Management Overview of Meningioma Pituitary adenoma Spinal cord tumours

1. Management overview of Meningioma,
Pituitary gland and Spinal cord tumours
By – Dr Satyajeet Rath
Guided by – Prof Kamal Sahni
Dt – 20/04/2017

2. Meningioma

3. Meningioma
 Meningiomas: MC primary intracranial tumours.
 majority are benign, with about 1%-3% classified as malignant
 98% are intracranial but may arise anywhere in central nervous system
 Classified into grades : WHO grade I,II and III : On the basis of local invasiveness
and cellular features of atypia.
 Histological verification is not mandatory in all cases
 Originates from arachnoid cap cells
 Incidence increases with age, More common in females
 40% and 80% of meningiomas contain an abnormal chromosome 22 (22q12.2)
 NF type 2 :Multiple meningiomas
 Express ER (40%)/PR(70%) +ve , may grow faster in pregnancy

4. Supratentorial – 85-90%
Infratnetorial – 5-10%
Extradural <1%

5. MRI
• MRI is preferred , as it is superior in demonstrating dural origin, as well as
vascularity, edema, sinus and bone invasion.
• Present as solitary round tumours, with close contact to the duramater and strong
enhancement with contrast.
• Thickening of the duramater at the perimeter of the tumour (so-called dural tail) is
displayed by T1 with gadolinium.
• Isointense or hypointense to gray
matter on T1.
• Isointense or hyperintense on T2
weighted images.
• Areas of necrosis and calcification
do not enhance

6. Meningioma of the
right convexity
with typical
radiological signs
(A) Bone window of
the cerebral CT scan
in coronal view
showing hyperostosis
facing the tumour
(arrow). (B) Cerebral
MRI (fluid-attenuated
inversion recovery)
showing the tumour
slightly hyperintense.
The oedema of the
parenchyma adjacent
to the tumour is shown
by the arrow. (C) T2
sequences in coronal
view showing
cerebrospinal fluid
(arrows) interposed
between tumour and
parenchyma, showing
the extra-axial nature
of the tumour. (D) T1-
weighted MRI after
gadolinium injection
depicting intense
enhancement of the
tumour. The arrow
shows the large
contact of the tumour
with the dura mater
and the thickening of
the adjacent dura
mater

8. Treatment Options
• MC intracranial tumours BUT the level of evidence to provide
recommendations for the diagnosis and t/t is low compared with other tumours
such as HGG
• Surgery
– Objective: total removal of the meningioma, dural attachment and bone involved
with the tumor
– Priority: preserve and improve neurological function
• Radiotherapy
– Indications:
• Residual tumor left at operation
• Recurrence
• Tumors could not be treated surgically
• Malignant histology
The available treatment
modalities are-
Observation Surgery Radiotherapy Chemotherapy

9. Management outline
EANO 2016 Recommendations

10. Simpson Grade of Resection

11. Observation
• Asymptomatic patients with little or no edema in the adjacent brain
areas
• Patients with mild or minimal symptoms
• Patients in whom treatment carries a significant risk

12. Meningioma Grade 1 – Role of Sx
• Asymptomatic: Observation (6 monthly to annually: Clinical examination
and MRI )
• Imaging strongly S/O Meningioma => Histological verification is not
mandatory.
• However, exclusion of rare differential diagnoses such as metastasis is
recommended
• Radiologically growth / clinical symptoms: Surgery is the First Choice
• Extent of resection should be confirmed by a postoperative MRI (within 48 h
after surgery / after 3 months to avoid artefacts)

13. Meningioma Grade 1 – Role of Radiotherapy
• Indications:
 Elderly patients (older than 65 years)
 Not safely accessible by surgery.
 Incomplete surgical resection
 SRS-for small tumours
Evidence**: 35 retrospective studies showed a 5-year progression-free survival of 86−100% after primary
stereotactic radiosurgery.
 Fractionated EBRT: 50−55 Gy given in doses of 1·8−2·0 Gy per fraction can be applied
(Evidence level III, Recommendation level B).
• **Rogers L, Barani I, Chamberlain M, et al. Meningiomas: knowledge base, treatment outcomes, and uncertainties.
• A RANO; review. J Neurosurg 2015; 122: 4–23.
• Radiotherapy with subtotal resection: is associated with disease control and
survival rates similar to those reported for gross total resection
• IMRT/ fSRT: to spare critical neurovascular structures surrounding the tumour and
to reduce the risk of long-term cognitive deterioration => similar disease control to
conventional radiotherapy.

