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

2. Brain tumors 72 male 72 male HPI: presents to E.R. with history of confusion, change of personality, left sided H/A HPI: presents to E.R. with history of confusion, change of personality, left sided H/A P/E: disorientation and aggressiveness, no focal signs P/E: disorientation and aggressiveness, no focal signs Labs: WNL Labs: WNL Imaging: Imaging:

3. Brain tumors

4. anatomy anatomy

5. Brain tumors

8. DDx: DDx: Benign Benign Congenital Congenital AVM/aneurism AVM/aneurism Acquired Acquired Infectious (toxoplasmosis, cyst) Infectious (toxoplasmosis, cyst) stroke stroke Malignant Malignant Primary Primary metastatic metastatic

9. Brain tumors Glioblastoma multiforme Glioblastoma multiforme Astrocytoma Astrocytoma Oligodendroglioma Oligodendroglioma Meningioma Meningioma Brain stem tumors Brain stem tumors Medulloblastoma Medulloblastoma Ependymoma Ependymoma Sarcoma Sarcoma Lymphoma Lymphoma Craniopharyngioma Craniopharyngioma Neurofibroma Neurofibroma Germ cell tumors Germ cell tumors Schwannoma Schwannoma Pituitary tumors Pituitary tumors meningioma meningioma

10. Brain tumors Metastases Metastases Single Single Multiple Multiple

11. Brain tumors

12. Brain tumor

13. Brain tumors

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

15. Brain tumors

17. GBM Radiation therapy Radiation therapy Standard dose: 60 Gy / 30 fractions Standard dose: 60 Gy / 30 fractions O.S. = 42 weeks (1979 study) O.S. = 42 weeks (1979 study) Radiation therapy + chemotherapy Radiation therapy + chemotherapy Meta analysis shows improvement in general Meta analysis shows improvement in general

18. GBM Best results to date: Best results to date: Combination with temozolomide Combination with temozolomide 75 mg/m2 po od x 6 weeks (concurrent with xrt), then 150 mg/m2 po od on d1-5 every 28 days x 6 cycles 75 mg/m2 po od x 6 weeks (concurrent with xrt), then 150 mg/m2 po od on d1-5 every 28 days x 6 cycles RTRT/TMZ Median OS (months) 12.114.6 2 yr survival 10%26%

19. GBM If poor performance status If poor performance status Hypofractionated xrt: Hypofractionated xrt: 40/15 40/15 35/10 35/10

20. Brain tumors 57 male 57 male HPI: known lung cancer; developped gait instability HPI: known lung cancer; developped gait instability P/E: cerebellar exam abnormal P/E: cerebellar exam abnormal Imaging Imaging

21. Brain tumors Cerebellar metastasis on CT scan Cerebellar metastasis on CT scan Management: Management: Supportive care Supportive care Decadron (10 mg stat, then 4 mg po QID) + PPI Decadron (10 mg stat, then 4 mg po QID) + PPI

22. Brain mets Depends on stability of peripheral disease and extend of intra cerebral disease: Depends on stability of peripheral disease and extend of intra cerebral disease: Peripheral disease stable: Peripheral disease stable: confirm solitary status with MRI confirm solitary status with MRI If solitary: If solitary: consider surgical resection or stereotactic radiosurgery consider surgical resection or stereotactic radiosurgery Whole Brain Radiation Therapy (WBRT) Whole Brain Radiation Therapy (WBRT)

23. Brain mets Surgery Surgery Diagnostic Diagnostic Quicker steroid taper Quicker steroid taper Quicker symptom relief Quicker symptom relief Limited by localisation Limited by localisation SRS SRS Non invasive Less risk Less expensive Limited by size Radioresistance Melanoma Sarcoma

24. Brain mets peripheral disease stable peripheral disease stable More than 1 lesion More than 1 lesion Surgery less of a consideration Surgery less of a consideration WBRT +/- stereotactic radiosurgery boost WBRT +/- stereotactic radiosurgery boost Criteria: Criteria: < or = 3 lesions < or = 3 lesions Volume: < 4 cm Volume: < 4 cm Prognostic > 3 months Prognostic > 3 months KPS >70 KPS >70

25. Brain mets Survival WBRT + SRS WBRT p value p value Overall6.55.70.13 1 met 6.54.90.04 1-3, age<50 9.98.30.04 1-3, NSCLC 5.93.90.05 1-3, RPA 11.69.60.05

26. Brain mets peripheral disease not stable peripheral disease not stable Palliative radiation therapy Palliative radiation therapy Re-irradiation on a case by case basis Re-irradiation on a case by case basis

27. Brain mets

28. Prognostic: Prognostic: Untreated: 1 month Untreated: 1 month Steroids: 2 months Steroids: 2 months

29. Brain mets Radiation therapy Radiation therapy KPS>70>70<70 Age<65>65 Primary control Yesno Mets Brain only Multi organ Survival7.14.22.3

30. Brain mets Side effects Side effects Alopecia Alopecia Skin erythema Skin erythema Fatigue Fatigue Neurocognitive changes Neurocognitive changes

31. Brain mets Single met Symptomatic,Resectable First/only met Surgery + WBRT Single met Little / no symptom Non resectable / surgery refused SRS + WBRT 2-3 mets, KPS>70 RPA 1, NSCLC, <50 yo SRS + WBRT 2-3 mets, KPS>70 None of favorable Px factors WBRT +/- SRS 4 mets, KPS>70 RPA 1, NSCLC, <50 yo WBRT +/- SRS

32. Brain mets Role of WBRT Role of WBRT Decrease rate of new mets (50% to 25%) Does not increase OS Some histologies have less distant failures (RCC, melanoma, sarcoma) No increase in toxicity (objectively) Subjective increase in toxicity Case where Dx is in doubt (meningioma)