Brain and Spine Tumors

Transcription

1 Brain and Spine Tumors Andrew J. Fabiano, MD Assistant Professor of Neurosurgery Roswell Park Cancer Institute SUNY at Buffalo School of Medicine

2 Brain Tumor Basics Types of Tumors Cases Brain Tumors

3 Brain Tumors Skull is a fixed space Symptoms develop due to compression of normal brain

4 Brain Tumors

5 Brain Tumors Inflammation/Edema occurs in the surrounding normal brain

6 Brain Tumors Tumors cause edema and irritation of normal brain Steroids for edema Anti-epileptics to prevent seizures

7 Steroids Dexamethasone traditionally used Reduces vasogenic edema GI prophylaxis

8 Multiple side effects: Diabetes Myopathy Infection LE edema Weight gain Wound issues Steroids

9 Anti-Epileptic Drugs Used for cortical lesions Not required for cerebellar lesions Dilantin requires monitoring Keppra

10 Gliomas Meningiomas Metastatic Tumors Pituitary Tumors Tumor Types

11 Gliomas Arise from native cells within the brain

12 Gliomas WHO I Pilocytic Astrocytoma WHO II Fibrillary Astrocytoma WHO III Anaplastic Astrocytoma WHO IV Glioblastoma Multiforme

13 Gliomas WHO I

14 Gliomas WHO II & III

15 Gliomas - GBM

16 Gliomas - Treatment Start steroids and anti-epileptics

17 Gliomas - Treatment Surgery Biopsy External Beam XRT Chemotherapy (Temodar)

18 Gliomas - Treatment

19 Glioma Case 51 yo male presents with headaches and imbalane PMH significant for HTN PE lateral nystagmus and right-sided dysmetria

20 Glioma Case

21 Glioma Case Underwent Suboccipital craniotomy for removal of tumor

22 Glioma Case

23 Case 2 Pathology = Pilocytic astrocytoma Dysmetria improved Back to work at the Post Office Followed with serial imaging

24 Meningiomas

25 Meningiomas Develop from arachnoid cap cells More common in females Most are WHO I WHO II, III, IV malignant meningiomas

26 Meningiomas

27 Meningiomas - Treatment Anti-epileptics, steroids in some instances Observation Gamma Knife (<3 cm) Open Surgery

28 Meningiomas 62 yo female presented with gait instability On PE, had an ataxic gait and lower extremity hyperreflexia

29 Meningiomas

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31 Meningiomas 60 yo female presents with change of personality Over the past 6 months 1 year, patient has been confused and has poor shortterm memory Always pleasant, which is unusual Diagnosed with Depression with psychotic features

32 Meningiomas Exam: Awake and pleasant Obese Confused, poor recall No sense of smell Some difficulty moving legs

33 Meningiomas

34 Meningiomas

35 Patient started on steroids and antiepileptics Underwent bifrontal craniotomy for tumor removal Meningiomas

36 Meningiomas

37 Meningiomas Patient has had slow recovery over 6 months Edema slowly resolving Now doing crosswords, but still a shortterm memory deficit

38 Metastatic Tumors

39 Metastatic Tumors Single lesion < 3 cm Gamma Knife Single lesion > 3 cm Open Surgery Multiple lesions: Gamma Knife vs. XRT

40 Gamma Knife Radiosurgery

41 Gamma Knife Radiosurgery

42 Gamma Knife Radiosurgery

43 Gamma Knife Radiosurgery

44 Gamma Knife Radiosurgery

45 Leptomeningeal Disease Poor prognosis Patients may develop cranial nerve palsies

46 Leptomeningeal Disease Intrathecal chemotherapy

47 Leptomeningeal Disease

48 Leptomeningeal Disease Ref:

49 Hydrocephalus Cerebrospinal fluid build-up resulting in an increased intracranial pressure

50 Hydrocephalus Patients develop symptoms from increased intracranial pressure Headaches, N/V, confusion, lethargy, coma

