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Brain Tumours

Brain Tumours. Mostafa EL-Haddad M.B.B.ch., Msc ., MD., FRCR(UK)., Kasr El- Ainy Hospital Cairo University (NEMROCK ) 2012. Genetic Syndromes. Infra tentorial tumors more common in children ( inf ants). Also in midline. in adults Supratentorail more. Sex. In general male more.

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Brain Tumours

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  1. Brain Tumours Mostafa EL-Haddad M.B.B.ch., Msc., MD., FRCR(UK)., Kasr El-Ainy Hospital Cairo University (NEMROCK)2012

  2. Genetic Syndromes

  3. Infratentorial tumors more common in children (infants). Also in midline. • in adults Supratentorail more.

  4. Sex • In general male more. • Meningioma and Shwannomas more in female • Ependymoma and nerve sheath equally distributed.

  5. Anatomy • Circle of Willis. • Optic Chiasma.

  6. ANATOMY

  7. Staging • AJCC 2002: NO • Old TNM • M staging and medulloblastoma • Biopsy no biopsy.

  8. Commonest Brain Tumor? • Brain Metastasis.

  9. Imaging • T2 and FLAIR (fluid-attenuated inversion recovery) images are more sensitive for detecting edema. • For nonenhancing tumors, especially glial neoplasms, the FLAIR sequence and T2 sequences are best for the definition of tumor extent.

  10. WHO Grading • Classification idea: -Neuroepithelial. -Germ cells. -Meningeal . -Etc……… OLIGODENDROGLIOMA WHY SPECIAL?

  11. Brain Alpha-Beta ratio • Implication in Dose and fractionation.

  12. General Management • Newer generation anticonvulsants, such as levetiracetam, lamotrigine, and pregabalin that do not affect cytochrome P450 activity are now preferred.

  13. Choose Your Patient • Low Grade. • High grade. • Children. • Boost or No Boost? • Dose escalation in low and High grade gliomas. • Risk structures.

  14. CT-Simulator • Patient preparation. • IV contrast. • Treatment position: Supine? Prone?. • Neck flexed or extended .WHEN? • Fixation methods

  15. Define your target • Margin for Low grade tumors • Margin in High grade tumors.

  16. GTV • A central low-density area is evaluated as necrosis and is surrounded by an annular enhancing area corresponding to a densely cellular zone of viable neoplasm called the “rim.” (IF any) The external limit of the rim corresponds to the GTV

  17. GTV In High Grade Glioma • MRI or CT? both with contrast. • Best with T1 MRI with contrast.

  18. GTV in Low grade Glioma • CT in Low grade glioma, tumor is non enhancing so its very difficult to delineate. • MRI T1 or T2?

  19. CTV in High Grade Glioma • 2-3 cm beyond any existing edema. • Which imaging study will you use to adequately define your edema?? MRI ?? T1 or T2? .

  20. Brain Metastasis

  21. Brain Metastasis Gaspar et al IJROBP 1997

  22. Factors NOT in The RTOG Prognostic Factors • Number of the lesions. • Primary site (breast, lung…). • Time interval between the Metastasis and the primary. • Location. • Neurologic Function. • Radiation dose. • Tumor response.

  23. Karnofsky scale • 100%: Normal no complaints; no evidence of disease • 90%: Able to carry on normal activity; minor signs or symptoms of disease. • 80%: Normal activity with effort; some signs or symptoms of disease. • 70%: Cares for self; unable to carry on normal activity or to do active work. • 60%: Requires occasional assistance, but is able to care for most of his personal needs.

  24. 50%:Requires considerable assistance and frequent medical care. • 40%: Disabled; requires special care and assistance. • 30%:Severely disabled; hospital admission is indicated although death not imminent. • 20%: Very sick; hospital admission necessary; active supportive treatment necessary. • 10%: Moribund; fatal processes progressing rapidly. • 0 Dead

  25. Value of Whole Brain Irradiation • Increase Median Survival from 1 to 4 months.

  26. Radio-surgery When? • RTOG 9508. • RPA class III. • RPA class I. • Single Mets.

  27. Can we avoid WBI? • EORTC: 22952 –26001. • The American Surgeons Oncology Group. • Japanese Radiation Oncology Study Group.

  28. Landmarks • Sella turcica is centrally located and marks the lower border of the median telencephalon and diencephalon. • Reid's baseline and the Frankfort horizontal plane. • Optic canal runs at most 1 cm superior and 1 cm anterior to that point. • Pineal body 1 cm posterior and 3 cm superior to the external auditory meatus.

  29. What’s FLAIR? • Think of the FLAIR sequence as a bit of a 'negative', in that FLAIR will show areas of differing fluid concentration (not blood). • FlAIR are modified T2-weighted sequences on which fluid in motion, such as cerebrospinal fluid, remains dark, whereas tumor or edema remains white. • This sequence is useful for the delineation of periventricular lesions.

  30. MR Spectroscopy • MR spectroscopy is a promising approach for both metabolic and functional evaluation of GTV and CTV. This technique provides information about tumor activity based on the levels of cellular metabolites.

  31. Choline is a neurotransmitter and membrane component that is increased in glioma and the degree of elevation of the choline level correlates with elevation of tumor cell density. • N-acetylaspartate is a neuronal metabolite that is decreased in glioma implying an increase in the choline-to-N-acetylaspartate ratio.

  32. Creatine indicates a cellular energetic process, and lactate is a catabolite of anaerobic metabolism that can be used as a surrogate marker for necrosis or hypoxia.

  33. CT and MRI delineation of GTV and CTV for untreated glioma remains a controversial and difficult issue, mainly because of the discrepancy between real tumor invasion and that estimated by CT or MRI.

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