14.  Surgery is the first choice of treatment.
 Should aim to achieve Simpson Grade I resection
• Role of adjuvant radiotherapy after partial resection??
 Adjuvant radiotherapy (54–60 Gy given in 1·8−2·0 Gy per fraction) should
be considered (evidence level III, recommendation level C)
Fractionated RT is preferred over SRS techniques
although SRS offers similar results for small tumours/ tumour residual
Meningioma Grade 2 – Role of Sx

15. • Role of adjuvant radiotherapy after gross complete resection?????
– ROAM/EORTC 1308 trial (ISRCTN71502099) : whether radiotherapy reduces the risk of or delays
tumour recurrence.
 Newly diagnosed Atypical Meningioma (WHO grade II)
 Gross total resection (Simpson grade I–III)
 early adjuvant radiotherapy (60 Gy in 30 fractions) vs. observation
• Role of adjuvant radiotherapy after partial resection??
 Adjuvant radiotherapy (54–60 Gy given in 1·8−2·0 Gy per fraction) should be
considered (evidence level III, recommendation level C)
Fractionated RT is preferred over SRS techniques
although SRS offers similar results for small tumours/ tumour residual
Meningioma Grade 2 – Role of Radiotherapy

16. Meningioma Grade 2 – Role of Chemotherapy
and targeted therapy
Retrospective studies and small prospective studies: (WHO grade II and III meningiomas)
o Hydroxycarbamide
o Cyclophosphamide/Doxorubicin/Vincristine chemotherapy,
o interferon-alfa,
o Megestrol acetate, Medroxyprogesterone acetate, Octreotide, Pasireotide (long-acting
release),
o Imatinib, Erlotinib, Gefitinib, Vatalanib, Sunitinib,
o Bevacizumab.
Most promising results for Bevacizumab, Vatalanib, and Sunitinib
EORTC phase 2 trial (NCT02234050): efficacy of TRABECTEDIN shown promising activity in
recurrent WHO grade II and grade III meningiomas.

17. Meningioma Grade 3
• Surgical resection:
– should be as radical as possible
• Adjuvant Radiotherapy: Fractionated
– Dose: at least 54 Gy 1·8−2·0 Gy fractions
– Dose:
– Complete resection: 54 Gy
– Incomplete resection: 6o Gy

18. Ongoing trials
RTOG 0539 trial (NCT00895622):
• WHO Grade II: RT with 54 Gy in 30 fractions after gross total resection
• High-risk meningioma (ie, WHO Grade II recurrent disease, WHO Grade II after
subtotal resection, and all WHO grade III) are receiving up to 60 Gy.
EORTC 22042-26042 trial (NCT00626730):
WHO Grade II and III after Gross Total resection: 60 Gy in 30 fractions
After subtotal resection: 60 Gy in 30 fractions followed by Boost 10 Gy in 5 fractions to
residual
- Results awaited

19. Spinal Meningioma
• Surgical resection: 1st Choice
• To remove the tumour and decompress the spinal cord is the therapy of choice
• If surgical resection not possible: SRS or hypofractionated RT
(recommendation level: good practice point)
• Adjuvant therapy is done according to WHO grade and resection.