51 Hydrocephalus Can be communicating or obstructive

52 Hydrocephalus Treatments include VP Shunt and Endoscopic Third Ventriculostomy (ETV)

53 Hydrocephalus 58 yo man with a history of colon cancer with worsening headaches and confusion Patient had just completed external beam radiation tx for multiple brain metastases On PE he was confused and sleepy

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56 ETV

57 Pituitary Tumors

58 Pituitary Tumors Pituitary gland is a marble-sized gland at the base of the brain that controls hormone regulation in the body

59 Pituitary Tumors Most common Pituitary Adenomas (nonsecreting) Cushing s Disease Acromegaly Prolactinomas

60 Pituitary Adenoma Benign Tumor Seen in ~5% of normal population Microadenoma < 1 cm Macroadenoma > 1 cm Treat with observation

61 Pituitary Adenoma If it is growing, or putting pressure on surrounding structures should be treated Endocrine function Visual field testing

62 Pituitary Adenoma Transsphenoidal Resection

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64 Cushing s Disease ACTH-secreting tumor Treat with surgical resection

65 Acromegaly Excess growth hormone secretion Enlarging hands and feet Bilateral carpal tunnel syndrome Diabetes mellitus Dilated cardiomyopathy

66 Acromegaly Measure IGF-1 Can try somatostatin analogs Oftentimes requires surgical resection

67 Acromegaly 41 yo female who had an abnormal MRI as part of a work-up for headaches She had carpal tunnel repair of her right wrist and repair of her left wrist is scheduled No significant other PMH PE Large hands

68 Acromegaly

69 Acromegaly Visual Field testing WNL IGF-1 level 378

70 Acromegaly Underwent expanded endonasal endoscopic transsphenoidal tumor resection

71 Acromegaly Tumor removed and patient doing well Following IGF-1 levels

72 Prolactinoma Patient may have nipple discharge Elevated Prolactin Usually greater than > 200 ng/ml Can be treated with Bromocriptine

73 Spinal Metastatic Disease

74 Spinal metastatic disease Most frequent area of spine for metastases is vertebral body May present with pain or neurologic deficit

75 Spinal metastatic disease Spinal Cord Compression: Myelopathy hyperreflexia, clonus Numbness Weakness Incontinence

76 Spinal metastatic disease General Indications for surgery: Neurologic deficit Spinal Instability

77 Spinal Metastatic Disease

78 Patchell Study Non-blinded randomized controlled trial Patients with metastatic disease causing spinal cord compression Radiation alone (n=51) Surgery + Radiation (n=50) Primary endpoint ability to ambulate

79 Patchell Study Surgical group: Improved ambulation Improved survival and functional status Decreased need for steroids and opiods

80 Spinal Metastatic Disease

81 Spinal Metastatic Disease <3 months prognosis Surgery not indicated 3-6 months prognosis Grey zone >6 months prognosis Consider surgery

82 Case 1

83 47 yo male presents with several week history of difficulty gripping items with his hands now having diffuculty walking No significant PMH Smoking since he was 14 2/5 strength left hand, 3/5 right hand, ataxic, LE hyperreflexic with clonus

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85 Case 1 Patient underwent C7/T1 anterior corpectomy and fusion and posterior C6- T2 instrumented fusion

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87 Path metastatic adenocarcinoma Underwent chemotherapy At 1 year post-op he has regained full strength

88 Case 2

89 42 yo female with colon adenocarcinoma and back pain PET scan hot in thoracic spine Full strength on exam, hyperreflexic

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91 Underwent thoracic corpectomy and fusion followed by radiation

92 Case Intradural Intramedullary Metastasis

93 Intradural Intramedullary Metastasis 66 yo Left LE pain and weakness Hx of Renal mass removed 2 years ago at OSH without follow-up L4 radiculopathy and Left 4/5 dorsiflexion

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97 Summary Consider surgery when evaluating patients with spinal metastatic disease Patients with a neurologic deficit from spinal compression and > 6 months prognosis are the best candidates

98 Learning Points Dexamethasone Side Effects High Grade glioma = GBM Meningioma Hydrocephalus Intrathecal Chemotherapy Acromegaly Indications for Spine surgery

99 Thank you!