In this section : Neurology
: Oncology
Cancer of Unknown Primary
Prescribing Advice on Admission – Patients on Chemotherapy Regimes
Acute Oncology
Systemic Anticancer Therapy Toxicity
Lung Cancer
Neutropenic Sepsis
Oncology Contact Details & General Advice
Brain Tumours
Malignant Spinal Cord Compression
Brain Tumours
Last updated 2nd November 2023
Incidence
- Primary tumours 8/100,000 per year: Gliomas 50%, Meningiomas 21%, Pituitary Adenomas 15%, Nerve Sheath Tumours 8%
- Metastasis more common than primary > 40 years old; commonest primary sites: lung, breast, genitourinary tract, melanoma, osteosarcoma, head and neck cancers.
Primary Brain Tumours
- Gliomas: ependymomas, astrocytomas, oligodendrogliomas
- Meningioma – slow growing and usually benign
- Acoustic neuroma (or vestibular schwannoma) – may cause cranial nerve palsies 5, 6, 7, 8
- CNS lymphomas – may be immunocompromised
- Pituitary tumours – can present due to mass effect eg bi-temporal hemianopia or endocrine upset eg XS prolactin, GH, ACTH or hypofunction.
- Medulloblastoma: malignant tumour originating in cerebellum/posterior fossa, more common in children.
Presentation of Space Occupying Lesion
- Headache – with or without features of raised intracranial pressure eg worse in the morning, when bending/straining/coughing
- Vomiting
- Gradual or acute onset of focal neurological signs
- Seizures
- Papilloedema and altered vision
- Alteration in behaviour or personality
- Decreased consciousness, lethargy
- May be diagnosed incidentally
Diagnosis
- History, examination and cranial imaging (CT & MRI).
- Tumours may enhance with contrast on imaging aiding differentiation of the tumour type. Surrounding oedema, if present, can have a significant mass effect.
- Enhancing lesions in continuity with the skull vault, falx, tentorium or base of skull are suggestive of meningioma. These may or may not have associated brain oedema.
- Cerebral metastases and cerebral lymphoma but rarely malignant gliomas can be multifocal in distribution.
- Differential diagnosis of an intracranial mass includes:
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- Traumatic contusion or clot
- Stroke – haemorrhagic or ischaemic
- Abscess (a very important differential)
- Aneurysms
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- Low grade primary tumours may not enhance with contrast
- Gliomas may have foci of calcification within them (eg oligodendroglioma)
- If cerebral metastasis is suspected on imaging, priority is to look for the primary tumour. Useful investigations include: CXR, abdominal ultrasound, mammography and most importantly a CT chest/abdo/pelvis. Don’t forget tumour markers.
- If cerebral metastasis is suspected on CT, a cranial MRI is necessary to rule out multiple small metastasis.
- For further advice and to arrange any specialist treatment, referral to the tertiary centre with Neurology and Neurosurgery on site is often necessary.
Referral
- Once you have a complete history, examination and results of relevant investigations
- See link below for advice on when to refer and to whom
- Incidental presentation – refer directly into weekly Edinburgh Centre for Neuro-Oncology (ECNO) MDM by emailing [email protected]
- Symptomatic with GCS 14-15 and <5mm midline shift on CT – discuss with Neurosurgery SpR at Western General, Edinburgh within 24 hours during ‘daytime’ hours, short code **171.
- Symptomatic with GCS <14 or drop in GCS by 2 points at any stage or midline shift ≥5mm on CT – immediate discussion with Neurosurgery SpR, short code **171.
Treatment
- See link below for detailed advice on immediate management
- Incidental presentation – dexamethasone not indicated
- Symptomatic with GCS 14-15 and <5mm midline shift on CT – dexamethasone 4-8mg and PPI
- Symptomatic with GCS <14 or drop in GCS by 2 points at any time or midline shift ≥5mm on CT – dexamethasone 16mg orally or IV with PPI
- Marked functional improvement within 12-24 hrs may guide further treatment plans, so important to document accurately the response to steroids.
- Ensure no contraindication to steroids eg infection/brain abscess
- Anti-epileptic drugs are first line treatment for tumour related seizures – Levatiracetam 250mg bd recommended
- Surgery – used for obtaining diagnosis (biopsy/resection), relieving symptoms or curative for benign tumours.
- Radiotherapy – commonly used for malignant primary and secondary tumours.
- Chemotherapy – in selected cases of malignant glioma, primary cerebral lymphoma and some metastatic disease.
- Low grade gliomas & small asymptomatic meningiomas may simply be followed up with routine imaging.
- Palliative care – consider referral to Alexandra Unit for all.
Prognosis
- Varies according to multiple factors such as tumour type, age and co-morbidities of patient, type of surgery needed & availability of adjuvant treatments.
- Malignant glioma survival tends to vary from a few weeks to several months.
- The best guess of tumour type from radiological appearances alone can be wrong. After any type of surgical intervention, pathology result available within 7-10 days, for discussion with patient and family at the ECNO Clinic. It is best not to discuss prognosis until there is tissue diagnosis available.
Links
- Guidance for the Management of Intracranial Tumours in the Acute Setting – NHS Lothian
- ECNO Referral Form [docx]
- Brain Mets Referral Form [docx]
- NOTE – Referrals will only be accepted on these forms and MUST be typed, NOT Handwritten.