Date post: | 10-Apr-2018 |
Category: |
Documents |
Upload: | eurofighter |
View: | 222 times |
Download: | 0 times |
of 21
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
1/21
Brain Tumors:Neurosurgic al treatment(inc luding Gamma Knife)
An Introduction
The LSU-Shreveport Department of Neurosurgery
Presenting Authors: Neurosurgery Residents & Faculty
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
2/21
Brain Tumors: Classification
Categorized & Considered by c ell layer of origin
World Health Organization (WHO) Classification:
Tumors of Neuroepithelial tissue
Tumors of Meninges
Tumors of Craniospinal Nerves
Hematopoietic Neop lasms Germ Cell Tumors
Sellar Tumors
Metastatic Tumors
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
3/21
Common Intrac ranial Tumors
Metastatic tumors to brain (lung, breast, rena l, GI mostfreqeuent; melanoma has highest affinity for brain)
Gliomas (astroc ytoma, anaplastic astroc ytoma,gliob lastoma multiforme)
Meningioma & Hemangiopericytoma
Pituitary adenoma Craniopharyngioma
Vestibular schwannoma (a.k.a. acoustic neuroma) &Neurofibroma
Lymphoma
Pinea l region tumors
Cystic lesions which mimic intrac ranial tumors
Inflammatory lesions which mimic intrac ranial tumors
Infec tious lesions which mimic intrac ranial tumors
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
4/21
Brain Tumors in General
Presentation
Headac he, seizure, neurolog ical defic it
History Progressive onset of sym ptoms (weeks to months)
Physical Exam Depends upon brain reg ion affec ted
Diagnostic Imaging Studies CT, MRI, PET (if r/ o nec rosis)
Diag nostic Laboratory Studies
Important for systemic tumors, e.g. leukem ia Treatment
Varies per histology of spec ific tumors
Prognosis Varies per histology of spec ific tumors
http://www.neurobc.com/conditions/Brain_metastases.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
5/21
Metastatic Brain Tumor History
Rapid ly p rog ressive o nset of symp tom s (weeks vs. months)
Mo st c ommon sources a re LUNG, BREAST (in women), RENAL, & G.I. trac t
Diag nostic Imaging Stud ies MRI: Tumor a t g rey-white ma tter junc tion, usually assoc ia ted with edema
Systemic work-up inc ludes CT sc an o f chest and a bd omen
Diagnostic Labora tory Stud ies Liver func tion tests, CBC w / d iff
Trea tment For solita ry lesion or less tha n 4 lesions a ll < 3 cm. b iop sy
if undiagnosed, plus Gamma Knife
For > 3 cm. tumor, surge ry followed by WBRT
For > 4 lesions, biop sy for diag nosis, plus whole b ra in
rad ia tion therapy
Prognosis: 7 12 mos.http://www.neurobc.com/conditions/Brain_metastases.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
6/21
Gliomas Presenta tion
Depends upon b rain loc ation, usually H/ A over
severa l mos., seizure, wo rd finding d ifficulty
Physic al Exam Depends upon brain region affected
Diag nostic Imaging Studies CT, MRI
Trea tment Surge ry, Radiation, Chemo (varies/ age group &
type)
Survival dep ends on pa thology: Piloc ytic astroc ytoma: resec tion cure; Grad e 1 Astroc ytoma (nuclear atypia) 8-10 yrs;
Grade 2 Anaplast ic astrocytoma (+endothelia lp rolifera tion) 2 yrs.