20. Follow-up
 WHO grade I:
 First 5 years: Annually
 After 5 years: every 2 years.
 WHO grade II :
 First 5 years: Every 6 months
 After annually after 5 years
 WHO grade III :
 Every 3–6 months indefinitely

21. Radiotherapy
• Conventional radiation therapy
• Stereotactic radiosurgery
 Gamma Knife
 Cyber Knife
• Fractionated stereotactic radiosurgery
• Intensity-modulated radiation therapy (IMRT)

22. SRS
Kondziolka et al. (1999):
– 99 patients from U. Pittsburgh
– 43% SRS alone, 57% surgery + SRS
– median tumor margin dose 16 Gy, max dose 32 Gy, median tumor volume 4.7
cc.
• LC 93-95% ,PFS 90- 93% in both arms at 5–10-year.
Stafford et al. (2001):
– 190 patients from Mayo Clinic,
– 59% had prior surgery, 12% with atypical or malignant histology.
• Median tumor margin dose was 16 Gy. Median prescription isodose
volume was 8.2 cm3.
• Five-year LC for patients with benign, atypical, and malignant tumors
were 93, 68, and 0%, respectively.
• Five-year CSS for patients with benign, atypical, and malignant tumors
were 100, 76, and 0%, respectively.

23. • 628 patients (130 men and 498 women) - gamma knife radiosurgery for intracranial
meningioma,
• with single lesion meningioma, followed up after 6 months with imaging, and then
at 24 months with a clinical examination.
• The median patient's age was 56.8 years. Maximal dosage was 27.8 Gy and
marginal dosage was 13.9 Gy.
Results
• The overall tumor control rate was 95%.
• Twenty-eight patients (4.4%) showed evidence of tumor recurrence.
• Ninety-eight patients (15%) developed peritumoral edema (PTE) after gamma-knife
surgery; two of them (2%) underwent surgical resections due to PTE.
• Nine patients had craniotomy and tumor removal after gamma knife surgery.
Conclusion
• Gamma knife surgery for intracranial meningioma has proven to be a safe and
effective treatment tool with successful long-term outcomes.

24. Pituitary Tumours

25. Anatomy
• It is called the Master of endocrine
orchestra
• 15 mm in ant-post and 12 mm in
supero inferior axis
• It weighs about 0.5 gm.
• The pituitary gland occupies a
cavity of the sphenoid bone called
sella turcica
• Roof is formed by diaphragm sellae
• Floor – hypophyseal fossa
• On each side :The cavernous sinus
with its content
• The stalk of pituitary is attached
above to the floor of third ventricle

26. • Anterior and intermediate lobe
– Rathke’s pouch
• The posterior lobe or
neurohypophysis
– Downward pocketing of third ventricle.
• Posterior lobe
– Oxytocin and Vasopressin which are
synthesised in the supraoptic and
paraventricular nuclei in
hypothalamus
• Anterior lobe
– ACTH,TSH,GH,FSH,LH,Prolactin

27. Epidemiology
• Pituitary neoplasm account for 10% to 15% of diagnosed primary intracranial neoplasm
• 10% of healthy population has pituitary abnormality detected by MRI
• Approximately 70% are endocrinologically active
• 70% of adenomas present between the ages 30 -50 yrs
• Women have high incidence of pituitary adenomas(15-44 yrs)
• Incidence of macroadenomas is similar between males and females
• Annual incidence ranges from 0.5 to 0.7/100,000
• A genetic predisposition to develop adenomas has been described in
– MEN I syndrome
– Carney complex
– Isolated familial somatotropinomas(IFS)

28. Natural History
• Usually has a long natural history with an insidious onset of symptoms
• Symptoms are usually present for years prior to diagnosis
• When small pituitary tumour tends to be smooth round tumours
• Macroadenomas are known for their local invasive properties
• Malignant behaviour with distant metastases is rare

29. Hyperpituitarism
• HYPERPROLACTINEMIA
 Most common cause of pituitary hormone hypersecretion
 Amennorhoea
 Galactorrhoea
 Infertility
• INCREASED GH
 Acromegaly in adults
 Frontal bossing
 Increased hand foot size
 Mandibular enlargement,Prognathism
 Large fleshy nose
 Proximal muscle wasting,carpal tunnel syndrome,macroglossia
 Gigantism in children
• INCREASED ACTH
 Causes cushing syndrome
 Central obesity
 Plethoric moon facies
 Purple striae,increased bruisability
 Glucose intolerence
 Acne,hirsuitism
 Proximal muscle weakness
 Hypertension
 Amennorhoea,infertility

