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

2. Causes of brain tumours

3. 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

5. Diagnosis
So – how do you suspect a brain tumour?

6. 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

7. Investigations
What would you do?

8. Ix?
CT brain
MRI brain/spine – to exclude multiple metastaic deposits; to better characterise tumour

9. How would you classify brain tumours?

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

11. Primary brain tumour

12. Primary brain tumour

13. Radiology - brain mets

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

15. Secondary Brain Tumours
Lung
Breast GI
Any primary potentially

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

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

18. 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#)

19. Types of primary brain tumours?
BENIGN

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

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

22. Types of primary brain tumours?
MALIGNANT

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

24. Primary Brain Tumours
GLIOMA

25. 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

26. GBM – radiology

27. Treatment of gliomata
Observation – low grade Surgery

28. 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)

29. Benefits of Temozolamide

30. 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%

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

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

33. Primary CNS Tumours
Ependymoma

34. Ependymoma

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

36. Primary CNS Lymphoma

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

38. Primary CNS Lymphoma

39. Pathology
Blue cells
B Cells
Perivascular cuffing

40. 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

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

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

43. ??

44. Research