CNS Case
Presentation
By: Grace Schiefer
64 yr old female
Glioblastoma
Diagnosis
Right Frontal Lobe
Grade 4
• IDH1 negative, ATRX intact
Anatomy
What are the primary lobes
and structures of the brain?
1. Frontal Lobe
2. Temporal Lobe
3. Brainstem
4. Cerebellum
5. Occipital Lobe
6. Parietal Lobe
Structures
CSF Flow
Lateral • Through Intervertebral
Ventricle Foramen
s
Third • Through Cerebral
Ventricle Aqueduct
Fourth • Spinal Canal
Ventricle
Functions of the Brain4
Right Side Frontal Lobe
o Creativity oAttention
oConcentration o Personality
o Imagination
oSelf-Monitoring o Inhibition of
o Intuition oOrganization Behavior
o Conceptual oExpressive Language o Emotions
o Empathetic
(Speaking)
o Problem Solving
oMotor Planning &
o Figurative Initiation o Judgment
oAwareness of
Abilities & Limitation
Brain Injuries4
Right Side
o Visual-spatial impairment
o Visual memory deficits
o Left neglect
o Decreased awareness of deficits
o Altered creativity and music perception
o Loss of “the big picture” type of thinking
o Decreased control over left-sided body
movements
Medical History
Allergies:
Personal History: o Morphine
o Lynch Syndrome
o Depression
o Essential
Previous Surgery:
o Ankle Surgery - right
hypertension- benign
o Mitral value prolapse o Skin Lesion
o skin cancer removed
o Asthma
o Muir-Torre Syndrome o Cholecystectomy
o Hysterectomy
o Bilateral Knee Replacement
Social History
Previous 5 pack year smoking Smoked 1 pack a day for five years
history Quit 31 yrs ago
Previous alcohol use
Never used smokeless tobacco
Never used drugs
Signs and Symptoms2
o Persistent headaches
Driving difficulties
o Doubled or blurred vision
Loss of memory
o Vomiting
Noticed most by husband
o Loss of appetite
Left side weakness
o Changes in mood and personality
Less interested in hobbies
o Changes in ability to think and learn
Changes in mood and personality
o New onset of seizers** Noticed most by husband
o Speech difficulty of gradual onset
Glioblastomas3
o Malignant grade 4 tumors of the brain and CNS
o Generally found in the cerebral hemisphere
o Frontal Lobe
o Diagnosed as either IDH-wildtype or IDH-mutant
o IDH-wildtype glioblastomas are more common/ more
aggressive/ have worse prognosis
o Abnormal astrocytic cells
o Infiltrative and invade
o Opposite side of the brain
o Rarely spread outside of the brain
o Glioblastomas may arise de novo
o most common form of glioblastoma
o more aggressive and tend to affect older patients
CNS and Brain Tumors
o 22,910 adults diagnosed with brain and
other nervous system tumors
o 12,630 men
o 10,280 women
o 13,700 of these diagnoses will result in
death
EPIDEMIOLOGY3,1
Glioblastoma
o 15% of all brain tumors (primary and malignant)
o 52% of all primary
o Ages 45-70
o slightly more common in men than in women
o IDH mutant glioblastomas account for
approximately 10% of all glioblastomas
CNS and Brain Tumors
• Mostly unknown
• Genetic link
Glioblastoma: unknown
ETIOLOGY7
Risk Factors:
o Age
o Exposure to radiation
o Family history of Glioma
Grading1
G1 Well differentiated (closely resembles the normal cells)
G2 Moderately differentiated
G3 Poorly differentiated
G4 Undifferentiated (does not resemble the normal cells)
•Most malignant
•Gliobastoma multiforme (G
•Raid growth, aggressive BM)
