Case Study

CNS CANCER - MENINGIOMA

-Courtney Chaney

Patient Information
White
32

Female

Years of Age

Social History

Married, Mother of one

Works in finance

Never Smoked

Socially Drinks

Breastfeeding

Medical History

Recent Child Birth

Dysmenorrhea

Meningioma

Family History

Asthma

Allergic to Codeine

Breast Cancer (mom,

aunt)

-tested for carrier but was

negative

Prostate Cancer

Hypertension

diabetes

Surgical History

MANDIBLE FRACTURE SURGERY

ADENOIDECTOMY

APPROACH CRANIAL FOSSA ANTERIOR

ORBITOCRANIAL

EXCISION LESION CRANIAL FOSSA MIDDLE

INTRADURAL

EXCISION LESION CRANIAL FOSSA ANTERIOR

EXTRADURAL

CRANIOPLASTY FOR SKULL DEFECT

ASSISTANCE STEREOTACTIC NAVIGATION

CRANIAL INTRADURAL ADD-ON PX

EXCISION BONE TUMOR CRANIAL W/ OR

W/O OPTIC NERVE DECOMPRESSION

EXCISION BRAIN TUMOR INTRACRANIAL

TRANSNASAL APPROACH
NEUROENDOSCOPIC

ASSISTANCE STEREOTACTIC NAVIGATION CRANIAL EXTRADURAL ADD-ON

PX
EXCISION BRAIN TUMOR INTRACRANIAL TRANSNASAL APPROACH
NEUROENDOSCOPIC

ASSISTANCE STEREOTACTIC NAVIGATION CRANIAL EXTRADURAL ADD-ON

PX
INTRAUTERINE DEVICE INSERTION

CESAREAN SECTION DELIVERY

CESAREAN APPROACH

CRANIAL FOSSA ANTERIOR ORBITOCRANIAL

EXCISION LESION CRANIAL FOSSA MIDDLE INTRADURAL

ASSISTANCE STEREOTACTIC NAVIGATION CRANIAL INTRADURAL ADD-ON

PX

Presenting Signs & Symptoms

Localized headaches

Blindness of left eye Jan 2015

Proptosis 2013

Chronic rhinitis Dec 2014

Seizures
Hyperostosis - 2013

Behavioral changes

Personality changes

Ptosis Dec 2013

Blurry vision - 2013

Diplopia - Dec 2014

Speech pattern changes

Coordination skills changes

Vision abnormalities - Dec 2014

Mental changes

Nausea & vomiting Jun 2013

Motor skill changes

Vertigo Jun 2013

Sensory Function Changes

Orbital CT showed expansive tumor on left sphenoid wing

Edema cerebral -2015

Reflex changes

ICP symptoms

Papilledema

Defective memory

Aphasia

Pathology

Malignant neoplasms of the cerebral meninges

- typically happens in the dura mater

left greater sphenoid wing intraosseous meningioma involving the cavernous

sinus about 20 % of meningiomas are sphenoid wing meningiomas

Anatomy & Physiology

Meninges are the protective outer

covering of the brain

Meninges are Dura Mater, Arachnoid,

Pia Mater

Dura Mater- hard

Arachnoid-

Pia Mater- adheres directly to the

brain

Brian is made up of 6 lobes and sits

in the skull

The greater wing of the sphenoid

helps create the cranial fossa of the
skull

No lymph nodes in the brain

Epidemiology

1.5% of all malignancies are in the brain

1/3 of all CNS are meningioma

5.2 our of 100,000 people in the population a year

Most CNS CA effects patients 50-80 yr. olds

Meningiomas affect more women than men, 2:1

-Atypical and anaplastic meningiomas show a male predominance
-Childhood meningiomas occur more often in males

Meningiomas associated withneurofibromatosis type 2(NF2) tend to occur in

younger individuals

meningiomas are rather uncommon in children and almost never occur in infants

Etiology

Ionizing Radiation

Head Injury

Hormones (Estrogen & Progestogen)

Dental Radiographic exams

Occupational exposure
- healthcare workers & health care workers show higher incidence

Environmental Exposure

Lifestyle and Dietary Factors

- cell phones, nitrates, hair dye, and smoking

Genetic Factors (>5% of etiology of brain tumors)

Recklinghausens disease and autosomal dominant disorders (NF2)

Family has history

Histopathology

Anaplastic Meningioma & Atypical Meningiomas - >10%

WHO grade I includes the following histologic patterns:

