Case study session High grade gliomas: Dilemmas in the ... · Dr Frank Saran, Consultant Clinical...
Transcript of Case study session High grade gliomas: Dilemmas in the ... · Dr Frank Saran, Consultant Clinical...
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The Royal Marsden
Women's cancers Breast cancer introduction 1
Case study session
High grade gliomas: Dilemmas in the
decision making process and new
radiotherapy options
Dr Frank Saran,
Consultant Clinical Oncologist
Head of Neuro-Oncology
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The Royal Marsden
Management of glioblastoma
GBM
Radical
RT and TMZ
Palliative
RT (short) or
TMZ
Best supportive
care
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The Royal Marsden
Management of glioblastoma
KPS <40 40-70 >70
Age 70yrs Palliative or
BSC
Radical or
palliative
Radical
Age 70 yrs Best supportive
care
Palliative or
best supportive
care
Palliative or
radical
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The Royal Marsden
Management of glioblastoma
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The Royal Marsden
Management of glioblastoma
– Male in his fifties
– PMH of hypertension
– Maternal history of GBM
– Married with children, professional
– Presented with partial seizure
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The Royal Marsden
Management of glioblastoma
Diagnostic MRI
– Contrast enhancing
isolated lesion
– Radiological Diagnosis:
Glioblastoma
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The Royal Marsden
Management of glioblastoma
Post Surgical MRI
– Awake craniotomy
– Near total resection
– Glioblastoma, WHO
Grade IV
– MGMT methylated
– EGFRvIII positive
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The Royal Marsden
Management of glioblastoma
Post Surgical MRI
Radiotherapy, 60Gy/30#
Concomitant temozolomide
Treated on ACT-IV Phase III
Trial
4 cycles of adjuvant
temozolomide with
vaccine/placebo
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The Royal Marsden
Management of glioblastoma
– 54 years old male
– No PMH of note
– Married, 2 children, teacher, lives in South London
– Debulking of GBM right frontal lobe
– PS 0, no deficits
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The Royal Marsden
Management of glioblastoma
– 54 years old male
– PMH: iv drug abuser on methadone, Hep C pos
– unemployed, no permanent address, no reg. family
contacts
– Debulking of GBM right frontal lobe
– PS 0, no deficits
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The Royal Marsden
Management of glioblastoma
– 54 years old male
– No PMH of note
– Married, 2 children, teacher, lives in South London
– Complete excision of posterior left frontal GBM
– PS 2, right sided hemiparesis
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The Royal Marsden
Management of glioblastoma
– 54 years old female
– No PMH of note
– Married, 2 children, teacher, lives in South London
– Biopsy of frontal GBM (butterfly glioma)
– PS 1, “frontal” poor short term memory
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The Royal Marsden
Management of glioblastoma
– 54 years old male
– No PMH of note
– Married, 2 children, journalist, lives in Surrey
– Biopsy of left temporo-parietal GBM
– PS 1, severe expressive and receptive dysphasia
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The Royal Marsden
Management of glioblastoma
– 34 years old female
– No PMH of note
– Married, 2 children, housewife, lives in Croydon
– Complete excision of posterior left frontal GBM
– PS 0
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The Royal Marsden
Women's cancers Breast cancer introduction 15
New therapeutic approaches
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The Royal Marsden
Intensity modulated radiotherapy (IMRT)
IMRT involves the production of a non-uniform beam
intensity across a field using advanced planning,
verification and delivery techniques.
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The Royal Marsden
IMRT LINAC
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The Royal Marsden
IMRT example
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The Royal Marsden
RADIOTHERAPY RapidArc HGG
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The Royal Marsden
RADIOTHERAPY RapidArc LGG
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The Royal Marsden
Cyberknife
1 fraction
Radiosurgery
Small volumes (brain/neck)
1 - 7 fractions
hypofractionated RT
small to medium volumes
1 - ∞ fractions
radiosurgery, hypo~, conventionally ~,
hyper-fractionated RT
any volume
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The Royal Marsden
Cyberknife – “Linac on a stick”
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The Royal Marsden
CYBERKNIFE – CNS Indications
Brain metastases
–Recurrent spinal metastases
–Menigiomas
–Pituitary adenomas
–AVMs
–Acoustic neuromas
–Spinal/paraspinal tumours
–Craniopharyngiomas
–Small, localised recurrences
–“Functional” radiosurgery (e.g. trigeminal neuralgia etc.)
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The Royal Marsden
Cyberknife - Skull
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The Royal Marsden
Cyberknife – brain metastasis
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The Royal Marsden
Cyberknife – Pituitary adenoma
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The Royal Marsden
Cyberknife – Ependymoma
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The Royal Marsden
Summary
– Glioblastomas are a rare tumour
– Treatment paradigms exist but MUST be tailored to
individual patients
– Clinical assessment is vital for treatment decisions
– Newer techniques in radiotherapy available and
applicable in specific indications
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The Royal Marsden
Acknowledgement
Radiotherapy Department
The Royal Marsden NHS Foundation Trust
Joint Department of Physics
Institute of Cancer Research
Cancer Research UK
Children’s Cancer Unit
NHS Executive