Tumors of the Brain and Spine Joe Hlavin PA-C, MS Texas Brain and Spine Institute Bryan, TX firstname.lastname@example.org
Introduction/Bio US Navy – Corpsman – 1984 to 1989 Cuyahoga Comm College – 1991 – surgical PA ◦ Went right into private practice neurosurgery 22 years of neurosurgery experience BS in Education – BGSU MS in Organizational Learning – TAMU PhD Student - Organizational Design - TAMU Designer & director of the TAMHSC/TBSI Postgraduate PA Residency in Neurosurgery
Objectives• For this lecture: • Review of the normal brain and spine anatomy and physiology, including CT and MRI • Review neurological exam • Discuss selected intracranial and intraspinal lesions • Provide current treatment schemes • Discuss reasoning for treatment decisions • Case studies
Spinal Cord• Understanding the medullary component • Simply – relay station for input and output of transmissions • Important to know: • Medial to lateral IS: • Cervical to Sacral
Spinal Cord• Focusing for function • Keys • Ascending – sensory • Lesions are not as easily identified due to subjective nature • Descending – motor • Easier to find level due to objectiveness of the exam
Lesion Types• Benign • Non-aggressive but can be devastating based on size and location • Meningioma is most common – ARISE FROM? • less common • Neuromas – acoustic • Dermoid • Pituitary adenomas
Lesion types• Metastatic • The primary cancer: lung, breast, colon, kidney, or skin (melanoma), but can originate in any part of the body
Malignant lesions Glial tumors• World Health Organization grading (WHO) scale ASTROCYTOMAS, I – VI • Grade – I – e.g. Pilocytic and Subependymomas • Grade – II – low grade astrocytoma and oligodendrocytoma • Grade – III – medium, anaplastic astrocytoma • Grade – VI – high, Glioblastoma Multiforme (GBM)
Examples• Four different astrocytic lesions, four different looksSub-ependymoma GBM – grade VI Oligodendroglioma Anaplastic astrocytoma
Cerebellar Lesions• Very similar to CEREBRAL lesions• Have increased risks with compression of essential component of CSF drainage• Primarily noted in children, e.g. medulloblastoma, PNET (prim. neuroecto. Tumor)• Will present in adults as astrocytoma and cystic• Common area for metastatic seeding
General Descriptions for Brain and Spinal Lesions• For the brain • Extra-axial • Intra-axial• For the spinal cord • Extra-dural vs. Intra-dural • Extra-medullary vs. Intra-medullar• For both • Non-enhancing vs. enhancing (MRI)
General Descriptions for Brain and Spinal Lesions• Location, location, location • For the brain • What lobe? Size? Edema? Shift? Obstructive? • For spinal cord • What level? Size? Syrinx? • Lesion consistency PA circa 1989 • Heterogenous vs. homogenous • Ring enhancing (w/ cyst) vs. diffuse enhancement
Neuro Exam• Tenets of the approach to the NS patient • DO NOT BELIEVE ANYONE ELSES EXAM – • DO YOUR OWN • LOOK at the studies yourself, NOT just the report • SEE the patient as MORE THAN the studies
Neuro exam• The mental status • “normal” or “Sleeping” is not a good descriptor. Use: • Awake/alert/talking • Less than alert – obtunded • Unresponsive – comatose, stupor • In this case, give the Glasgow Coma Scale as descriptor
Neuro exam• Glasgow Coma Scale • Eyes – 4, spontaneous, 3, to voice, 2, to pain, 1, none • Motor – 6, obeys, 5, localizes, 4, w/drawls, 3, flexion response, 2, extension to pain, 1, none • verbal – 5, oriented, 4, confused, 3, inappropriate words, 2, incomprehensible words, 1, none• PEARL – if pt is brought in by EMS – GET THE GCS NOTED AT THE SCENE• Remember, everything has a GCS – even a rock has a GCS of 3
Neuro exam• Cranial nerves • LOOK AT THE EYEs • Symmetry – light response, movements, gaze pref • LOOK AT THE FACE • Symmetry – right = left, pay attention to motor • LOOK IN THE MOUTH • Symmetry – tongue and pharynx
Neuro exam• Motor exam • Abbreviated evaluation • Look for: (KEEP IN MIND – Right cortex = left body) • Right vs. left strength – if equal then • Check individual groups – start with upper extremities • Keep level of any deficit in mind • example: bilateral weakness from biceps down = C6 level
Neuro exam• Reflexes • Know the difference between UMN and LMN reflex changes
Neuro exam• Upper motor neuron reflexes• Cranial nerve reflexes are considered normal and loss of reflex is concerning – e.g. pupillary response • Primitive Reflexes – found in newborns, but can present in patients with neurological disease due to loss of blunting of reflexes.• Hyper-reflexia and ankle clonus – unsustained/sustained• Babinski Reflex – blunted by myelination of SC• Hoffman Reflex – blunted also
Neuro exam• Lower motor neuron reflexes • Spinal reflexes • Relay station in the medullary cord • E.g. knee jerk, triceps jerk • Loss: indicative of root irritation/compression, e.g. HNP, tumor • May be associated with motor group deficit
Neuro exam• Cerebellar exam • Coordination • Rapid movements • Finger-to-nose• KEEP IN MIND – RIGHT cerebellum = RIGHT body • Docusates twice – once at peduncle and then medulla
Treatment• Initial treatment plan – generally speaking • Dependent on the patient presentation and clinical status • Steroids – Decadron • H2 blocker du jour • Admission to hospital for continued treatment, w/u, and neurosurgical consultation (UNLESS THAT IS YOU)
Treatment• The treatment is based on clinical exam, age, comorbidities, and patient’s/family’s wishes – KNOWING risk/complications and outcomes.• Benign lesions can be followed, treated with surgical decompression (if clinically warranted), and/or radio-surgical techniques, e.g. Gamma knife, Linear accelerator, etc.
