CNS Neoplasms

What are primary brain tumors?

Originate directly from cells in the brain

What are metastatic brain tumors?

Originate from tissue outside of the brain (most commonly Lung, Breast, Melanoma)

What is a grade I brain tumor?

-Most discrete, slow growing

-Example: Pilocytic astrocytoma

What is a grade II brain tumor?

-Slow growing, invade adjacent normal tissue, may recur

-Example: Astrocytoma, Oligodendroglioma, Oligoastrocytoma

What is a grade III brain tumor?

-Active reproducing abnormal cells that infiltrate

-Example: Anaplastic astrocytoma, Anaplastic oligodentroglioma

What is a grade IV brain tumor?

-Most malignant, rapid proliferation and infiltration

-Example: Glioblastoma

What are most common brain tumors?

-Gliomas

-Meningiomas

-Matestases to the brain

What are the most common Spinal cord tumors?

-Metastases to the spinal cord

-Meningiomas

-Neurofibromas

What is a brain meningioma?

-Second most common primary intracranial tumor in adults (37% of all brain tumors)

-Slow growing

-Most common of the benign brain neoplasms

-Often found incidentally during imaging or autopsy

— Approx. 25% symptomatic when diagnosed

What is a brain Glioblastoma (GBM)?

-Most common primary brain tumor in adults

-Classified as Grave IV astrocytoma

-Frequently occurs in the frontal lobe

— Can also occur in the temporal, parietal, or occipital lobes, with rare occurrence in the cerebellum, brain stem or spinal cord

-Prognosis: Median survival rate of 12-18 months following diagnosis

What are characteristics of metastases of the brain and spinal cord?

-Spread to brain through arterial circulation or lymphatic system from primary systemic cancer site — Lung, breast, melanoma

-Majority of brain tumors (60% of all brain tumors)

-Approx 20-40% of people with systemic cancer

-Frontal lobe is the most common site in the brain

-Spinal cord

— Thoracic level (70%)

— Lumbosacral level (20%)

— Cervical (10%)

-Poor prognosis: generally < 1 year and treatment is often palliative

What is the clinical presentation of spinal cord tumors?

-Pain

-Burning/aching

-Sensory changes

-Numbness, hyperasthesia

-Motor impairments

-Weakness, hypo/hyperreflexia, impaired bladder/bowel function, ataxia

What is the general characteristics of brain tumors?

-Type, size, and site of tumor determine presentation Initial/General signs :

-Headache: 1/3 cases initially; develops at some time during disease course in 70%

-Generalized, intermittent, non specific, often same side as tumor

-Worse in morning, improves later in day (15-36%)

-Intensified by activity that increases ICP (stooping, straining, exercise, coughing)

-Interrupts sleep (10-32%)

-Recent onset HA that is more severe or of different type than usual

-New onset HA in previously asymptomatic person

-Associated with N/V (30-40%), papilledema, or focal neurological signs

What is the clinical presentation of brain tumors?

-Seizure: Presenting symptom in 1/3 cases; occurs in 50-70% during disease course

-10-20% adults with new onset seizures have brain tumors

-AMS: Initial symptom in 15-20% of cases

-Vision deficits: decreased visual acuity, diplopia, visual field deficits

-Focal neurological deficits

-Elderly patients are more likely to present with confusion, aphasia, or memory loss; less likely to present with headaches and seizures

What are signs and symptoms of a frontal love brain tumor?

-Delayed initiation/cognitive impairments

-Hemiparesis

-Seizures

-Broca's aphasia -Dominant

-Gait difficulties

-Personality changes

-Disinhibition

-Irritability

-Impaired judgment

-Lack of initiative / apathy

What other signs and symptoms of a temporal lobe brain tumor?

-Highest incidence of psychiatric disturbance and seizures

-Anterior aspect: seizures when tumor becomes large (can be clinically silent until large)

-Lateral hemispheres: auditory and perceptual changes

-Medial aspect: changes in cognitive integration, long term memory, learning, emotions

-Dominant lobe: anomia, agraphia, acalculia, Wernicke's aphasia

What are signs and symptoms of a parietal lobe brain tumor?

-Contralateral sensory loss

-Visual-spatial deficits

-Homonymous visual deficits/ neglect

-Agnosias

-Apraxias

-Language comprehension impairments

-Dominant lobe: aphasia, seizures

-Non-dominant lobe: contralateral neglect, inability to recognize deficits

What visual clinical signs of a occipital lobe brain tumor?

