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250 Fractionated Radiation Therapy for
Malignant Brain Tumors
Youmans Neurological surgery
13/09/2559
George M. Cannon
Min...
Outline
• Brain metastasis
• Malignant glioma
• Anaplastic Astrocytoma
• Anaplastic Oligodendroglioma
• Primary CNS lympho...
Brain metastasis
• Most common : lung, breast, melanoma
• Less common : primary tumors of the gastrointestinal tract and
g...
Fractionation Trials
Prognostic Factor analysis
Class I : KPS ≥ 70, Age ≤ 60, control primary and absence of extracranial metastasis
Class III ...
Prognostic Factor analysis
• 0-1 median survival time 2.6 months
• 1.5-2.5 median survival time 3.8 months
• 3 median surv...
Role of Adjuvant Whole-Brain Radiotherapy
no significant difference in overall survival between the two groups,
even thoug...
Side Effects of Whole-Brain Radiotherapy
• Acute side effect
• fatigue, hair loss, particularly along the midline and vert...
Reirradiation of Brain metastasis
• Aggressive, primary treatment interventions to provide durable local
control is obviou...
Summary
• 30 Gy in 10 fractions given over 2 wks
Glioblastoma multiforme
• Diffusely infiltrative the brain parenchyma
• Can’t complete microscopic surgical excision
• Gra...
Utility of radiation therapy
Compare mithramycin vs surgical alone
; no differ in mithramycin use
Post-operative carmustin...
Radiation Target Volume
• Planned target volume 1 (PTV1)
• the contrast-enhancing lesion,
• resection cavity
• surrounding...
Recurrence Patterns
• The recurrent tumor that surpassed the outside surface of the PTV
was still predominantly centered w...
Dose Escalation
Prognostic Factor Analysis
Prognostic Factor Analysis
Methylguanine-deoxyribonucleic acid methyltransferase (MGMT) methylation has
also proved to be ...
Anaplastic Astrocytoma
• Grade III astrocytoma
• Median survival in the 2- to 3-year range
• Partial brain fields
• GTV(Gr...
Anaplastic Oligodendroglioma
• Chemotherapy potentially improves PFS, but the effect on survival is
not statistically obvi...
Primary central nervous system lymphoma
• lymphoma confined to the CNS
• Dissemination through the craniospinal axis
• Rad...
Malignant Meningeal Tumors
• Hemangiopericytoma
• Slow but progressive radiographic response to ionizing radiation
• Signi...
Primitive Neuroectodermal Tumors
• sheets of small round blue cells with scant cytoplasm
• supratentorial PNET, pineoblast...
Primitive Neuroectodermal Tumors
• Craniospinal RT at recommended doses of 36 Gy to the craniospinal
axis and a posterior ...
Germ Cell Neoplasms
• CNS germinomas have been managed with craniospinal RT
• Nongerminomatous germ cell tumors of the CNS...
Complication
• Acute : occur during and immediately after completion of a course of
external beam
• Acute skin reaction : ...
Complication
• Subacute : several week of month after complete RT
• Lethargy and somnolence
• Children : acute somnolence ...
Complication
• Late complication : several month to years
• Unclear because short-term survivor
• Impairment of intellectu...
250 Fractionated radiation therapy for malignant brain tumors
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250 Fractionated radiation therapy for malignant brain tumors

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Youmans Neurological Surgery

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  • We are a Brain Tumor Treatment Center and most of our treatment depends on a number of factors including the type, location and size of the tumor as well as the patient's age and general health. The Treatment methods may vary and at Primus Hospital we provide treatment for both benign and non benign tumor. Visit - http://www.primushospital.com and Call 9953722892
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250 Fractionated radiation therapy for malignant brain tumors