30. Hypopituitarism
• Growth hormone deficiency: Short stature(Dwarfism)
• Gonadotrophins deficiency: Infertility, decreased sexual functions ,loss
of secondary sexual characters, menstrual
irregularities
• TSH deficiency : Hypothyroidism
• ACTH deficiency :Hypocortisolism
• Prolactin deficiency :Lactation failure
• Vasopressin deficiency : Diabetes insipidus

31. FEATURES OF SELLAR MASS LESION
• PITUITARY
 Hypopituitarism
• OPTIC CHIASMA
 Bitemporal Hemianopia
 Superior temporal defect
• CAVERNOUS SINUS
 Ophthalmoplegia
 Ptosis
 Diplopia
• OTHERS
 Head ache
 Hydrocephalus
 Dementia

32. Diagnostic Work-up
 Detailed History and complete physical examination
 Confirmation of diagnosis
• Radiological Examination
MRI-preferred modality better visualisation of soft tissue and
vascular structure than CT Scan
• Biopsy –In a case of non secreting lesion

33.  HORMONALANALYSIS
• Serum Prolactin level
• Growth hormone:basal growth hormone level
IGF-I
Glucose suppression,insulin tolerence
• ACTH Hypersecretion:
Serum ACTH,Dexamethasone supression test
24 hrs urine for 17-hydroxy corticosteroids
and free cortisol
• Gonadal function: FSH, LH, Esradiol,Testosterone
• Thyroid function test
• Adrenal function: basal plasma,urinary steroids
cortisol response to insulin induced hypoglycaemia

34. Classification of Pituitary tumours
• ANATOMICAL SIZE
 Microadenoma(<10 mm)
 Macroadenoma(>10 mm)
• PHYSIOLOGICAL
 Ant pituitary
1. Prolactin
2. Growth hormone
3. Adrenocorticotrophic hormone
4. Leutinizing hormone
5. Follicle stimulating hormone
6. Thyroid stimulating hormone
 Post pituitary
1. Oxytocin
2. Vasopressin

35. Classification(Cont…)
• ACCORDING TO CLINICAL SYMPTOMS
 Functional
 Non functionaL
• ACCORDING TO EXTENT OF EXPANSION OR EROSION OF SELLA
 Grade 0: Intrapituitary microadenoma with normal sellar appearance
 Grade I: Normal-sized sella with asymmetric floor
 Grade II: Enlarged sella with an intact floor
 Grade III: Localized erosion of sellar floor
 Grade IV: Diffuse destruction of floor
• ACCORDING TO SUPRASELLAR EXTENSION
 Type A: Tumor bulges into the chiasmatic cistern
 Type B: Tumor reaches the floor of the 3rd ventricle
 Type C: Tumor is more voluminous with extension into the 3rd ventricle up to the foramen
of Monro
 Type D: Tumor extends into temporal or frontal fossa

36. Pathological classification
Ant Pituitary has 5 specific cell types
• Somatotrophs:
– produces growth hormone,acidophilic
• Lactotrophs:
– produces prolactin,acidophilic
• Corticotrophs:
– produces ACTH,MSH,basophilic
• Thyrotrophs:
– produces TSH,basophilic
• Gonadotrophs:
– FSH,LH,basophilic
• Post pituitary: pituicytes and non
myelinated fibres

37. Management
• Observation
• Surgery
• Radiotherapy
• Medical Management

38. Observation
• In asymptomatic non secreting microadenomas
• Small asymptomatic prolactinomas
2-4 mm no testing required
5-9 mm MRI can be done once yearly
• Indications for intervention
Tumour growth on imaging
symptoms of hypersecretion
development of visual field defects

39. Surgery
INDICATIONS
• It is the first line treatment for
most symptomatic pituitary
tumours
• Useful when medical therapy
fails
• When prompt relief from mass
effect and hormone secretion is
required
• Pituitary apoplexy
Transfrontal
Trans-sphenoidal