-Disorders of eye movements

-Homonymous hemianopsia

-Occasion ally visual seizures

-Parieto-occipital junction: visual agnosia and agraphia

What are signs and symptoms that occur from a cerebellum brain tumor?

-Headache, nausea/vomiting

-Ataxia

-Ipsilateral dysmetria

-Dysdiadochokinesia

-Intention tremor

-Nystagmus

-Pediatric astrocytomas

What are signs and symptoms that occur from a brainstem brain tumor?

-Insidious onset of symptoms

-Gait disturbances

-Diplopia

-Dysphagia

-Headaches, vomiting

-Facial numbness/ weakness

-Altered consciousness/ attention

-Apnea, hypoventilation, orthostatic hypotension or syncope

What is the medical management of brain tumors?

-Surgery

-Radiation

-Chemotherapy

What complications possible with brain tumor surgery?

-Focal deficits

-Hydrocephalus

-Hemorrhage

-Brain Edema

-Infection

-Development of seizures

What side effects of brain tumor radiation?

-Fatigue

-Occasional Nausea

-Myelosupression

-Headaches

-Possible worsening of neurological symptoms

-Immunosuppression

What side effects of brain tumor chemotherapy?

-Nausea/vomiting

-Fatigue

-Neuropathy

-Thrombocytopenia (platelet levels <150,000 cells/uL)

—Strenuous exercise and straining could precipitate a hemorrhage (skin, muscles, eyes and brain)

What benefits of corticosteroids with brain tumors?

-Reduction in inflammation

-Increase in appetite

-Adjunctive treatment for pain management and nausea control

What are the side effects of corticosteroids with brain tumors?

-Morbid weight gain,

-Cushingoid syndrome

-Hyperglycemia/diabetes

-Myopathy

-Increased susceptibility to infections, osteoporosis, psychiatric symptoms, and adrenal insufficiency.

What are side effects of anti-convulsants and brain tumors?

-Slowing of their cognitive functioning, altered reaction time, confusion, and even movement disorders such as ataxia or dysarthria

What is cancer-related fatigue?

An unusual persistent subjective sense of tiredness related to cancer or cancer treatment that interferes with usual functioning

What factors are associated with cancer-related fatigue?

-De-conditioning

-Treatment effect

-Metabolic/endocrine changes

-Infection

-Anemia

-Nutrition

-Depression

What is cancer-related fatigue treated with?

-Education

-Exercise

-Behavioral/coping strategies

-Nutritional adjustments

-Medical management

What is restorative cancer rehab?

-Targeted interventions to alleviate functional impairments and restore function.

-Return the patient to a pre-illness level of functioning without residual disabilities from disease of treatment.

What is supportive cancer rehab?

-Interventions to optimize function for those who experience disability after cancer treatments.

-Persistence of the disease, continued need for treatment, and emotional, social, sexual, and vocational perspective

What is palliative cancer rehab?

-Intervention to maintain function and quality of life.

-Increasing loss of function.

-Eliminate or reduce complications of the disease process, provide comfort and emotional support for the patient and family.

What are considerations for physical therapy rehab for cancer?

-Phase of Cancer Rehabilitation

-Neurological examination and prognosis related to neurological recovery

-Patient and family goals

-Cancer prognosis and anticipating fluctuations and/or potential decline in function

What does cancer PT rehab look like?

-Aerobic + Resistance Exercise @ Moderate Intensity

What is goal setting like for cancer rehab patients?

-Wide range of possible goals for this population ranging from independent mobility and return to work to caregiver training

-Realistic, patient-centered goals

-Estimate patient status at discharge — Current level of function

-Prognosis

-Disease course

-Consider patient and caregiver/family goals

What is discharge planning like for cancer patients?

-Transition to home vs SNF vs hospice

-DME

-Thorough FED

-Community Resources

-Support groups

What are DME considerations for cancer patients?

—Wheelchair

▪ Manual vs. powered

—Slide board

—Hospital bed

▪ Mattress

—Lift

▪ Mechanical

▪ Electric

What is palliative care?

-Is a holistic approach that includes an interdisciplinary specialty medical care model for patients facing serious illnesses as well as families and direct caregivers.

• Includes:

1. Evidence-based curative and rehabilitative medical intervention options

2. Provision of truthful information

3. Open-minded discussions

4. Cultural sensitivity

What is hospice care?

Encompasses all aspects of palliative care with the omission of curative approach interventions