WHO Grade IV •Widely infiltrative •Pineoblastoma
•Rapid recurrence •Medulloblastoma
•Necrosis prone •Ependymoblastoma
Detection and
Diagnosis2,5
o Neurological Exam
o Imaging
o CT
o MRI
o w/ Contrast
o PET
o MRS
o spectroscopy to examine chemical profile
o Biopsy
CT
12/17/19
first measures 3.8 x 4.5 x 4.0cm
smaller lesion measures 2.1 x 2.6 x 1.6cm
MRI
12/20/19
TIMELINE
12/17/19 12/20/19 12/23/19 12/25/19 1/6/20 1/21/20 3/3/20
• CT • MRI • Surgery • Post OP • CT Sim • Started • Last
MRI RT and Day of
Chemo RT and
Chemo
Treatment2,5
Typical Patient Treatment
o Surgery o Right frontal craniotomy
o Craniotomy o Intraoperative MRI assistance
o Chemotherapy o Chemotherapy
o Wafers can be placed directly on o Temozolomide 75mg/m2 daily x 42 days
brain during surgery
o Radiation Therapy
o Temozolomide pill after surgery
o 6000 cGy in 30 Fx
o Radiation
o Following ChemoRT:
o EBRT
o 4 weeks of rest followed by initiation of
o VMAT/IMRT
adjuvant therapy with temozolomide for
o Stereotactic up to 6 subsequent cycles
TREATMENT
SET
UP:
Organs at Risk
oBrainstem - 5000 cGy
oOptic Chiasm – 5000 cGy
oOptic Nerves – 5000 cGy
oRetinas – 4500 cGy
oLens – 1000 cGy
oLacrimal Glands – 2600 cGy
oHippocampus** – 2300 cGy
Arc 1:
G182-18
Arc 2:
T315
G1-182
Arc 3:
T270
G182-1
Side Effects8
Acute: Chronic:
o Fatigue o Possible focal necrosis
o Erythema o Possible long-term brain damage causing
o Nausea and Vomiting
symptoms like a stroke
o Headaches or seizers o Possible decreased hormone production
o Hair loss o Decreased intellect or dementia
o Temporary brain swelling
Side Effects
Management
o Nausea and Vomiting
o Zofran
o Fatigue
o Dexamethasone 2 mg daily
o Mood swings
o met with PCP who is managing
o Disorientation
o diarrhea (pre-morbid issue) with
Incontinence and bowel urgency
o oxybutynin, scheduled lomotil,
Hair lose
o hyoscyamine
Moderate erythema
o Rest
o Tremor in left hand
o Light exercise
o Denies headaches, vision changes, or
other neurological symptoms most days
Survival6
Often determined by:
Age of diagnosis
Grade
Type of tumor
Size and location
Cell type/ mutations
If it can be removed in surgery
Spread
Metastasis
Inside Brain
Outside Brain
References
[Link]. (2020). Brain Tumors - Classifications, Symptoms, Diagnosis and Treatments. [online] Available at:
[Link] [Accessed 4 Mar. 2020].
[Link]. (2020). Glioblastoma Multiforme – Symptoms, Diagnosis and Treatment Options. [online] Available at:
[Link] [Accessed 4
Mar. 2020].
[Link] Brain Tumor Association. (2020). Glioblastoma (GBM) - American Brain Tumor Association | Learn More.
[online] Available at: [Link] [Accessed 4 Mar. 2020].
[Link] Injury Association of America. (2020). Brain Injury Basics | Brain Injury Association of America. [online]
Available at: [Link] [Accessed 4 Mar.
2020].
[Link]. (2020). Survival Rates for Selected Adult Brain and Spinal Cord Tumors. [online] Available at:
[Link]
[Accessed 5 Mar. 2020].
References
6. Mayo Clinic. (2020). Glioma - Symptoms and causes. [online] Available at: [Link]
-conditions/glioma/symptoms-causes/syc-20350251 [Accessed 4 Mar. 2020].
7. [Link]. (2020). Glioblastoma - Overview - Mayo Clinic. [online] Available at:
[Link] [Accessed 4 Mar. 2020].
8. Texas Oncology. (2020). Radiation Therapy for Brain Tumors. [online] Available at:
[Link] [Accessed 5 Mar. 2020].
