Do you know what’s in people’s Do you know what’s in people’s head?head?

Brain tumorsBrain tumors

72 male72 male HPI: presents to E.R. with history of HPI: presents to E.R. with history of

confusion, change of personality, left confusion, change of personality, left sided H/Asided H/A

P/E: disorientation and P/E: disorientation and aggressiveness, no focal signsaggressiveness, no focal signs

Labs: WNLLabs: WNL Imaging:Imaging:

Brain tumorsBrain tumors

Brain tumorsBrain tumors

anatomyanatomy

Brain tumorsBrain tumors

Brain tumorsBrain tumors

Brain tumorsBrain tumors

Brain tumorsBrain tumors

DDx:DDx: BenignBenign

CongenitalCongenital AVM/aneurismAVM/aneurism

Acquired Acquired Infectious (toxoplasmosis, cyst)Infectious (toxoplasmosis, cyst) strokestroke

MalignantMalignant PrimaryPrimary metastaticmetastatic

Brain tumorsBrain tumors

Glioblastoma Glioblastoma multiformemultiforme

AstrocytomaAstrocytoma OligodendrogliomaOligodendroglioma MeningiomaMeningioma Brain stem tumorsBrain stem tumors MedulloblastomaMedulloblastoma Ependymoma Ependymoma

SarcomaSarcoma LymphomaLymphoma CraniopharyngiomaCraniopharyngioma NeurofibromaNeurofibroma Germ cell tumorsGerm cell tumors SchwannomaSchwannoma Pituitary tumorsPituitary tumors meningiomameningioma

Brain tumorsBrain tumors

MetastasesMetastases SingleSingle Multiple Multiple

Brain tumorsBrain tumors

Brain tumorBrain tumor

Brain tumorsBrain tumors

Brain tumorsBrain tumors

Management:Management: Medical support (steroids + PPI)Medical support (steroids + PPI) Staging Staging Surgical resection if indicatedSurgical resection if indicated Adjuvant therapiesAdjuvant therapies

Brain tumorsBrain tumors

Brain tumorsBrain tumors

GBMGBM

Radiation therapyRadiation therapy Standard dose: 60 Gy / 30 fractionsStandard dose: 60 Gy / 30 fractions O.S. = 42 weeks (1979 study)O.S. = 42 weeks (1979 study)

Radiation therapy + chemotherapyRadiation therapy + chemotherapy Meta analysis shows improvement in Meta analysis shows improvement in

generalgeneral

GBMGBM

Best results to Best results to date:date: Combination with Combination with

temozolomidetemozolomide 75 mg/m2 po od x 6 75 mg/m2 po od x 6

weeks (concurrent weeks (concurrent with xrt), then 150 with xrt), then 150 mg/m2 po od on d1-mg/m2 po od on d1-5 every 28 days x 6 5 every 28 days x 6 cyclescycles

RTRT RT/TMZRT/TMZ

Median Median OS OS (months(months))

12.112.1 14.614.6

2 yr 2 yr survivalsurvival

10%10% 26%26%

GBMGBM

If poor performance statusIf poor performance status Hypofractionated xrt:Hypofractionated xrt:

40/1540/15 35/1035/10

Brain tumorsBrain tumors

57 male 57 male HPI: known lung cancer; developped HPI: known lung cancer; developped

gait instabilitygait instability P/E: cerebellar exam abnormalP/E: cerebellar exam abnormal ImagingImaging

Brain tumorsBrain tumors

Cerebellar metastasis on CT scanCerebellar metastasis on CT scan

Management: Management: Supportive careSupportive care Decadron (10 mg stat, then 4 mg po Decadron (10 mg stat, then 4 mg po

QID) + PPIQID) + PPI

Brain metsBrain mets

Depends on stability of peripheral Depends on stability of peripheral disease and extend of intra cerebral disease and extend of intra cerebral disease:disease:

Peripheral disease stable: Peripheral disease stable: confirm solitary status with MRIconfirm solitary status with MRI If solitary: If solitary:

consider surgical resection or stereotactic consider surgical resection or stereotactic radiosurgeryradiosurgery

