Case Study
CNS CANCER - MENINGIOMA
-Courtney Chaney
Patient Information
White
32
Female
Years of Age
Social History
Married, Mother of one
Works in finance
Never Smoked
Socially Drinks
Breastfeeding
Medical History
Recent Child Birth
Dysmenorrhea
Meningioma
Family History
Asthma
Allergic to Codeine
Breast Cancer (mom,
aunt)
-tested for carrier but was
negative
Prostate Cancer
Hypertension
diabetes
Surgical History
MANDIBLE FRACTURE SURGERY
ADENOIDECTOMY
APPROACH CRANIAL FOSSA ANTERIOR
ORBITOCRANIAL
EXCISION LESION CRANIAL FOSSA MIDDLE
INTRADURAL
EXCISION LESION CRANIAL FOSSA ANTERIOR
EXTRADURAL
CRANIOPLASTY FOR SKULL DEFECT
ASSISTANCE STEREOTACTIC NAVIGATION
CRANIAL INTRADURAL ADD-ON PX
EXCISION BONE TUMOR CRANIAL W/ OR
W/O OPTIC NERVE DECOMPRESSION
EXCISION BRAIN TUMOR INTRACRANIAL
TRANSNASAL APPROACH
NEUROENDOSCOPIC
ASSISTANCE STEREOTACTIC NAVIGATION CRANIAL EXTRADURAL ADD-ON
PX
EXCISION BRAIN TUMOR INTRACRANIAL TRANSNASAL APPROACH
NEUROENDOSCOPIC
ASSISTANCE STEREOTACTIC NAVIGATION CRANIAL EXTRADURAL ADD-ON
PX
INTRAUTERINE DEVICE INSERTION
CESAREAN SECTION DELIVERY
CESAREAN APPROACH
CRANIAL FOSSA ANTERIOR ORBITOCRANIAL
EXCISION LESION CRANIAL FOSSA MIDDLE INTRADURAL
ASSISTANCE STEREOTACTIC NAVIGATION CRANIAL INTRADURAL ADD-ON
PX
Presenting Signs & Symptoms
Localized headaches
Blindness of left eye Jan 2015
Proptosis 2013
Chronic rhinitis Dec 2014
Seizures
Hyperostosis - 2013
Behavioral changes
Personality changes
Ptosis Dec 2013
Blurry vision - 2013
Diplopia - Dec 2014
Speech pattern changes
Coordination skills changes
Vision abnormalities - Dec 2014
Mental changes
Nausea & vomiting Jun 2013
Motor skill changes
Vertigo Jun 2013
Sensory Function Changes
Orbital CT showed expansive tumor on left sphenoid wing
Edema cerebral -2015
Reflex changes
ICP symptoms
Papilledema
Defective memory
Aphasia
Pathology
Malignant neoplasms of the cerebral meninges
- typically happens in the dura mater
left greater sphenoid wing intraosseous meningioma involving the cavernous
sinus about 20 % of meningiomas are sphenoid wing meningiomas
Anatomy & Physiology
Meninges are the protective outer
covering of the brain
Meninges are Dura Mater, Arachnoid,
Pia Mater
Dura Mater- hard
Arachnoid-
Pia Mater- adheres directly to the
brain
Brian is made up of 6 lobes and sits
in the skull
The greater wing of the sphenoid
helps create the cranial fossa of the
skull
No lymph nodes in the brain
Epidemiology
1.5% of all malignancies are in the brain
1/3 of all CNS are meningioma
5.2 our of 100,000 people in the population a year
Most CNS CA effects patients 50-80 yr. olds
Meningiomas affect more women than men, 2:1
-Atypical and anaplastic meningiomas show a male predominance
-Childhood meningiomas occur more often in males
Meningiomas associated withneurofibromatosis type 2(NF2) tend to occur in
younger individuals
meningiomas are rather uncommon in children and almost never occur in infants
Etiology
Ionizing Radiation
Head Injury
Hormones (Estrogen & Progestogen)
Dental Radiographic exams
Occupational exposure
- healthcare workers & health care workers show higher incidence
Environmental Exposure
Lifestyle and Dietary Factors
- cell phones, nitrates, hair dye, and smoking
Genetic Factors (>5% of etiology of brain tumors)
Recklinghausens disease and autosomal dominant disorders (NF2)
Family has history
Histopathology
Anaplastic Meningioma & Atypical Meningiomas - >10%
WHO grade I includes the following histologic patterns:
Meningothelial (syncytial) meningioma
Transitional (mixed) meningioma
Fibroblastic (fibrous) meningioma
Psammomatous meningioma
Angiomatous (vascular) meningioma
Microcystic meningioma
Secretory meningioma
Lymphoplasmacyte-rich meningioma
Metaplastic meningioma
WHO grade II includes the following histologic patterns: Chordoid meningioma
Clear cell meningioma (intracranial) (showing signs of this now)
Atypical meningioma
WHO grade III includes the following histologic patterns:
Papillary meningioma
Rhabdoid meningioma
Anaplastic (malignant) meningioma
WHO Grading System
Grade I Benign meningioma: This non-cancerous type of brain tumor grows
slowly and has distinct borders. Approximately 78-81% of meningiomas are
benign (non-cancerous).
