Neuro-Oncology Tumour Management
There are a large number of different types of brain tumour. The guidelines below give an outline of possible management of a particular tumour but the oncologist will explain the details of management specific to each patient's individual care plan.
LOW GRADE GLIOMA
(astrocytoma, oligodendroglioma, mixed glioma, glioneurocytoma & DNET)
Patients will receive maximum safe resection.
Patients with high-risk features will be offered post-operative radiation. These features are at least three of the following: age 40 years or greater; largest preoperative diameter of tumour of 6 cm. or greater; tumour crossing midline; tumour subtype of astrocytoma or astrocytoma dominant; or preoperative function affected.
All other patients will be treated as follows:
(a) Patients without symptoms (except seizures) and no evidence of progression on MRI will be followed with regular imaging.
(b) Patients with new symptoms and / or progressive disease will have maximum safe surgical resection and then further management depends on extent of surgical resection, age of patient and subtype of glioma.
HIGH GRADE GLIOMA
(anaplastic astrocytoma, oligodendroglioma and mixed glioma, atypical glioneurocytoma and glioblastoma multiforme (GBM))
Patients will receive maximum safe surgical resection. Radiation treatment is recommended except for patients aged > 65 years with poor functional status. Patients aged < 65 will be offered in addition chemotherapy with temozolomide during and after radiation treatment (for up to one year).
Patients will receive maximum safe surgical resection. The patient will be followed with regular MRI scans unless there is:
1. concern regarding the tumour location;
2. the meningioma has aggressive features; or
3. the tumour is recurrent.
In these situations, postoperative radiation is recommended. Radiosurgery may be an option for small lesions.
Radiation treatment is recommended for surgically inoperable lesions. Radiosurgery may be an option for small lesions.
CHORDOMA / CHONDROSARCOMA
Patients will receive maximum safe surgical resection with postop radiation treatment in all cases.
PITUITARY ADENOMA & CRANIOPHARYNGIOMA
Patients will receive maximum safe surgery. If there is a complete removal or minimal remaining and there is no elevation of hormone levels, follow up with regular MRI scans is recommended. Radiation treatment is given in cases that have a large amount of residual tumour post-surgery or elevated hormone levels in cases where medical management is not feasible. Radiation is also recommended in recurrent cases and radiosurgery may be an option in small tumours.
Patients receive a biopsy or surgical resection (when needed) and are then treated with chemotherapy for 10 weeks and then whole brain radiation.
MEDULLOBLASTOMA / PNET
Patients will receive maximum safe surgical resection and will then be treated with radiation to the whole brain and spine followed by a boost to the tumour volume. For patients with higher risk of recurrence, chemotherapy is added during and for up to one year after radiation treatment.
All patients with brain metastases will be treated with whole brain radiation treatment, unless their condition will not allow. If the patient has a single large metastasis, this may be surgical resected first. Smaller metastases and patients with 1-3 lesions, may be treated by radiosurgery as well as whole brain treatment if their primary cancer and any other disease is controlled or potentially controllable with chemotherapy or radiotherapy to other parts of the body.
BRAIN STEM GLIOMA
No surgery is recommended if glioma is a diffuse type in the brain stem itself. If largely outside the brain stem, a biopsy or debulking surgery may be possible. Radiation treatment post surgery is recommended and chemotherapy may be offered in selected cases.
EPENDYMOMA & ANAPLASTIC EPENDYMOMA
Patients will receive maximum safe surgical resection with a gross total resection attempted where possible. Postop radiation treatment is recommended in all cases to the site of the tumour in those with no spread to other parts of the brain and spine, or to the whole brain and spine if there is spread.
(pineocytoma and pineoblastoma)
Patients will receive maximum safe surgical resection. Postoperative radiation treatment is recommended in most cases of pineocytoma. Postoperative radiation treatment to the whole brain and spine with a boost to the tumour area along with chemotherapy is recommended in all cases of pineoblastoma.
Patients will receive maximum safe surgical resection with a gross total resection attempted where possible. Postoperative radiation treatment is recommended in most cases unless a gross total resection is achieved (when patients can be observed with regular MRI scans).
HAEMANGIOBLASTOMA & HAEMANGIOPERICYTOMA
Haemangioblastoma will be resected surgically and not usually followed by radiation treatment. Haemangiopericytoma patients will receive maximum safe surgical resection followed by postoperative radiation treatment. Radiosurgery may be an option for small tumours.
GERM CELL TUMOURS
(germinoma and non-germinomatous germ cell tumour (NGGCT))
Patients will receive maximum safe surgical resection. Radiation treatment is recommended post surgery for all patients, the volume treated depending on the type of tumour. Chemotherapy in addition is recommended for NGGCT.