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Presented By: Dr. Vandana  Deptt. of Radiotherapy CSMMU, Lucknow
Introduction ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Origin ,[object Object],[object Object],[object Object],[object Object]
Anatomy ,[object Object],[object Object],[object Object],[object Object],Relevant Neuroanatomy
CSF Pathways ,[object Object],[object Object],[object Object],[object Object],[object Object],Lateral Ventricle Foramen of Munro Third Ventricle Foramen of Luschka Foramen of Magendie Central canal of Spinal Cord Subarachnoid Space
Epidemiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Figure:  Distribution of pediatric central nervous system (CNS) tumors by location in the CNS and by tumor type.
Adult vs. Paediatric Medulloblastoma Child Adult Usual age ~ 4 - 8 yrs Median age ~ 24 - 30 yrs Shorter clinical History (~ 3 months) Longer history ( ~ 5 months) Classical type predominates Desmoplastic type relatively commoner Median cerebellar syndrome predominates Lateral cerebellar syndrome seen Biologically more agressive Biologically less aggressive Poorer resectability - median location Greater resectability - lateral location Higher surgical morbidity and mortality Lower surgical morbidity and mortality - impact of location and age Poorer RT tolerance Better RT tolerance Poorer long term survival Better long term survival
Natural History Arising in the midline cerebellar vermis (roof of the 4 th  ventricle) Grows into the 4 th  ventricle Fills into the 4 th  ventricle Spread around the 4 th  ventricle Invasion of ventricular floor Invasion of brain stem Invasion of brachium pontis CSF Spread Extra neural spread :Y oung age, males and diffuse subarachnoid disease
Mode of Spread ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Pathological Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],WHO classification  -  2007  large cell / anaplastic (LCA) 10% to 22%.
[object Object],[object Object],classic medulloblastoma medulloblastoma with extensive nodularity
[object Object],[object Object],[object Object],[object Object],large cell medulloblastoma  anaplastic medulloblastoma
Chang Surgical classification 1969  T1 Tumour < 3 cm in diameter and limited to classic position in vermis, roof of fourth ventricle, or cerebellar hemisphere T2 Tumour > 3 cm in diameter and further invading one adjacent structure or partially filling the fourth ventricle T3a Tumour further invading two adjacent structures or completely filling the fourth ventricle, with extensions into aqueduct or foramina of Magendie or Luschka with marked internal hydrocephalus  T3b Tumour arising from the floor of fourth ventricle or brain stem  and filling the fourth ventricle T4 Tumour penetrates aqueduct to involve third ventricle or midbrain or extends to cervical cord No N Stage  M0 No metastases M1 Microscopic evidence of tumour cells in CSF. M2 Macroscopic metastases in cerebellar and/or cerebral subarachnoid space and/or supratentorial ventricular system M3 Macroscopic metastases to spinal subarachnoidal space M4 Metastases outside the central nervous system
Clinical Features ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Diagnostic Work up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Confirmation of diagnosis ,[object Object],[object Object],Resection of tumor VP Shunting + Biopsy High dose steroids +  Neuro radiological examination Patient stable Medulloblastoma Histopathological examination Patient extremely somnolent
Neuro Radiological examination CT finding ,[object Object],[object Object],[object Object],[object Object],Fig: A,  Axial noncontrast CT image demonstrates a large lobulated hyperdense round tumor ( arrow ) with an internal hypodense cavity. An ill-defined faintly hypodense band surrounding the hyperdense mass represents white matter edema.
MRI features : MRI is the gold standard. ,[object Object],[object Object],[object Object],[object Object]
Fig:  ( B, ) non-contrast axial T1-weighted  (C,)  T2-weighted MR images; the solid portion of the tumor appears mildly hypointense on T1-weighting and mildly hyperintense on T2-weighting ( arrow ). Following intravenous gadolinium, an axial T1-weighted image  ( D, ) demonstrates irregular patchy contrast enhancement of the solid areas of the tumor ( arrow ).