Whole Brain Radiation Therapy (WBRT)Whole Brain Radiation Therapy (WBRT)

Brain metsBrain mets

SurgerySurgery DiagnosticDiagnostic Quicker steroid Quicker steroid

tapertaper Quicker symptom Quicker symptom

reliefrelief

Limited by Limited by localisationlocalisation

SRSSRS Non invasiveNon invasive Less riskLess risk Less expensiveLess expensive

Limited by sizeLimited by size RadioresistanceRadioresistance

MelanomaMelanoma Sarcoma Sarcoma

Brain metsBrain mets

peripheral disease stableperipheral disease stable More than 1 lesionMore than 1 lesion

Surgery less of a considerationSurgery less of a consideration WBRT +/- stereotactic radiosurgery boostWBRT +/- stereotactic radiosurgery boost

Criteria:Criteria: < or = 3 lesions< or = 3 lesions Volume: < 4 cmVolume: < 4 cm Prognostic > 3 monthsPrognostic > 3 months KPS >70KPS >70

Brain metsBrain metsSurvivalSurvival WBRT + WBRT +

SRSSRSWBRTWBRT p valuep value

OverallOverall 6.56.5 5.75.7 0.130.13

1 met1 met 6.56.5 4.94.9 0.040.04

1-3, 1-3, age<50age<50

9.99.9 8.38.3 0.040.04

1-3, NSCLC1-3, NSCLC 5.95.9 3.93.9 0.050.05

1-3, RPA1-3, RPA 11.611.6 9.69.6 0.050.05

Brain metsBrain mets

peripheral disease not stableperipheral disease not stable Palliative radiation therapyPalliative radiation therapy Re-irradiation on a case by case basisRe-irradiation on a case by case basis

Brain metsBrain mets

Brain metsBrain mets

Prognostic:Prognostic: Untreated: 1 monthUntreated: 1 month Steroids: 2 monthsSteroids: 2 months

Brain metsBrain mets

Radiation therapyRadiation therapyKPSKPS >70>70 >70>70 <70<70

AgeAge <65<65 >65>65

Primary Primary controlcontrol

YesYes nono

MetsMets Brain Brain onlyonly

Multi Multi organorgan

SurvivalSurvival 7.17.1 4.24.2 2.32.3

Brain metsBrain mets

Side effectsSide effects AlopeciaAlopecia Skin erythemaSkin erythema Fatigue Fatigue Neurocognitive changesNeurocognitive changes

Brain metsBrain metsSingle metSingle metSymptomatic,ResectableSymptomatic,Resectable

First/only metFirst/only met

Surgery + WBRTSurgery + WBRT

Single metSingle metLittle / no symptomLittle / no symptom

Non resectable / surgery Non resectable / surgery refusedrefused

SRS + WBRTSRS + WBRT

2-3 mets, KPS>702-3 mets, KPS>70RPA 1, NSCLC, <50 yoRPA 1, NSCLC, <50 yo

SRS + WBRTSRS + WBRT

2-3 mets, KPS>702-3 mets, KPS>70None of favorable Px factorsNone of favorable Px factors

WBRT +/- SRSWBRT +/- SRS

4 mets, KPS>704 mets, KPS>70RPA 1, NSCLC, <50 yoRPA 1, NSCLC, <50 yo

WBRT +/- SRSWBRT +/- SRS

Brain metsBrain mets

Role of WBRTRole of WBRTDecrease rate of new mets Decrease rate of new mets (50% to 25%)(50% to 25%)

Does not increase OSDoes not increase OS

Some histologies have less Some histologies have less distant failures (RCC, distant failures (RCC, melanoma, sarcoma)melanoma, sarcoma)

No increase in toxicity No increase in toxicity (objectively)(objectively)

Subjective increase in Subjective increase in toxicitytoxicity

Case where Dx is in doubt Case where Dx is in doubt (meningioma)(meningioma)