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

Causes of brain tumours

Causes: DNA damage NF- 1 (acoustic neuromas) HIV Radiation Genetics 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

How would you classify brain tumours?

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

Primary brain tumour

Primary brain tumour

Radiology - brain mets

Where do brain metastases come from? Questions: Where do brain metastases come from?

Secondary Brain Tumours Lung Breast GI Any primary potentially

How will you initially treat brain secondaries? Questions: How will you initially treat brain secondaries?

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

How to treat - secondaries Depends on Primary cancer and its extent / control Depends on patient fitness and wishes Can occasionally debulk and give post op XRT, or XRT alone (20Gy in 5#)

Types of primary brain tumours? BENIGN

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

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

Types of primary brain tumours? MALIGNANT

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

Primary Brain Tumours GLIOMA

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

GBM – radiology

Treatment of gliomata Observation – low grade 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)

Benefits of Temozolamide

Survival with TMZ OS TMZ + XRT XRT 2 27.2% 10.9% 3 16.0% 4.4% 4 12.1% (Years) TMZ + XRT XRT 2 27.2% 10.9% 3 16.0% 4.4% 4 12.1% 3.0% 5 9.8% 1.9%

Gliadel Wafers Gliadel wafers at time of surgery (carmustine soaked) in completely resected high grade glioma (3 or 4)

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

Primary CNS Tumours Ependymoma

Ependymoma

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

Primary CNS Lymphoma

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

Primary CNS Lymphoma

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, pathologist, radiologist Community Macmillan, DNs Social work, OT, physiotherapy input

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Research