40. Types
 MICROSCOPIC TRANSSEPTAL TRANSSPHENOIDAL
• Current standard surgical procedure
• Safe procedure with mortality rate 0.5%
• Contraindications are sphenoid sinusitis,
ectatic midline carotid arteries
lateral surpasellar extent
 ENDOSCOPIC TRANSNASAL TRANSSPHENOIDAL
• Allows better visualisation of pituitary gland, hyophyseal stalk,
cavernous sinuses,optic nerve and suprasallar areas
 TRANSCRANIAL
• Requires craniotomy and retraction of frontal lobes
• Used for large invasive tumours with significant suprasellar
extension
• When transsphenoidal approach is contraindicated

41. COMPLICATIONS OF SURGERY
• CSF rhinorrhoea
• Meningitis
• Haemorrhage
• Stroke
• Damage to pituitary
• Visual loss

42. Management algorithm for a nonfunctioning Pituitary Microadenoma

43. Management algorithm for a nonfunctioning Pituitary Macroadenoma

44. Management algorithm for a Prolactinoma

45. Management algorithm for a GH-secreting adenoma

46. Management algorithm for a ACTH-secreting adenoma

47. Radiotherapy
• INDICATIONS
1. Hypersecretion and mass effect due to large tumours
2. Incomplete resection of tumour
3. Progressive disease after surgery
4. Recurrent tumours

48. Radiotherapy
• TECHNIQUES
 Conventional External Beam Radiotherapy
 Manual planning
 2D Planning
 3D CRT
 Fractionated Stereotactic Radiation Therapy
 Gamma Knife Radiosurgery

49. MANUAL AND 2D PLANNING
Positioning
 Supine with neck flexed and head at
45 degrees
 Pituitary board can be used to achieve
this
 Immobilisation done with
thermoplastic mask
VOLUME
 The entire pituitary gland with
extensions and a margin of 1-1.5
cm

50. PORTALS
 Two parallel and opposite lateral fields and one anterior or vertex beam that
enters above the eyes
 The centre of the pituitary is located at a point 2-2.5 anteriorly to tragus and
2-2.5 cm superiorly to that point
 Taking this point as centre a field of( 4*4)cm-(6*6) cm is marked
ENERGY
 4-10 Mev or Co 60
DOSE
 Nonfunctioning tumours 45-50.4 Gy@1.8 Gy/#
 Functional tumours 50.4-54 Gy

51. 3D PLANNING
• Image based treatment planning using a 3D
technique is the standard of care
• Defining the tumour volume
 MRI,CT as well as clinical and surgical
findings should be used to define the tumour
volume
 CT simulation assists in defining treatment
volume
 GTV is the pituitary adenomas including any
extention into adjacent anatomic regions
 CTV :GTV+5 mm in a clear defined tumour or
entire sella and cavernous sinus with invasive
tumours
 PTV:CTV+5mm

52. FRACTIONATED STEREOTACTIC RADIOTHERAPY(FSRT)
 FSRT is characterised by improved patient localisation,tighter volume
definition more conformal isodose distributions
 It has better safety profile and efficacy
• IMMOBILISATION
Aim is to achieve a patient positioning error of less than 3mm by
various means like
Invasive halo ring
Radiocamera bite block
Non invasive Head frames

53. Stereotactic(cont…)
• TARGET VOLUME DELINEATION
• GTV is designed with help of MRI and extent of cavernous sinus invasion
should be included
• No additional margins is required for CTV
• PTV:CTV +2-3 mm margin
• TREATMENT PLANNING
• Depends on the delivery systems available
• Options include
Multiple spherical shots
Dynamic conformal arches
Nonisocentric robotic delivery
• DOSE 50.4 Gy in 28#@1.8Gy/#

54. STEREOTACTIC
RADIOSURGERY
 Accepted treatment for smaller,radiologically well defined tumours located at a
distance (3-5 mm) from optic apparatus
 Contraindicated if optic chiasma is closer than (3 -5)mmto the tumour
 Delivery systems include linear accelerator and gamma knife
 Head is fixed with an appropriate stereotactic head frame and a high resolution
imaging study is obtained
 Gamma knife uses smallest collimators and maximum number of isocentres .
 The dose to optic chiasma is limited to <8-9 Gy
 DOSE
• Non functioning (12-20Gy)
• Functioning (15-30 Gy)

