Brain Tumors

Primary CNS lymphoma

Rare: 1% of intracranial tumors, recurrence of 90%. More frequent with AIDS and other immunosuppressed disorders. Arise in cerebrum, cerebellum, or brain stem. More frequent in males.

SxS: Parietal Lobe

Contralateral sensory loss, hemiparesis, homonymous visual deficits or neglect, visual-spatial disorders

Primary brain tumors

Gliomas, Meningiomas, Pituitary adenomas, Schwannomas, Primary CNS lymphoma

SxS: Cerebellum

Headache, nausea, vomiting (40%). Poor balance, dyskinesia, ataxia (25%), intition tremor.

General Signs & Symptoms

Headaches, seizure activity, altered mental state

Theories of development

Heredity, chemical & farming/manufacturing materials, electromagnetic field exposure, ionizing radiation

Sterotactic Radiosurgery

High dose of ionizing radiation with high-energy accelerators. Targets centrally located lesions less than 3 cm. Indicated for high surgical risk factor pts. Gamma knife and cyberknife.

SxS: Brain stem

Loss of consciousness and attention. Small changes can lead to devistating s/s. Death.

Tumor classification

Primary: originate in the CNS. Secondary: metastic spread from systemic cancer outside of the brain.

Grade 4: glioblastoma multiform

17%. Grow rapidly and invade nearby tissue. Located in deep white matter of cerebral hemispheres. Uncommon in children. Poor prognosis: surgical resection, chemotherapy, radiation.

SxS: Temporal lobe

Auditory changes, perceptual changes, memory impairments, learning impairments, aphasia

Pituitary adenomas

Benign epithelial tumors. Cause hyper/hypo secretion of hormones. Onset of all adult ages and rare before puberty. Females 3:1.

SxS: Headaches

Dull, intermittent, similar to migraine or cluster headaches. Interrupts sleep, worse on awakening and improves through the day. Elicited by postural changes, coughing, exercises. More severe than normal. Nausea/vomiting.

SxS: Occipital lobe

Homonymous hemianopsia. Impaired extraocular mm movement

Meningiomas

Slow growing. Originate in the dura mater or arachnoid membrane. 33% of reported brain tumors. Usually benign. Incidence increase with age & more in females.

Medical Treatment

Traditional sx, chemotherapy, radiation therapy, stereotactic radiosurgery. Determined by histological type, location, grade, size, age at onset, medical hx.

Secondary brain tumors

25% of systemic cancers metastasize to the brain. Majority occur in cerebral hemispheres. 1/3 from lung, breast, skin, GI tract, kidneys. Frontal lobe most common site.

State Imaging

CT Scans: produces tomographic images, used for diagnosing and after surgical intervention. MRI (superior to CT scan): diagnostic imaging procedure of choice, uses magnetic fields rather than ionizing radiation.

Diagnosis

Clinical diagnosis, biopsy, lab diagnosis (further access focal deficits, CSF fluid), Static vs. dynamic and computer integration types of radiological diagnosis (imaging)

Schwannomas

Encapsulated. Arise from any cranial nerve or spinal nerve. CN 8 - most commonly involved, acoustice neuroma. Prognosis grood, but with residual symptoms: facial paralysis, equilibrium deficits, hearing, etc. Rarely fatal.

Most frequently occurring malignant tumor

Glioblastoma multiform

Incidence & Etiology

Increasing in the US. Cause unknown. Occurs in two distict categories of pts: children 0-15, adults 50-70. >60% of tumors in adults are cerebral.

SxS: Altered Mental State

Initial symptom 15-25% of brain tumor cases. Subtle changes in concentration, memory, affect, personality, initiative, abstract reasoning. Severe cognition problems and confusion.

Most frequently occurring benign tumor

Meningioma

Gliomas

Most common type of brain tumor 40-50%. Four main classifications: Astrocytomas, Oligodendrogliomas, Ependymomas, Meduloblastomas.

SxS: Frontal Lobe

Movement disorders: hemiparesis, seizures, aphasia, gait issues. Personality changes: disinhibition, irritability, impaired judgment, lack of initiation. Cognitive impairments, Emotional lability, dementia, language deficits.

Ependymomas

Originate from ependymal cells. Arise from cells lining the ventricles and central spinal canal. Most common side: 4th ventrical, mostly in children. Frequently reoccur after tx. Prognosis dependent on success of resection.

Astrocytomas

Originate from glial cells. Most common primary brain tumor in adults and children. Diffuse or encapsulated. Typically found in the frontal lobe: adults. Typically found in the cerebellum: children. Grade 1-4, the higher the grade the poorer prognosis.

Oligodendrogliomas

Originate from glial cells. Slow growing but progressive. 50% occur in multiple lobes. Seizures: only clinical manifestation. Occurrence: 40-60 years. Males>females. Positive prognosis: less than 40 years, tumor grade 1/2.

Meduloblastoma

Originate from primitive cells. Malignant embryonic tumors. Location: posterior fossa. Usually in the 4th ventricle -> blocks CSF flow: hydrocephalus and incr intracranial pressure. Most malignant primary tumor in children (20%).

Dynamic Imaging

PET: positron emission tomography, metabolism and physiology of brain tumor and surrounding tissue. CT (SPECT): single photon emission computed tomography, uses gamma rays, identify high and low grade tumors, radiation necrosis, and recurrence. MRS: magnetic resonance spectroscopy, metabolic changes of brain tumors, document early treatment response. Functional MRI: maps cerebral blood flow at capillary level.

Side effects of tx

Physical: hair loss, fatigue, nausea, skin burns, dry/sore mouth. Bone marrow: decreased ability to produce RBC/WBC, platelets -> anemia, infection, or hemorrhage. GI: nausea, vomiting, diarrhea, or constipations -> impaired mobility/energy. Psychological: depression, hopelessness, anxiety, emotional issues.

SxS: Seizure Activity

Presents in 1/3 of cases. Usually focal. May become generalized causing loss of consciousness.

Traditional Sx

Primary goal: maximal resection with least amount of damage. Gross total resection: longer survival rates, decreased neurological impairments. Partial resection: decreased tumor mass to be treated by other methods.

Rehabilitation Overview

Survival rates improved. Need for interdisciplinary therapeutic intervention. Prevent complications, maximize function, provide support. Rehab plan must be flexible.

PT Intervention

Ultimate goal: maximize return of function, within the limits imposed by tumor and treatment, improve QOL. Treatment plans must be flexible to accomodate fluctuation in the persons presentation. Continually reassessing.

Radiation Therapy

Used alone or with sx or chemotherapy. Option for large inaccessible tumors. Eradicates residual cells after a partial resection. Conventional: delivered directly to tumor site.

Chemotherapy

Used independently or with sx or radiation. Administered IV, placed directly into tumor bed, IM, orally, or by implanted device. Goal: stop reproduction of the tumor cells. Delivery challenge: blood brain barrier.