Adult Medulloblastoma ,[object Object],[object Object],Fig:  ( A,)  Axial T2-weighted MR image demonstrates a poorly circumscribed mass with a heterogeneous signal pattern in the anteroinferior portion of the right cerebellar hemisphere. ( B,)  After intravenous administration of gadolinium, the tumor demonstrates homogeneous contrast enhancement with well-circumscribed margins ( arrow ). Punctate intratumoral hypointensities represent enlarged vascular channels and/or focal calcifications.
Spinal MRI ,[object Object],[object Object],[object Object],[object Object],[object Object]
Advantage of MRI over CT ,[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object]
Risk Factor ,[object Object],[object Object],[object Object],[object Object],[object Object],Risk Factor Standard Risk  High Risk Age > 3 yrs. < 3 yrs Residual Tumor < 1.5 cm 2  (Complete or near total resection) > 1.5 cm 2  (subtotal or biopsy) Mets M 0  M 1  - M 4
Treatment ,[object Object]
Surgery ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ventriculoperitoneal Shunt ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RADIOTHERAPY  ,[object Object],[object Object],[object Object],[object Object],[object Object]
Cont… ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
PLANNING STEPS ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Patient position  ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Immobilization method ,[object Object],[object Object],[object Object],[object Object]
Different RT techniques for CSI ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
German Helmet Technique ,[object Object],[object Object],[object Object],[object Object]
Field Arrangements ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],In Medulloblastoma nearly 15-20% of recurrences occur at cribriform plate site which is attributed to overzealous shielding ,because of its proximity to ocular structure it often get shielded.
SPINAL FIELD  ,[object Object],[object Object],[object Object],[object Object],[object Object],SSD technique Gantry Angle = 0  degree IMP point is length and depth of spinal fields. Field of approx.4–6 cm wide box over the spinal cord/vertebral bodies  extends from  C2 –S2 .
Post fossa boost ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
TECHNIQUES OF MATCHING CS FIELDS ,[object Object],[object Object],[object Object],[object Object]
Collimator Couch rotation  ,[object Object],[object Object],[object Object]
Collimator rotation :  While treating cranial field rotate Collimator of lateral field so that its inferior border is parallel to divergence of sup. Aspect of spinal field . θ Collimator rotation allows cranial field to match spinal field divergence Coll θ  = arc tan ( L1 /2 x SSD ) For Co 60  SSD = 80 Zone of overlap of spinal field if collimator rotation is not applied in cranial field SSD L1
[object Object],[object Object],[object Object],[object Object],[object Object],COUCH ROTATION Fig:  Rotation of the couch toward the gantry is necessary to match the caudal margin of the lateral cranial fields with the cephalad margin of the posterior spinal field. 
COUCH ROTATION Couch θ  = arc tan ( L2/2 x SAD ) For Co 60  SAD = 80 L2  ( Length of  cranial field) Cranial field SAD Zone of overlap Spinal field Couch rotation during treatment of cranial  field θ
Disadvantage of Couch Collimator rotation ,[object Object],[object Object]
[object Object],[object Object],Figure:  This figure illustrates a potential complication of the craniospinal setup. A couch angle on the lateral cranial fields can cause the contralateral temporal lobe to be underdosed
Half Beam Blocking Actual Field Length Spinal field
Moving junction in CSI ,[object Object],[object Object],[object Object],[object Object],“ Feathering” refers to movement of the junction of the two fields across the treatment length.
