Anaplastic Astrocytoma Post Craniotomy with R2 Residual Tumors: the Role and Treatment Consideration of Radiotherapy

Transcription

1 Anaplastic Astrocytoma Post Craniotomy with R2 Residual Tumors: the Role and Treatment Consideration of Radiotherapy Case Number: RT (M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case of anaplastic astrocytoma post craniotomy with partial removal of brain tumor with R2 residual tumors; to discuss the role and treatment consideration of post-op RT Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation: This 67 year-old male patient, 林 OO, was referred from other hospital for brain tumors post craniotomy with gross residual tumors for post-op RT assessment. S: 1. In 2008/07, craniotomy was done for removal of his left brain tumor but left his right brain tumors in place. Pathology reported anaplastic astrocytoma, WHO grade III or IV. 2. Seizure attack yesterday. 3. On 2008/08/15, his family came to OPD for further RT evaluation. Review of symptoms: seizure attack; severe insomnia Hx: NDKA O: 1. The patient absent and his family came to OPD for RT assessment 2. *** Pathology in other hospital, 2008/07, craniotomy: anaplastic astrocytoma, WHO grade III or IV (?) 3. MRI in 2008/07, brain, pre-op: no report available

2 Key Image(s): Fig. 1. Brain MRI, pre-craniotomy Fig. 2. Brain MRI, pre-craniotomy Fig. 3. Brain MRI, post-craniotomy

3 Questions & Discussions: (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) Q7: What group of patients with anaplastic astrocytoma can gain the greatest survival benefits from the addition of Temodal to RT?

4 Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending physician.) Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this case? A2: no AJCC stage is available for brain tumors. Q3: What is your pathologic cancer stage, according to the AJCC 2006, for this case? A3: no AJCC stage is available for brain tumors. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: Anaplastic astrocytoma, WHO grade III or IV (?), of bilateral hemisphere, post craniotomy (2008/07) with removal of the left brain tumor but left the right brain tumors in place Q5: What is your Oncology Plan for this case? A5: 1. Planned RT with Temodal 2. RTC 2 weeks later Q6: What is your Radiotherapy Plan for this case? (Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.) A6: RT Plan may be designed as the following one: (1). Indication: Anaplastic astrocytoma or GBM, post partial craniotomy, with R2 residual brain tumors (2). Goal: potentially curative to prolong survival in definitive CCRT setting (with Temodal) (3). Target & Volume: T2 flare sequence high-signal lesions and their associated peri-focal edema with 2-cm margin (4). Technique: CT-based 3DCRT or IMRT (5). Dose & Fractionation: cgy in fractions Q7: What group of patients with anaplastic astrocytoma can gain the greatest survival benefits from the addition of Temodal to RT? A7: Temozolomide, given during and after radiotherapy, provides a significant survival advantage that is greatest in patients with methylation of the promoter region of the MGMT gene. [Perez 2008] Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006 Radiation Oncologist Hon-Yi Lin 2009/03/15

5 Key Image(s): (with marked) Fig. 1. Fig. 1. Pre-craniotomy brain MRI sequence, the T2 flare sequence shows multiple high-signal nodular lesions over bilateral hemisphere, the right more than the left one (as the white arrows); significant peri-focal edema was also noted (as the white arrow heads). Fig. 2. Fig. 2. In the pre-craniotomy brain MRI, the T2 flare sequence film shows multiple high-signal lesions, main part over the right hemisphere with cross midline to the left hemisphere (as the white arrows); a large area of peri-focal edema over the right hemisphere was also noted (as the white arrow heads). Fig. 3. Fig. 3. Post-craniotomy, a surgical defect on the left hemisphere was noted (as the long white arrow); on the right hemisphere, no removal tumor was done and still a small enhanced tumor was found (as the short white arrow); the peri-focal edema over the small enhanced lesion also noted (as the white arrow heads).