Grade II Atypical meningioma: Approximately 15-20% of meningiomas are
atypical, meaning that the tumor cells do not appear typical or normal.
Atypical meningiomas are neither malignant (cancerous) nor benign, but may
become malignant. Grade II atypical meningiomas also tend to recur and grow
faster.
Grade III Malignant or anaplastic meningioma: Malignant or anaplastic
meningioma is an aggressive type of brain tumor that tends to invade the
parts of the brain nearest to the tumor. Approximately 1-4% of meningiomas
are grade III (cancerous).
Patient Grading & Staging
Grade 1 on WHO Grading System
On recent biopsy though Cells have mucinous, myxoid or vaguely chordoid pattern
and even occasional PAS-positive clear cells
cannot be classified histologically as a specific WHO
grade II variant, the clinical behavior, elevated Ki-67 labeling index and
partial clear cell and chordoid features suggest a WHO grade II lesion
No universal staging system
Imaging
Orbit CT revealed initial tumor
Head CT
Brain MRI confirmed meningioma and placement
Head CTA
Craniotomy (LEFT ORBITO-FRONTO-TEMPORAL CRANIOTOMY FOR RESECTION
OF A SPHENOID WING MENINGIOMA)
- tumor reoccurred and had second craniotomy
Biopsy
CT Simulation Plan Treatment
Treatment Options
Surgery Subtotal resection or Gross total resection
Radiation Therapy- Post Op (after 2nd surgery) 54-59 Gy
-if after gross total resection 6000 GY
- stereotactic or external beam
Chemotherapy Not Recommended
Treatment Plan
Lt. Base of Skull
4-field V-Mat
6MV
Prescription of 5220 cGy
29 Fx
180 cGy/day
Treatment Plan
Treatment Plan Parameters
Supine, head first
Brain Lab aquaplast mask
Headrest C
Hands on Chest
2mm shims
2mm clips
Conformal board
MLCs
Treatment Borders
Based upon location and size of tumor
Try to block as much healthy tissue as you can while still effectively treating
Dose Distribution
Dose Distribution
DRRs
Critical Structure (cGy)
Optic Chiasm 5000
Optic Nerve 5000
Brain 4700
Lt. Parotid Gland - 3200
Brian Stem - 5000
Retinas 4500
Spinal Cord- 4700
Ears 3000 or 5500
Eyes 1000
Lens - 1000
TMJ joint & Mandible 6000
Lacriminal Gland - 2600
Side Effects
ACUTE
-hair loss, fatigue, skin erythema, headaches, nausea, brain swelling, speech
problems, muscle weakness, vision problems
-Medicine can be given for headaches and nausea
- Corticosteroids or steroids
- less strenuous activities and naps for fatigue
CHRONIC
- reoccurrence, decreased intellect, memory impairment, confusion,
personality changes, alteration of normal function
Prognosis and Survival
Survival rates for meningioma depend on several factors, including the age of
the patient and whether the tumor is cancerous
93.1% of benign meningiomas, 65.4% of atypical meningiomas, and 27.3% of
malignant meningiomas were cured by surgery
Metastatic Sites
Meningioma very rarely spreads to other parts of the body
If they do, lung is the most common followed by the abdominal viscera,
bones, and lymph nodes
References
1. IHIS
2. Aria
3. Notes
4. John Hopkins University and Health Staff. Treatment for Meningiomas.
2014. February 26, 2015. [Link]
5. Fung, K. (2014, April 21). Meningiomas Pathology (A. Adesina, Ed.).
February 26, 2015. [Link]
6. Washington, C. (2010). Central Nervous System [Link] and
practice of radiation therapy(3rd ed.). St. Louis, Mo.: Mosby Elsevier.
