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Neurologic
Complications of
Cancer
Dr. Kathryn Giles
MD, MSc, FRCPC
Cambridge Ontario
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Copyright © 2017 by Sea Courses Inc.
All rights reserved. No part of this document may be
reproduced, copied, stored, or transmitted in any form or
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including photocopying, recording, or information storage
and retrieval systems without prior written permission of
Sea Courses Inc. except where permitted by law.
Sea Courses is not responsible for any speaker or
participant’s statements, materials, acts or omissions.
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Faculty/Presenter Disclosure
• Faculty: Dr. Kathryn Giles
• Relationships with commercial interests:o Grants/Research Support:
• Biogen Idec, Genzyme
o Speakers Bureau/Honoraria:
• Bayer, Biogen Idec, EMDSerono
o Consulting Fees:
• Biogen Idec, EMDSerono, Genzyme
o Other:
• none
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Disclosure of Commercial Support
• Potential for conflicts of interest:
o none
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Neurological Effects
of Cancer
➢Direct
✓Primary
✓Metastatic
➢Indirect
✓Paraneoplastic
✓Treatment
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Primary Malignancy
• BRAIN
o When in hemispheres
usually present with
seizures, personality
or cognitive change,
visual change or
headache
o Cerebellar present
with raised ICP,
balance
o Brainstem multifocal
• SPINAL CORD
o Cord syndrome
o Acute/subacute
o Often bladder and
bowel
o Often painless
o Usually multiple
segments
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Neurological Effects
of Cancer
➢Direct
✓Primary
✓Metastatic
➢Indirect
✓Paraneoplastic
✓Treatment
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Direct Effects of Metastatic Cancer
• PNS
o Root
o Plexus
o Nerve
• CNS
o Brain
o Spinal Cord
Localization
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CNS
• Brain
o Focal Symptoms/Deficit
o Cognitive/Personality Change
o Headache
o Diagnosis
o CT with contrast
o MRI
o CSF (meningeal involvement)
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CNS
• Spinal Cord
o Focal/cord deficit
o Pain
o Diagnosis
• X-ray
• MRI
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PNS• Root
o Radicular Symptoms
o Often multiple
o +/- Spinal cord
o Pain
o Diagnosis
• MRI
• EMG
• CSF
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PNS• Plexus
o Multiple root/nerves
o Pain
o Diagnosis
• MRI + gadolinium
• EMG
• CSF
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PNS• Peripheral Nerve
o Rare
o Usually indirect
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Treatment of Secondary Cancer in the Nervous
System• Diagnosis
• Referral
• Pain
o Narcotics/Opioids
o Pregabalin (Lyrica)
o Cannabinoids (Sativex, Cesamet/Nabilone, medical
marijauna)
• Treatment of the Tumor
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Neurological Effects
of Cancer
➢Direct
✓Primary
✓Metastatic
➢Indirect
✓Paraneoplastic
✓Treatment
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Paraneoplastic Syndromes
• Immune mediated/onconeuronal antigens
• Cytotoxic T-cell responses (CD8+/CD4+)
• Precede tumor diagnosis in 60%
• Check CSF + blood for antibody (Anti-Hu, Anti-
Ri, Anti-Yo)
• Occult neoplasm presumed
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Paraneoplastic Syndromes
• Most common in:
o SCLC
o Breast
o Ovary
o Neuroblastoma
o Plasma cell tumors
• Acute/subacute onset
• Blood/CSF/MRI/PET
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Paraneoplastic Syndromes in CNS
o Cerebellar degeneration
• SCLC, Breast, Ovary, Lymphoma
• Anti-Yo
o Encephalomyelitis (Limbic encephalitis)
• Lung
• Anti-Hu
o Opsoclonus – Myoclonus
• Neuroblastoma, SCLC, Breast
• Anti-Hu, Anti-Ri
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Paraneoplastic Syndromes in PNS
oSensory neuronopathy (dorsal root
ganglion)
• Lung
• Anti-Hu
oSubacute or chronic sensorimotor
peripheral neuropathy
• Plasma cell dyscrasias, B-cell lymphoma
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Paraneoplastic Syndromes
of the Neuromuscular
Junction
o Lambert-Eaton myasthenic syndrome
• Fatigue, weakness, myalgia, paresthesias
• Cholinergic dysautonomia – dry mouth
• Characteristic EMG
• SCLC
• Anti – VGCC
• Treat with 3,4-diaminopyridine
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Paraneoplastic Syndromes of Muscle
• Dermatomyositiso Subacute muscle weakness, elevated CK
o dysphagia
o Skin changes
o Breast, lung, ovarian, gastric
o Anti-Jo
• Acute Necrotizing Myopathyo Solid tumors
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Paraneoplastic SyndromesTreatment
• Steroids
• IVIg
• Plasma Exchange
• Treatment of underlying tumor
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Indirect
Paraneoplastic Treatment
Chemo Radiation
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Chemotheraphy• Neuropathy
• Encephalopathy
• Acute cerebellar syndrome/ataxia
• Myelopathy
• Cerebral Vasculopathy
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Radiation• Brain
o Acute (hours to days)
• ↑ ICP
• vasogenic edema
o Early Delayed (weeks)
• Diffuse (somnolence), or focal
• demyelination
o Delayed (months to years)
• Diffuse (dementia), or focal
• glial and vascular destruction
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Radiation• Spinal Cord
o Early delayed (weeks)
• L’hermittes sign
• demyelination
o Delayed (months to years)
• Necrosis
• MND
• Arachnoiditis
• Glial and vascular destruction
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Radiation• Cranial Nerves
o Visual loss (retina, optic nerve, central
artery occlusion)
o Hearing loss ( radiation otitis)
o 12th nerve (hypoglossal)
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Radiation
• Plexopathy (brachial/lumbosacral)
o Delayed
o Fibrosis
o No pain
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Radiation• Radiogenic tumours
• Vascular abnormalities
• Endocrinopathies
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Summary• Neurologic complications of cancer are
common
• Think of them
• Refer
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QUESTIONS?