55. RT Dosing Guidelines
EBRT
(1.8Gy/fx)
Radio-surgery
(optic chiasm
dose < 9 Gy)
Local
Tumor
Control
Biochemical
Control
Nonfunctioning
tumors
45-50.4
Gy
12-24 Gy to
margin
95% NA
Functioning
tumors
45-54 Gy 25-30 Gy to
margin
90-95% 33-95%

56. Results
MODALITY SURGERY
VS
SURG+POSTOP RT
SURG+POST OP
RT
VS
RT ALONE
GAMMA KNIEF
RADIOSURGERY
RESULTS Park et.al
10 yrs recurrence rate
2.3%with rt,50.5%only
surgery
Grigsby et al
Proggression free
survival at 5 yrs 96%
and 20 yrs 88%
Maschiro.et al
Tumour control at 5 yrs is
93.6% and
endocrinological
improvement is 80.3%
CONCLUSION Post op RT should be
preferred
Surg+rt had a greater
control of local disease
Results are similar to
#EBRT but gamma knief
seems to be safer in terms
of complications

58. • In acromegaly, the rate of reduction of GH after conventional therapy is a
50% drop in 27 (± 5) months (Biermasz et al., 2000).
• It has also been expressed as halving of mean GH level in a population of
acromegalic patients in about 2 years (Ciccarelli et al., 1989).
• The rate of reduction of IGF-I is slower with normalization in 60% of
patients 5–10 years after treatment (Biermasz et al., 2000).
• In Cushing's disease, the normalization of plasma and urinary cortisol has
been reported in 50–100% of patients. A detailed prospective study of 30
adults demonstrated remission in all patients 60 months after radiotherapy,
with the majority normalizing in the first 2 years after treatment
(Estrada et al., 1997).

59. COMPLICATIONS OF RADIOTHERAPY
• ACUTE REACTIONS
Fatigue, Focal alopecia, Otitis
• CHRONIC REACTIONS
1. Hypopituitarism
 primarily due to hypothalamic injury. In patients with normal pituitary function around the time of radiotherapy, hormone
replacement therapy is required in 20–40% of patients at 10 years
2. Damage to optic apparatus
 1·5% risk of radiation optic neuropathy (Brada et al., 1993; Tsang et al., 1994)
3. Secondary brain tumours
 The reported frequency is in the region of 2% at 10–20 years (Brada et al., 1992; Tsang et al.,
1993; Erfurth et al., 2001).
4. Brain necrosis
 0·2% risk of necrosis of normal brain structures (Becker et al., 2002).
5. Although radiation is blamed for potential cognitive impairment, there is no clear evidence
that small-volume fractionated irradiation affects cognitive function beyond the deleterious
effect of surgery and the pituitary adenoma (Grattan-Smith et al., 1992; Peace et al., 1997).

60. Spinal Cord
Tumours

61. Introduction
• Rare heterogeneous group of tumors.
• 15% of all primary cns neoplasms arise in the sc.
• Incidence higher in males than females
• Age – 10 to 40 yrs
• Extramedullary tumors comprises around 2/3 & intramedullary ~ 10%.
• Cervical spine involvement is seen in 15-20%, thoracic in 50-55%, lumbar
in 25-30% cases.

63. BIOLOGIC CHARACTERISTICS & MOLECULLAR BIOLOGY
1. Diversity of spinal axis tumors due to large spectrum of
phenotypically distinct cells in the axis.
2. Most are benign.
3. Significant morbidity due to direct compression of important neural
structures.
4. Histology is an important prognostic factor
– Ependymoma better prognosis than > astrocytoma
– Low grade & pilocytic astrocytoma better prognosis.

