Neuro-oncology

Contacts

Alison Cameron

Neuro-oncology, SRS & Paediatric Radiotherapy

Chris Herbert

neuro-oncology, SRS, Melanoma

Lorna Hawley

neuro-oncology, lymphoma

Georgina Casswell

neuro-oncology, SRS, H&N

Anatomy/ Radiology

At the Learning for Healthcare website there are excellent short (15-40 min each) resources on anatomy and tumour radiology from RCR. These are interactive with built in self testing.

Website: e-learning for health

Search for "radiology" or "R-ITI" to access the hundred of radiology teaching sessions.

Go to: 6b Neuroradiology; Go to: brain; Go to: Primary and secondary neoplasms

There there are 8 sessions on different types of brain tumour and 1 session on radiation injury (6b_122).

For those wishing to develop a deeper knowledge there are additional sessions on Brain MRI scanning (6b_016) and pathology (6b_017)

For spinal tumours:

Go to: 6b Neuroradiology; Go to: spine; Go to: neoplasms

There are 3 sessions on spinal tumours.

Pathology Overview


The 2016 WHO pathology guidelines had a number of significant changes, removing some diagnoses (eg oligodendroglioma) in favour of combined histological and molecular diagnoses. The attached paper provides an overview of this. Pituitary tumours have a separate pathology review- see pituitary for this.

The 2016 World Health Organization Classification of Tumors of the Central Nervous System: a summary
David N. Louis1 · Arie Perry2 · Guido Reifenberger3,4 · Andreas von Deimling4,5 · Dominique Figarella‑Branger6 · Webster K. Cavenee7 · Hiroko Ohgaki8 · Otmar D. Wiestler9 · Paul Kleihues10 · David W. Ellison11
Acta Neuropathol

Investigations

MRI is usually the investigation of choice. However for review of bone involvement by tumours such as meningioma/chordoma etc, for identification of calcification in craniopharngioma/meningioma, and for identifying haemorrhage CT is required. CT can also quickly identify gross issues, such as hydrocephalus.

MDT

The adult general neuro-oncology MDT (use for mets, glioma, urgent suspected brain tumours) is at 9am weekly in Southmead. The skull base and pituitary neuro-oncology MDT (use for skull base tumours including acoustic neuroma, meningioma, chordoma, chondrosarcoma, germ cell tumour (though this may need to go through general first), craniopharngioma, pituitary adenoma, glomus tumour) is at 12 noon on thursday week 1/3/5 of the month at Southmead.

Referrals to both are made through the - BNOG referral website which will email back a response within 24 hours of the meeting.

Surgery

Neurosurgical centres in the South West are located at Southmead and Derriford Hospitals.

Radiotherapy General

The current protocols for radiotherapy within UHBW are located on the DMS. Within neuro-oncology there is a general brain protocol, a pituitary protocol (including gamma knife), and separate gamma knife protocols for meningioma, acoustic neuroma and brain metastases. The versions from 2020 are uploaded below, but for clinical use always refer to the DMS version.

How to find DMS RT protocols

This is how to find the RT protocols on UHBW DMS (Document management system)

RT protocol neuro-oncology general
UHBW
2020

RT protocol for pituitary tumours including SRS
UHBW
2020

SRS protocol for meningioma
UHBW
2020

SRS protocol for brain mets
UHBW
2020

SRS protocol for Acoustic neuroma and other nerve neuroma
UHBW
2020

The EPTN consensus-based atlas for CT- and MR-based contouring in neuro-oncology
ESTRO
Radiotherapy and Oncology 128 (2018) 37–43

This is a consensus paper from ESTRO (from the particle group, but OAR contouring is the same whatever type of radiation is used) regarding brain OAR contouring for 15 OAR. More images on the link www.cancerdata.org

View Online

Chemotherapy General

Protocols for temozolomide and PCV are located on the regional chemotherapy website .

NICE guidance 2018

NICE guidance adults with brain tumours
NICE
2018

Overview of how to investigate and treat those with meningioma, glioma and brain metastases

End of Treatment Summery

All patients require an end of treatment summary and forward care plan at completion of therapy. An example is attached below. This is to provide a record of the relevant treatment delivered in a contextualised fashion to ensure that those without expert radiotherapy knowledge understand the implications of the treatment and actions required to mitigate the long term side effects. For example risk of hypopituitarism is negligible if the dose of radiotherapy to the pituitary is less than 20Gy in a 30# treatment, but >20% if given a dose of >40Gy, and therefore those patients require yearly monitoring for this over the following 10-15 years.

Example of a neuor-oncology End of Treatment Summary and Care plan
Dr Cameron
UHBW

Steroids

Many patients with brain tumours require dexamethasone to control the oedema related to the tumour or the radiotherapy treatment. This use has short and long term consequences, so should be minimised as much as possible. Acute effects include insomnia, increased appetite, change in body fat deposition, mood changes (depression, psychosis, mania), increased risk of DVT/PE, and risk of precipitating or worsening diabetes mellitus. In the long term, thin skin, proximal myopathy, osteoporosis, infection, long term adrenal suppression and cardiac failure.

Always wean steroids if used for >10 days.