Grade 3 (+nec rosis) GBM 11 monthshttp://www.neurobc.com/conditions/
Astrocytoma Note absence of edema
GBM Note crossing of corpus callosum
http://sprojects.mmi.mcgill.ca/braintumor/section2/subsection1/Default.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
7/21
Meningioma &Hemangiopericytoma
Presenta tion Meningioma s oc c ur in midd le ag ed fema les more frequently
Hemangioperic ytomas oc c ur in younger pa tients
History Mening iomas are usually slow-growing (months to yea rs) vs.
hemangioperictyomas(months)
CT/ MRI: Show meninges-based tumor (usua lly), withvariab le a mount of edema
Trea tment Meninigioma s: Gross tota l resec tion cure;
Hemangiope ric ytoma s: Surgica l resec tion + XRT
Prognosis Meningioma s: Can be c ured with gross tota l resec tion
Hemang iop eric ytomas: Variab le, depends upon rec urrenc e
http://sprojects.mmi.mcgill.ca/braintumor/section2/subsection1/Default.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
8/21
Pituitary adenoma Presenta tion
Hea dac he, visual defec t (c lassic ally bitempo ra l hemianopsia),end oc rine abnorma lities (depend ent upon hormone sec reted )
Cushings d isease is life-threa tening (w / hypertension, stria , buffa lohump, morbid obesity); Prolac tin, GH, TSH, FSH/LH a lso p resent
History Slow-grow ing, over months to years
Diagnostic Labo ra tory Stud ies Endoc rine panel (with hormones noted ab ove); c an test IGF-1 for
GH-sec ret ing tumor; use d examethasone suppression test forCushing s d isea se vs. ec top ic Cushing s syndrome
Trea tment Surg ic a l exc ision usua lly initial trea tment (usua lly transnasa l
approa c h), with GK for rec urrenc e vs. loc a l foc used rad ia tion
Prognosis Genera lly benign, so p rop ortiona l to g ross tota l resec tion &
c ontrol of endoc rine effec ts; Cushing s d isea se is life-threa tening,so remove p ituitary g land if nec essary
http://www.clevelandclinic.org/neuroscience/treat/brain/neuroendocrine.htm
http://www.medschool.lsumc.edu/Nsurgery/case23.html
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
9/21
Craniopharyngioma Presenta tion
More co mmon in younger c hildren and olde r ad ults
History Endoc rinolog ic abo rma lity, often diabetes insipidus
Skull X-ray/CT: Often c a lc ified mass nea r
hypotha lamic a rea Diagnostic Labora tory Stud ies
R/ O D.I.: Serum sod ium > 145, Urine spec ific g ravity< 1.005, with c lea r d ilute urine up to 10,000 c c / day!
Trea tment Surgica l resec tion and / or focused rad ia tion
Prognosis 5-yea r survival 55%; morta lity 10% usua lly from
hypotha lamic injury
http://www.rbrs.org/database/82-3/page130.html
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
10/21
Vestibular sc hwannoma
Presenta tion Hea ring diffic ulty in a ffec ted ea r, vertigo ,
hea dac he/ fac ia l wea kness/ fac ia l numbness if la rgetumor
Physic al Exam Evaluate fac ia l weakness & hea ring ability
Diag nostic Imaging Stud ies MRI Brain
Trea tment Surg ic a l resec tion if >3 c m. or c ausing excessive
mass effec t bra instem c ompression; GK for sma llerlesions (
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
11/21
Lymphoma
Presenta tion Sporad ic , more c ommon in immunosuppresed or
immunocompromised patients (e.g . HIV+); ma y or ma y notbe systemic @ presentation.
Spinal co rd (epidural) compression or c arc inoma tousmeningitis multip le c rania l nerve deficits
Diag nostic Imaging Stud ies CT and / or MRI Brain
Trea tment Biop sy for estab lishing d iagnosis, follow ed by rad ia tion;
c hemotherap y (methotrexate ) has shown inc rea sed surviva l
Prognosis No tx 2.5 mos.; XRT 10 m os.; IntraVENTRICULAR
methotrexate 41 months. Prog nosis worse in AIDS p ts. (4months)
http://www.uhrad.com/mriarc/mri001.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
12/21
Pineal Region Tumors Presenta tion
Heada c he, Hydroc epha lus (if large)
Physica l Exam May develop Perinauds syndrome (upgaze pa lsy,
c onvergenc e, and ac c omod ation impairment) ifla rge tumor
Diag nostic Ima ging Studies MRI
Diagnostic Labo ra tory Stud ies CSF can be sent for ma rkers AFP, HCG, PLAP
Trea tment Depend s upon histology: Germinoma biopsy &
irrad ia te; Pineob lastoma : resec t & irrad ia te
Prognosis
Depend s upon histology: Pineocytoma better thange rminoma, pineob lastoma
Some tumors, particularly germinoma,can concomitantly present in the pinealand parasellar regions, as shown here.