68. Radiotherapy
• Controversial since SC tumors are indolent (SC toxicity)
• Not indicated in
– Completely excised intra medullary
– Ependymoma and astrocytoma low grade
• Incomplete / piece meal excision :- adjuvant radation
• Follow up after surgery and second surgery/adjuvant RT if recurrence
particularly in children
• RT induced spinal deformity due to damage of epiphyseal plate, soft tissue
fibrosis and contracture.
• In high grade astrocytomas & ependymomas adjuvant RT is recomended
irrespecive of extent of resection ( Mayo data –IJROBP:27-- 1986,2000)

70. Radiation Technique
Conventional technique
– Cervical:-parallel opposed portal
– Thoracic:-direct posterior or posterior wedge
– Lumbar & cauda equina:-opposed AP/PA fields
– In female :-lateral techniques are used to avoid the dose to ovary
• Depth of spinal cord:-determined from CT/MRI
Beam energy:-
– Cervical:-4 to 6 mv
– Thoracic & lumbar:-combination of low energy (4-6 mv) & high energy(8 to 25 mv)
• Dose:-
– Low grade astrocytoma and ependymoma gtr/50.4 Gy after str
– High grade astrocytoma:-54 Gy
– High grade ependymoma csi = 36Gy + boost 50.4 Gy – 54 Gy
– Meningiomas : 50.4 GY or 16 GY/fx 80% IDL by SBRT
• Margins:-
– 3-5cms suproinferior, thecal sac at S 2-3 needs to be covered in caudal
ependymomas
– 0.5-1 cm margin for low grade astrocytoma
• Imrt
• SRT & Proton beam therapy

72. Radiation toxicity
• Reversible myelopathy (2-6 mths) – Lhermitte’s sign is seen
characterized by shock like sensation in hands and feet when
neck is flexed.
– Lasts for weeks .
– Requires no treatment.
• Progressive myelopathy (13-29 mths) - characterized
parasthesia,progressive motor weakness pain/temp
lossbowel/bladder dysfunction
• Spinal cord tolerance– Quantec guidelines show for
conventional RT a dose of 50Gy, 60Gy& 69Gy is associated
with 0.2%, 6% & 50% rates of myelopathy.

73. Chemotherapy
• Limited role
• Used after all modalities are exhausted or in <3 yr age group to borrow
time for RT
• Platinums & etoposides are most active agents for ependymoma
• Temozolamide may be used in spinal glioma. Used as concurrent with
RT and then maintainance therapy
• In <3year age groups– intensive treatment with carboplatin,
procarbazine, vincristine, cyclophosphamide, etoposide, cisplatin
agents

74. Astrocytoma
• Age– paediatric and adolescent
• Site – mostly cervical & thoracic
• Mostly focal but whole cord involvement may occur.
• Majority are low grade (who gr I & II )
• Accompanying syrinx in 40 % cases.
• Complete surgical resection is often impossible.
• Juvenile pilocytic astrocytoma (who gr I) due to its non infiltrative nature can be
treated with radical resection
• Fibrillary(gr II), Anaplastic (gr III), GBM(gr IV)– due to local infiltration resection
enblock not possible onlybiopsy/subtotal resection done
• Adjuvant radiotherapy indicated

75. Nerve sheath tumours
• Arise from schwann cells
• Types – schwannoma, neurofibroma,ganglioneuroma
• Majority are intradural arising from dorsal sensory nerve root
• When it has both intra and extra dural component it is called dumbbell lesion.
Schwannoma –
– Most frequently seen in cervical and lumbar region
– Present with radicular sensory change with weakness being a less common sign
– Mostly solitary but when associated with nf2 & schwannomatosis these are
multiple
– Pathological types – conventional (mc),cellular,melanotic ,plexiform(do not
undergo malignant change)
– Grow eccentricaly without nerve infiltration
• Treatment – radical surgical resection(hemilaminectomy)
• Recurrence is rare and they usually donot undergo malignant
transformation.

76. Neurofibroma
• Commonly seen in NF-1
• Cervical spine most commonly affected
• Often multiple, benign
• Encases the nerve root hence excision without sacrificing the
nerve is difficult
Ganglioneuroma
• Mostly benign and paraspinal
• Arises from sympathetic nervous system
• Pathological types
– a. Ganglioneuroma (Extradural, Dumbell)
– b. Gangliocytoma
– c. Ganglioganglioma (Intradural, Intramedullary)

77. Hemangioblastoma
• Highly vascular tumors
• May be associated with Von- Whippel - Lindau
• Usually dorsal
• Sometimes multiple
• Renal cell carcinoma must be searched for
• Treatment – surgical resection

78. Thank You