  1. 1. 250 Fractionated Radiation Therapy for Malignant Brain Tumors Youmans Neurological surgery 13/09/2559 George M. Cannon Minesh P. Mehta
  2. 2. Outline • Brain metastasis • Malignant glioma • Anaplastic Astrocytoma • Anaplastic Oligodendroglioma • Primary CNS lymphoma • Malignant meningeal tumor • Primitive Neuroectodermal Tumors • Germ Cell Neoplasms
  3. 3. Brain metastasis • Most common : lung, breast, melanoma • Less common : primary tumors of the gastrointestinal tract and genitourinary system, lymphomas, sarcomas, and prostate cancer • Median survival time of untreated patients with brain metastases is approximately 1 month
  4. 4. Fractionation Trials
  5. 5. Prognostic Factor analysis Class I : KPS ≥ 70, Age ≤ 60, control primary and absence of extracranial metastasis Class III : KPS < 70
  6. 6. Prognostic Factor analysis • 0-1 median survival time 2.6 months • 1.5-2.5 median survival time 3.8 months • 3 median survival time 6.9 months • 3.5-4.0 median survival time 11 months
  7. 7. Role of Adjuvant Whole-Brain Radiotherapy no significant difference in overall survival between the two groups, even though the study was not powered to detect a survival difference
  8. 8. Side Effects of Whole-Brain Radiotherapy • Acute side effect • fatigue, hair loss, particularly along the midline and vertex, erythema, and otitis • Months to years side effect • Impairment of neurocognitive function • Survived longer than 1 yrs • Neurotoxicity with progressive dementia, ataxia and urinary incontinence • Neurocognitive function factor • presence of brain metastases, neurosurgical interventions, chemotherapy, and other neurotoxic therapies such as steroids and anticonvulsants
  9. 9. Reirradiation of Brain metastasis • Aggressive, primary treatment interventions to provide durable local control is obviously preferable to being backed into this unfortunate situation of recurrent intracranial disease with limited treatment options.
  10. 10. Summary • 30 Gy in 10 fractions given over 2 wks
  11. 11. Glioblastoma multiforme • Diffusely infiltrative the brain parenchyma • Can’t complete microscopic surgical excision • Grade IV
  12. 12. Utility of radiation therapy Compare mithramycin vs surgical alone ; no differ in mithramycin use Post-operative carmustine(BCNU) ; WBRT improve survival Post-operative semustine(MeCCNU) ; MeCCNU infeior GBM surgical resection with or without RT ; improve in WBRT
  13. 13. Radiation Target Volume • Planned target volume 1 (PTV1) • the contrast-enhancing lesion, • resection cavity • surrounding edema if present (best seen on T2-weighted images) • followed by a 2.0-cm expansion • Planned target volume 2 (PTV2) • After 46 Gy of radiation • the contrast-enhancing lesion with a 2.5-cm expansion
  14. 14. Recurrence Patterns • The recurrent tumor that surpassed the outside surface of the PTV was still predominantly centered within the tumor bed • Central or in-field
  15. 15. Dose Escalation
  16. 16. Prognostic Factor Analysis
  17. 17. Prognostic Factor Analysis Methylguanine-deoxyribonucleic acid methyltransferase (MGMT) methylation has also proved to be a powerful predictor of survival in patients receiving RT and TMZ
  18. 18. Anaplastic Astrocytoma • Grade III astrocytoma • Median survival in the 2- to 3-year range • Partial brain fields • GTV(Gross total volume) : hypodense edema or T2 abnormality, contrast-enhancing volume • CTV(Clinical target volume): 2- to 3-cm margin of tissue surrounding the GTV. • The initial volume is typically treated to 46 Gy and the boost volume to 60 Gy • Median survival decreased with more aggressive therapy • RT + CMT did not achieve better compare with RT alone
  19. 19. Anaplastic Oligodendroglioma • Chemotherapy potentially improves PFS, but the effect on survival is not statistically obvious • Patients with 1p and 19q deletions had significantly better outcomes • MGMT promoter methylation : TMZ
  20. 20. Primary central nervous system lymphoma • lymphoma confined to the CNS • Dissemination through the craniospinal axis • Radiosensitive tumor • 40-50 Gy total • Chemotherapy • Younger than 60 yrs,better prognois
  21. 21. Malignant Meningeal Tumors • Hemangiopericytoma • Slow but progressive radiographic response to ionizing radiation • Significant metastasis : liver, lung, bone and soft tissue • Effetiveness is dubious [Greenberg] • Malignant meningioma • Aggressive surgical resection followed by postoperative high-dose RT • 5 Yr survival less thans 20% • GTV : expan 1.5-2 cm. • 55-60 Gy [Greenberg]
  22. 22. Primitive Neuroectodermal Tumors • sheets of small round blue cells with scant cytoplasm • supratentorial PNET, pineoblastoma, medulloblastoma, and ependymoblastoma • “standard risk” or “high risk” • age, Chang M stage, location, and extent of resection • Standard-risk patients : • Chang M0 stage disease (no evidence of microscopic or macroscopic dissemination along the craniospinal axis) • posterior fossa origin • age older than 3 years • less than 1.5-cm2 tumor residual after surgery
  23. 23. Primitive Neuroectodermal Tumors • Craniospinal RT at recommended doses of 36 Gy to the craniospinal axis and a posterior fossa boost to 54 Gy • 35-40 Gy to whole craniospinal axis + 10-15 Gy boost to tumor bed(usually posterior fossa) [Greenberg] • Combination chemotherapy given with craniospinal RT continues to be pursued
  24. 24. Germ Cell Neoplasms • CNS germinomas have been managed with craniospinal RT • Nongerminomatous germ cell tumors of the CNS, survival is significantly poorer, and both surgical resection and chemotherapy are the primary modalities of treatment
  25. 25. Complication • Acute : occur during and immediately after completion of a course of external beam • Acute skin reaction : dry desquamation, erythema • Temporary alopecia • Fatigue • Flash of light • Serous otitis media • Uncommon : Nausea, increase intracranial hypertension
  26. 26. Complication • Subacute : several week of month after complete RT • Lethargy and somnolence • Children : acute somnolence syndrome • N/V, ataxia, dysphagia, cerebellar ataxia • Keratoconjunctivitis • Radiation necrosis : PET or MRS
  27. 27. Complication • Late complication : several month to years • Unclear because short-term survivor • Impairment of intellectual function : memory and mathmetical ability • Dementia, ataxia, confusion

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