surgical management of cns tumors - cancerwa.asn.au
TRANSCRIPT
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Surgical Management of CNS Tumors
Mr Arul Bala Neurosurgeon
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Fifteen Years Ago …
Information involved in surgery
Implicit knowledge : surgeon’s knowledge (surgical practice, anatomy, pathology)
Patient’s observations : standard 2D MR and CT imaging
Explicit knowledge : anatomical atlases
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Modern Neurosurgery
Improved anatomical and functional information – Endoscopic surgery _ Intra-operative MRI – Information management - Patient-based - Evidence-based
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Intraoperative photodynamic diagnosis
Systemic priming agent (photosensitiser)
Uptake by tumor cells
Intraoperative light therapy to identify / resect / destroy tumor cells
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Goals of surgery for brain tumors
1. Providing diagnosis
2. Relieving symptomatic mass effect
3. Adjunct to postoperative therapies
4. Prolonging survival through cyto-reduction
5. Applying locally-delivered therapies
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Surgical Options
Biopsy
Craniotomy
Shunt
For hydrocephalus
For cysts
As adjunct or for inoperable/palliation
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Aids to Surgery Imaging
CT / MRI / X-ray
Metabolic function
PET
Relation to eloquent cortex
fMRI, fPET
Vascularity
Angiography / embolisation
Cortical Mapping
Awake / sedation / GA
Neuronavigation
CT/MRI
Intra-op MRI
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Post-Operative Care
Brain edema - Dexamethasone
Taper it!
Hyperglycemia
Gastritis
Seizures
Keppra
DVT/PE
Pituitary disturbance
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Neurologic Diagnosis
Intra-cranial lesions do one of three things Seizure Focal neurological deficit Raised intra-cranial pressure
Where is the lesion ?
Signs and Symptoms
What is the cause? Acute Subacute Chronic
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Increased Intracranial Pressure
History Headache Nausea/Vomiting Personality change
Examination
Papilloedema Drowsiness Causing apropriate neurological deficit
Investigation CT/MRI
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Types of CNS Tumors
Low Grade (I/II)
Intermediate Grade (III)
High Grade
(IV)
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Common observations of high grade patients
“Brain cancer”
Search for alternative/better therapies
Trials?
Major Depression
Usually do not return to work after diagnosis
Steady progression of disability over 12 months to death
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Common observations of the low grade patient
Better adjusted patients
Usually return to work
Chemotherapy takes a bigger toll
(compared to high grade)
A small group can still show aggressive
progression and die in the short term
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Summary
Awareness of slide no. 9
Image early or late based on clinical features
Follow-up patients if you don’t image them upfront.
Grade 3/4 CNS tumours remain a depressing disease to treat!