Unless very low dose/short term steroids, all should be assessed for diabetic potential and have monitoring whilst on steroids. Current policy on this on UHBW DMS, though 2020 documents below.

If >3 months steroid use at >7.mg prednisolone, then assessment for osteoporosis needs to be considered with a DEXA scan. Spinal radiotherapy can also increase this risk of fracture. Full guidance regarding this on NICE. If DEXA scan demonstrates osteoporosis, then refer to GP or rheumatology for treatment of this. There is an award winning osteoporosis clinic in UHBW under Dr Shane Clarke for patents with complex needs.

Guidelines regarding monitoring of glucose in patients with low grade/good prognosis brain tumours on steroids
UHBW
2020

Guidelines on monitoring of glucose in patients with poor prognosis brain tumour on steroids
UHBW
2020

Seizures

Seizures are a common presenting symptom in patients with brain tumours, though almost exclusively those that are supratentorial. They may also occur secondary to surgery, secondary to the oedema from radiotherapy and secondary to relapse. Patients with seizures should be commenced on antiepileptic medication, they should be informed of the need to stop driving and inform DVLA, educated on practicalities of having epilepsy (as should their family/carers)- such as not bathing alone, educated on when to call an ambulance for status epilepticus and when to alert regarding an increase in seizures. They should be referred to an epilepsy specialist nurse and to a neurologist with an interest in epilepsy. The need for a scan in a patient with a know brain tumour and a single self resolving seizure should be discussed with the neuro-oncology consultant.

The nomenclature for catergorising seizures is changing.

Current NICE guidance (2012) recommends:

  • focal seizure first line is lamotrigine or carbamazepine, second line levetiracetam (kepra) or oxcarbazepine, or sodium valproate if male/female not childbearing potential
  • generalised tonic-clonic first line is sodium valproate (male/female not childbearing potential) or lamotrigine otherwise (though can worsen myoclonic seizures.

Clobazam can be a useful adjuctive treatment for those who have uncontrolled seizures whilst awaiting specialist review by the epilepsy team.

Patients should not suddenly stop antiepileptics- even weaning down can increase the risk of seizures and those who decide to discontinue their medication must inform DVLA if they have a driving license.

Driving

All patients with a new/recurrent diagnosis of a high grade brain tumour or new/recurrent diagnosis of seizures, and many with a new diagnosis of a low grade tumour MUST not drive and MUST inform DVLA. Treatment will also affect ability to drive. Many patients find this distressing. It is the role of the doctor to inform the patient regarding this. DVLA guidelines change from time to time, so always check the most recent guidelines on the DVLA website

When patients are able to reapply for their license- they will do this via DVLA. DVLA will send forms to the relevant consultants caring for the patient. These forms provide DVLA with factual information regarding their diagnosis. The medical team do not determine if the patient is suitable to drive and give no opinion on this.

Neurorehabilitation

Endocrinology

Patients with sella/suprasella tumours may present with endocrine loss, so should have had an assessment at baseline. Post radiotherapy there is a risk of loss over 10-15 years post RT. risk is exceptionally low in adults if pituitary dose is <20Gy (but in children growth hormone can be lost at much lower levels). Risks are dose dependent.

Screening blood tests include: 8am cortisol (over 350nmol/l ok, less may be ok- needs further assessment), U&E, free T4, LH/FSH/Oestradiol or testosterone, IGF-1 (for GH screening) or growth in children, prolactin.

Refer to local endocrine team if abnormal. Do not start thyroxine without clear evidence that ACTH axis is satisfactory.

Growth Hormone: affected at average 2.6 years post RT. Response blunted after 18Gy in 60% children and 30% adults. TD 50/5 in child is 16Gy.

LH/FSH affected at average 3.8 years- after 50-70Gy 30% are affected at 5 years.

ACTH affected at average 6 years. one report: 50-70Gy - at 5 years 20-30% risk; another: 35% risk at >40Gy

TSH affected at average 11 years. One report: 50-70Gy- at 5 year 3%, but at 10 years 30%; another: 15% risk after >40Gy

Ophthalmology

Tumours within or adjacent to the optic pathway may result in visual loss from tumour or treatment. This should be monitored prior to treatment and regularly afterwards. Depending on the level of risk this might be appropriate at a local opticians or may require opthlmology review. In BEH there is an excellent orthoptist lead clinic which provides regular review and very clear easy to compare reports. This is run by Dr Atan, neuro-opthalmologist, and patients can be referred directly to this clinic if there is no diagnostic concern- just monitoring required.

For DVLA an esterman visual field assessment is required (if there is any bilateral visual field loss)- this is done at opticians.

Stroke Risk

Risk of stroke is increased in patients with brain tumours. This is probably due to a combination of both tumour and treatment. In view of this all patients with an appropriate life expectancy should have advice regarding management of cardiovascular risk factors- including stopping smoking, healthy weight and diet, exercise and monitoring (and treatment if elevated via GP) of blood pressure, cholesterol profile (aim for ratio <4) and for diabetes (HbA1c).

Risk of Cerebrovascular Events in 178 962 Five-Year Survivors of Cancer Diagnosed at 15 to 39 Years of Age
Hawkins Birmingham group
Circulation. 2017;135:1194–1210.