 mU/L a. Microadenoma - hyperprolactinemia, galactorrhea, amenorrhea - infertility; males – impotence b. Macroadenoma - mild hyperprolactinemia due to disruption of pituitary stalk Growth hormone – deficiency a. Childhood - dwarfism, slow/absent growth - absent/delayed sexual development, cephalofacial disproportion b. Adulthood - increased body fat, decreased muscle mass - decreased bone density – increased risk of fractures, impaired glucose tolerance Neurofibroma ?? Genetic because of autosomal dominant mendelian trait; firm, encapsulated lesions ?? Attach to nerve ?? Benign ?? Occur late in childhood/early adolescence ?? Treated with surgery, radiation

Usually benign Slow growing Well circumscribed Easily excisable

Peritumoral edema Necrotic center Most common site is breast and lung •Seed to brain by lymphatic system or blood vessels

Benign Schwannoma cells CN VIII •Arises from the meninges •Slightly higher incidence in women •Very bloody •Benign

Benign Anterior pituitary Endocrine dysfxn

Cystic tumor Hypothalamic-pituitary axis dysfunction

Radiological Imaging LP/CSF analysis Pathology Computed Tomography scan (CT scan) with/without contrast Magnetic Resonance Imaging (MRI) with/without contrast Plain films Myelography Positron Emission Tomography scan (PET scan) LP/CSF analysis Pathology Diagnostic Procedures Computed Tomography (CT) Scan ?? Evaluate bony lesions, hemorrhages with enhancement – enhancing tumors ?? May miss smaller parenchymal lesions Magnetic Resonance Imaging (MRI) ?? Structures shown in three planes ?? With and without contrast – enhancing lesions ?? Document smaller parenchymal lesions ?? MRI technology variations MRI angiography – visualization of vascular structures MR spectroscopy – documents chemical composition, brain metabolites, increased choline peak, tumor lactate peak - tumor necrosis diagnostic and prognostic tool Positron Emission Tomography scan (PET scan) ?? F-18 fluorodeoxyglucose (FDG) ?? Measures tissue metabolism ?? Differentiates treatment-related necrosis vs. tumor necrosis

Resection Craniotomy Stereotaxis Surgery Biopsy Transsphenoidal ?? Brain surgery, partial resection, resection of tumor Steriotactic Surgery ??MRI–CT guided surgery to remove small superficial tumor Biopsy ?? To remove piece of tumor to determine type of tumor Transsphenoidal ??Approach through nasal passage to remove pituitary tumor http://youtu.be/d95K3unaNCs

Drug therapy – Palliative Done for symptom treatment and to prevent complications NSAIDs Analgesics – Vicodin, Lortab, MS Contin Steroids (Decadron, medrols, prednisone) Anti-seizure medications (phenytoin) Dilantin & Cerebyx Histamine blockers Anti-emetics Muscle relaxers (for spasms) Mannitol for ICP –New Hypertonic saline

Pre-op care Post-op care Patient teaching Activity Wound care Diet Meds F/U

Neuro assessment Vital signs H & P Teaching Diagnostic test info Pre & Post-op care ICU Dressings, edema, bruising, hair removal Sensations if done partially awake Emotional support Avoid false hope

Anxiety Risk for infection Risk for injury: seizures Pain (Acute) Impaired cognitive ability Impaired physical mobility Altered nutrition: less than body requirements Urinary retention Risk for constipation Disturbed self-esteem

Wound infection Seizures CSF leak Edema Increased ICP Hematoma Hypovolemic shock Hydrocephalus Atelectasis Pulmonary edema Meningitis Fluid and electrolyte imbalances (ADH)

Follow-up appointments and procedures Medications Exercise Diet Patient may need referral to dietician to help with diet planning while undergoing chemotherapy Seizures Are a risk for 1 or more years following surgery If expecting long term changes, coordinate discharge planning with appropriate members of health care team

Damages DNA of rapidly dividing cells 4000–6000 Gy total dose Duration of 4–8 weeks Brachytherapy Stereotactic radiosurgery Radiation is sensitive to cells that rapidly divide (e.g., brain tumors) and normal tissue too. Low-grade radiation Daily radiation doses of 150–200 Gy … goes +2 cm margin beyond tumor bed Types of Radiation ??External beam radiation ??Stereotactic radiosurgery (gamma, linac, cyberknife) ??Interstitial brachytherapy – isotopes inserted into tumor bed, removed in 4–5 days Considerations •Skin burns are a big concern and reddened skin from beam of radiation. •Corticosteroids are given during radiation to control cerebral edema •Radiation necrosis may occur after treatments are completed; may need to be surgically removed.

Side Effects Patient teaching Radiation necrosis Skin burns, hair loss, fatigue, local swelling Patient teaching Do not erase markings Steroids S/S of cerebral edema Radiation necrosis

Slows cell growth Cytotoxic drugs Gliadel wafers Ommaya Reservoir CCNU, BCNU, PCV, Cisplatin, Etoposide, Vincristine, Temozolomide (Temodar) Gliadel wafers Ommaya Reservoir Cancer cells are rapidly dividing cells. A combination of drugs is sometimes used. Chemotherapeutic drugs are administered by the PO, IV or intrathecal routes Acute side effects include the following: •Oral mucositis: Provide mouth care on regular basis •Check for bone marrow suppression: WBC with differential; Neurtrophils >1500 •Fatigue: Rest, check hemoglobin >10, platelets >10,000 •Hair loss: Encourage patients to wear scarves and use makeup; review cause of hair loss and that it will regrow •Nausea/vomiting: Antiemetics •Anxiety: Reassure positive attitude •Peripheral neuropathy: Non-narcotics, opioids, adjuvant (e.g., antidepressants, anticonvulsants, anxiolytics)

Side effects Patient teaching Oral mucositis, bone marrow suppression, fatigue, hair loss, nausea/vomiting, anxiety, peripheral neuropathy Patient teaching Meds/MV Nutrition/hydration/activity Avoid pregnancy Resources

Ineffective Tissue Perfusion Ineffective Airway Clearance Impaired Communication Decreased Intracranial Adaptive Capacity Activity Intolerance Disturbed Sensory disturbance Acute Confusion

Subjective data? Interventions? Goals? Evaluation?

A patient is being directly admitted to the medical-surgical unit for evaluation of a brain mass seen in the frontal lobe on a diagnostic CT scan. Which of the following signs and symptoms would the patient most likely present with? Personality changes Visual field cuts Difficulty hearing Difficulty swallowing

The nurse is evaluating the status of a client who had a craniotomy 3 days ago. The nurse would suspect the client is developing meningitis as a complication of surgery if the client exhibits a. A positive Brudzinski’s sign b. A negative Kernig’s sign c. Absence of nuchal rigidity d. A Glascow Coma Scale score of 15

Greenberg, Mark. (2006). Handbook of AANN Core Curriculum for Neuroscience Louis, MO. Nursing, 4th Ed. 2004. Saunders. St. Greenberg, Mark. (2006). Handbook of Neurosurgery. Greenberg Graphics, Tampa, Florida.