Aligning Spinal field ,[object Object],[object Object],[object Object],[object Object],[object Object]
Fixed or calculated gap spinal fields ,[object Object],Cold Spot Hot Spot SSD 2 SSD 1 L2 S L1
Double junction techniques ,[object Object],[object Object],[object Object],Upper Spine Lower Spine Day of Planning Upper Spine Lower Spine Day 1 : The upper spinal field is shortened Upper Spine Lower Spine Day 2:  The lower spinal field is shortened Junction on D 1 Junction on D 2
RADIATION TOXICITY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],LATE TOXICITY Spinal cord Chronic progressive myelitis Brain  Radiation necrosis Intellectual deficit Lens of eye  Cataract formation Retina  Radiation retinopathy Optic nerve  Optic neuritis Inner ear  Sensorineural hearing loss  Hypothalamic-pituitary axis Endocrinopathies ( hypothyroidism and decreased growth hormone secretion) Secondary Malignancy
CHEMOTHERAPY ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Chemotherapy regimen ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Follow up ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Recurrence ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
RECENT ADVANCES ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
Ongoing Trials ,[object Object],[object Object],[object Object]
Summary ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]
[object Object]

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Diagnosis, Treatment & Management of Medulloblastoma

  • 1. Presented By: Dr. Vandana Deptt. of Radiotherapy CSMMU, Lucknow
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  • 7. Adult vs. Paediatric Medulloblastoma Child Adult Usual age ~ 4 - 8 yrs Median age ~ 24 - 30 yrs Shorter clinical History (~ 3 months) Longer history ( ~ 5 months) Classical type predominates Desmoplastic type relatively commoner Median cerebellar syndrome predominates Lateral cerebellar syndrome seen Biologically more agressive Biologically less aggressive Poorer resectability - median location Greater resectability - lateral location Higher surgical morbidity and mortality Lower surgical morbidity and mortality - impact of location and age Poorer RT tolerance Better RT tolerance Poorer long term survival Better long term survival
  • 8. Natural History Arising in the midline cerebellar vermis (roof of the 4 th ventricle) Grows into the 4 th ventricle Fills into the 4 th ventricle Spread around the 4 th ventricle Invasion of ventricular floor Invasion of brain stem Invasion of brachium pontis CSF Spread Extra neural spread :Y oung age, males and diffuse subarachnoid disease
  • 9.
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  • 13. Chang Surgical classification 1969 T1 Tumour < 3 cm in diameter and limited to classic position in vermis, roof of fourth ventricle, or cerebellar hemisphere T2 Tumour > 3 cm in diameter and further invading one adjacent structure or partially filling the fourth ventricle T3a Tumour further invading two adjacent structures or completely filling the fourth ventricle, with extensions into aqueduct or foramina of Magendie or Luschka with marked internal hydrocephalus T3b Tumour arising from the floor of fourth ventricle or brain stem and filling the fourth ventricle T4 Tumour penetrates aqueduct to involve third ventricle or midbrain or extends to cervical cord No N Stage M0 No metastases M1 Microscopic evidence of tumour cells in CSF. M2 Macroscopic metastases in cerebellar and/or cerebral subarachnoid space and/or supratentorial ventricular system M3 Macroscopic metastases to spinal subarachnoidal space M4 Metastases outside the central nervous system
  • 14.
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  • 20. Fig: ( B, ) non-contrast axial T1-weighted (C,) T2-weighted MR images; the solid portion of the tumor appears mildly hypointense on T1-weighting and mildly hyperintense on T2-weighting ( arrow ). Following intravenous gadolinium, an axial T1-weighted image ( D, ) demonstrates irregular patchy contrast enhancement of the solid areas of the tumor ( arrow ).
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  • 44. Collimator rotation : While treating cranial field rotate Collimator of lateral field so that its inferior border is parallel to divergence of sup. Aspect of spinal field . θ Collimator rotation allows cranial field to match spinal field divergence Coll θ = arc tan ( L1 /2 x SSD ) For Co 60 SSD = 80 Zone of overlap of spinal field if collimator rotation is not applied in cranial field SSD L1
  • 45.
  • 46. COUCH ROTATION Couch θ = arc tan ( L2/2 x SAD ) For Co 60 SAD = 80 L2 ( Length of cranial field) Cranial field SAD Zone of overlap Spinal field Couch rotation during treatment of cranial field θ
  • 47.
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  • 49. Half Beam Blocking Actual Field Length Spinal field
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Editor's Notes

  1. medulloblastoma 09/30/11 Csi