http://home.earthlink.net/~radiologist/tf/100200.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
13/21
Pediatric tumors
Will be c overed in lec ture on Ped ia tric Neurosurgery
Inc lude medulloblastoma,ependymoma, p iloc ytic astroc ytoma ,
c horoid p lexus pap illoma &c arc inoma, and DNET
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
14/21
Cystic lesions that can mimican intrac ranial tumor on MRI
Example: ARACHNOID CYST vs. EPIDERMOID TUMOR
History: AC may be p resent from b irth; ET is benign, ma ybe a ssoc ia ted with H/ A a nd oc c asiona lly enla rge ve ryslowly
Diagnostic Ima ging Stud ies: MRI shows fluid -c onta iningc yst (use d iffusion ima g ing to r/ o ep idermo id tumor)
Patholog y: ET inc lusion of stra tified squamous ep ithelium(+/ - ha ir follic les/ swea t g lands = Dermoid ); AC = simp learachnoid
Trea tment: Exc ision of wa ll, with remova l of lesion; forarac hnoid c ysts, fenestra tion of a rac hnoid memb rane,ra rely shunt p lac ement
Prog nosis: Usually good with resec tion/ fenestra tion, aslong as no rec urrenc e
http://www.uchsc.edu/sm/neuroimaging/P0432/P0432_frameset.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
15/21
Example: SARCOID
History
May be a ssoc iated with pulmonarysa rc oid, but NOT ALWAYS!
Diagnost ic Imaging Studies
MRI
Diagnostic Lab oratory Studies
ACE leve ls (CSF, b lood helpful)
Trea tment
Steroids (ma y need b iop sy to estab lishdx show s non-ca sea ting granuloma)
Prog nosis
Dependent upon respo nse to steroids
Inflammatory lesions that canmimic an intrac ranial tumor
www.uiowa.edu/~c064s01/nr088.htmhttp://www.uiowa.edu/~c064s01/nr088.htm
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
16/21
Infec tious lesions canmimic an intrac ranial tumor
Disc ussed under sec tion of Vasc ula r, Critic a l
Care, & CNS Infec tions
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
17/21
Care of the Brain Tumor Patient
Steroid s Help resolve ed ema and symptoms assoc ia ted with it
Can confuse the issue of lymphoma , bec ause rap id d isappea rance is seen for lymphoma , followed byrecurrence
Anti-c onvulsants Rec ommended p artic ula rly for ep ilep togenic areas, e.g.
mesia l tempora l lob e, and with pa st h/ o seizures
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
18/21
Treatment Options in generalfor Intrac ranial Tumors
Sometimes need Biop sy for identific a tion then one orc omb ination o f:
Surgery
Rad ia tion Therapy
Whole b ra in
Focused beam
Ga mma Knife Stereota c tic Radiosurgery
Chemotherapy
Systemic
Loc a l
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
19/21
Gamma Knife Radiosurgery
Ind ic a tions Tumors (Benign & Ma lignant, Primary & Metasta tic ) Arteriovenous ma lforma tions
Trigemina l neura lg ia Func tiona l neurosurgery, to c rea te lesions (controversia l)
Suc c ess Rate Comp arab le succ ess ra te for tumors vs. surgery/c onventiona lrad ia tion, with few er side effec ts/ morb id ity/ morta lity
Lim ita tions
Tumors must be sma ller (
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
20/21
8/8/2019 Brain Tumors Neurosurgical Treatment Including Gamma Knife
21/21
The End