Meningothelial (syncytial) meningioma

Transitional (mixed) meningioma

Fibroblastic (fibrous) meningioma

Psammomatous meningioma

Angiomatous (vascular) meningioma

Microcystic meningioma

Secretory meningioma

Lymphoplasmacyte-rich meningioma

Metaplastic meningioma

WHO grade II includes the following histologic patterns: Chordoid meningioma

Clear cell meningioma (intracranial) (showing signs of this now)

Atypical meningioma

WHO grade III includes the following histologic patterns:

Papillary meningioma

Rhabdoid meningioma

Anaplastic (malignant) meningioma

WHO Grading System

Grade I Benign meningioma: This non-cancerous type of brain tumor grows

slowly and has distinct borders. Approximately 78-81% of meningiomas are
benign (non-cancerous).

Grade II Atypical meningioma: Approximately 15-20% of meningiomas are

atypical, meaning that the tumor cells do not appear typical or normal.
Atypical meningiomas are neither malignant (cancerous) nor benign, but may
become malignant. Grade II atypical meningiomas also tend to recur and grow
faster.

Grade III Malignant or anaplastic meningioma: Malignant or anaplastic

meningioma is an aggressive type of brain tumor that tends to invade the
parts of the brain nearest to the tumor. Approximately 1-4% of meningiomas
are grade III (cancerous).

Patient Grading & Staging

Grade 1 on WHO Grading System

On recent biopsy though Cells have mucinous, myxoid or vaguely chordoid pattern
and even occasional PAS-positive clear cells

cannot be classified histologically as a specific WHO

grade II variant, the clinical behavior, elevated Ki-67 labeling index and
partial clear cell and chordoid features suggest a WHO grade II lesion

No universal staging system

Imaging

Orbit CT revealed initial tumor

Head CT

Brain MRI confirmed meningioma and placement

Head CTA

Craniotomy (LEFT ORBITO-FRONTO-TEMPORAL CRANIOTOMY FOR RESECTION

OF A SPHENOID WING MENINGIOMA)
- tumor reoccurred and had second craniotomy

Biopsy

CT Simulation Plan Treatment

Treatment Options

Surgery Subtotal resection or Gross total resection

Radiation Therapy- Post Op (after 2nd surgery) 54-59 Gy

-if after gross total resection 6000 GY
- stereotactic or external beam

Chemotherapy Not Recommended

Treatment Plan

Lt. Base of Skull

4-field V-Mat

6MV

Prescription of 5220 cGy

29 Fx

180 cGy/day

Treatment Plan

Treatment Plan Parameters

Supine, head first

Brain Lab aquaplast mask

Headrest C

Hands on Chest

2mm shims

2mm clips

Conformal board

MLCs

Treatment Borders

Based upon location and size of tumor

Try to block as much healthy tissue as you can while still effectively treating

Dose Distribution

Dose Distribution

DRRs

Critical Structure (cGy)

Optic Chiasm 5000

Optic Nerve 5000

Brain 4700

Lt. Parotid Gland - 3200

Brian Stem - 5000

Retinas 4500

Spinal Cord- 4700

Ears 3000 or 5500

Eyes 1000

Lens - 1000

TMJ joint & Mandible 6000

Lacriminal Gland - 2600

Side Effects

ACUTE

-hair loss, fatigue, skin erythema, headaches, nausea, brain swelling, speech
problems, muscle weakness, vision problems
-Medicine can be given for headaches and nausea
- Corticosteroids or steroids
- less strenuous activities and naps for fatigue

CHRONIC

- reoccurrence, decreased intellect, memory impairment, confusion,

personality changes, alteration of normal function

Prognosis and Survival

Survival rates for meningioma depend on several factors, including the age of
the patient and whether the tumor is cancerous

93.1% of benign meningiomas, 65.4% of atypical meningiomas, and 27.3% of

malignant meningiomas were cured by surgery

Metastatic Sites

Meningioma very rarely spreads to other parts of the body

If they do, lung is the most common followed by the abdominal viscera,
bones, and lymph nodes

References

1. IHIS

2. Aria

3. Notes

4. John Hopkins University and Health Staff. Treatment for Meningiomas.

2014. February 26, 2015. http://www.hopkinsmedicine.org/

5. Fung, K. (2014, April 21). Meningiomas Pathology (A. Adesina, Ed.).

February 26, 2015. http://emedicine.medscape.com/

6. Washington, C. (2010). Central Nervous System Tumors.Principles and

practice of radiation therapy(3rd ed.). St. Louis, Mo.: Mosby Elsevier.