Treatment• Metastatic Lesions • Based on original lesion, location, and clinical picture • Surgical resection for symptomatic lesions AND diagnosis • Also based on surgical safety • Some metastatic lesions are very hemorrhagic – risk outweighs reward
Treatment - Survival• Astrocytomas • Grade I – surgery based on clinical picture, location, and risk but considered benign and can be followed with serial MRIs for growth. Stereotactic bx can also be considered or even total resection • Survival is quite acceptable and may have complete remission after surgical removal • Grade II – Same as above but consider the incidence of conversion to more aggressive lesion. • Can consider serial MRIs, bx, surgical resection. Survival based on diagnosis
Treatment - Survival• Astrocytomas • Grade III – these are considered malignant and are likely to convert to higher grade. Clinic picture likely to require surgical intervention. • Gross total resection, radiation therapy, possible include chemotherapy – Tamodar • Survival is tenuous based on lesion type, resection, and response to treatment
Treatment - Survival• Astrocytomas • Grade VI – most aggressive, Glioblastoma Multiforme, high mitotic changes, low percentage of overall cancers in the US but very devastating. • Best quality of life, ~ one (1) year, is w/ gross total resection, radiation, and Tamodar • Other treatments have been, or are being, studied: • Gene therapy • Immunotherapy • Novel delivery methods
Case Studies• 22 y/o WM presents to the ER with focal RUE seizures• No prior history – very healthy• Student at local university• Exam – mild “drift” of the RUE and ? Mild weakness, no UMN findings, gait not tested• Next step?
Case 1• Notify the NS service – UNLESS that’s you• Admit to the hospital• Start steroids• Start Dilantin• Order MRI w/ GAD
Case 1 DescribeIs this extra-axial, intra-axial, infiltrative, edematous?
Case 1• Next treatment course?• Surgery?• Watch?• Medicine?• Other studies?
Case 1• What we did: • Continued the steroids and Dilantin • Family discussion and surgical planning as outpatient • Craniotomy for biopsy and debulking • Initial postoperative course was uneventful • Awaited final diagnosis
Case 1• Final Diagnosis • Glioblastoma Multiforme • High grade lesion – aggressive• Oncology and radiation therapy involved• Family made one trip to MD Anderson for second opinion• Started treatment – We will be following up this month
Case 2• 30 y/o female presented to outlying clinic with progressive thoracic pain – ONLY• No significant PMHx• Exam was essentially normal• What would be your initial study if conservative medical treatment failed?
Case 2 Describe this MRI of the Thoracic spine w/ Gadolinium:Level?Extra-dural?intra-dural?extra-medullary?Intra-medullary?Enhancing?
Case 2• What we did: • Surgical discussion with patient and husband • Remember that patient’s only problem was pain • Thoracic laminectomy for partial resection and biopsy • Steroid treatment in post op phase • Stable post op exam w/ minor sensory changes
Case 2• Final diagnosis • Ependymoma – Grade II • High likelihood of future neurological dysfunction • Completed radiation treatment and first post radiation MRI was stable – exam also stable • Due for f/u with new MRI of the Tspine
Case 3• 63 y/o BM presented after struck in the head and pelvis by a toolbox• w/u by ER and trauma service was, initially, just the abd and pelvis• Head CT done as inpatient to complete work up• No neurological complaints or exam findings
Case 3• This is what we did: • Discharged from hospital after recovery from pelvic injury • Took to surgery for craniotomy and excision of the tumor • Excellent postoperative course with discharge w/ in 3 days to home – no loss of function
Case 3• Diagnosis • Meningioma – benign lesion – total resection with attachment to the dura upon entry • No need for aggressive post op treatment • Follow up MRI in 6 months • Return to normal activity
Case 4 – Last one• 50 y/o WF well known to our practice with multiple intracranial CAVERNOMAs• In 2008, developed new symptoms of neck and arm pain that progressed to gait instability• Her exam fits with parasthesias and UMN findings in extremities• What is the next step? Medications, studies?
Wrap up• Tumor types of the CNS are numerous but are categorized for description, correlation to clinical picture, and treatment strategies• Current imaging techniques are quite useful in identifying and predicting CNS lesions• Take the time to gather a history, obtain your own exam, and look at the actual studies (use the radiology report as reference)
Wrap up• The clinical picture of the patient upon presentation coupled with the studies is paramount to the development of a treatment strategy• Studies and new treatments of aggressive CNS lesions, e.g. GBMs, remain at the forefront of cancer research• Finally, all of you should endeavor to be neurosurgical PAs