Brain Tumors with Significant Mass Effects with Brain Stem Compression with No

Histologic Diagnosis: the Role and Treatment Consideration of Radiotherapy

Case Number: RT2009 - 179(M) Potential Audiences: Intent Doctor, Oncology Special Nurse, Resident Doctor Purpose: to present a case with brain tumors with mass effect to compress the brain stem with no histologic diagnosis; to discuss the role and treatment consideration of radiotherapy Scenario: You are radiotherapy (RT) Intent Doctor/Special Nurse/Resident Doctor, and you are assigned to evaluate the following patient before visiting of your RT attending physician. Please review the following description carefully; your RT attending physician will visit this patient later and discuss with you after your review. Case Presentation:

This 100–year-old female patient, 蔡 OO, was referred to us for radiotherapy assessment of ‘brain tumors’.

S: 1. In 2008/07, the 100-year-old woman admitted due to vomiting and general weakness for

1-2 months. Brain MRI showed left cerebella tumors and old lacunars infarct at right basal ganglion.

2. On 2008/07/12, you visited this patient in the ward. Histories: bed ridden for several months Review of systems: right eye blindness for several years; weakness; frequent falling down

injury for several months; vomiting for 10+ days O:

1. General Condition: ECOG: 4, lying on bed, speech: relatively OK 2. Physical Examinations:

(1). HEENT & SCF: No LNs; mild pale; right eye blindness (2). CHE: neg. (3). ABD: no tenderness (4). Back & Spine: no significant knocking pain (5). Extremities: free movement with muscle power of 4 on all four limbs (6). Others: neg.

3. ***Pathology: no formal pathology at visiting. 4. Images:

(1). Brain MRI and CT in 2008/07: There are two tumors over the left cerebellum (46.4x45.2x27.2 mm and 29.7x28.4x16.8 mm in size); brain lacunars infarction (2). CXR in 2008/07: suspect lesions behind the heart.

5. Others: no tumor makers

Key Image(s): Fig. 1.

Fig. 2.

Fig. 3.

Questions & Discussions: (Please answer the following questions commented from your RT attending

physician.)

Q1: What are your findings/interpretations for the above key image(s)? Q2: What is your clinical cancer stage, according to the AJCC 2006, for this

case? Q3: What is your pathologic cancer stage, according to the AJCC 2006, for

this case? Q4: What are your Oncology Diagnosis / Assessments for this case? Q5: What is your Oncology Plan for this case? Q6: What is your Radiotherapy Plan for this case?

(Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

Questions & Discussions: (with potential answers) (Please answer the following questions commented from your RT attending

physician.)

Q1: What are your findings/interpretations for the above key image(s)? A1: As described in the last attached page. Q2: What is your clinical cancer stage, according to the AJCC 2006, for this

case? A2: No cancer stage can be defined in current condition. Q3: What is your pathologic cancer stage, according to the AJCC 2006, for

this case? A3: No cancer stage can be defined in current condition. Q4: What are your Oncology Diagnosis / Assessments for this case? A4: 1. Oncology Diagnosis: Multiple brain tumors, over the left cerebellum, the largest one

near 5 cm, nature? Highly suspected malignancy 2. RT may be indicated under current clinical diagnosis after patient's family agreed it;

however, given RT after histologically proven is the best managed way for this patient. Q5: What is your Oncology Plan for this case? A5: 1. Suggest:

(1). Arrange brain tumor biopsy for tissue proven if patient’s family agreed it (the most important diagnostic procedure now if suitable). (2). Arrange abdominal sono (3). Tumor maker survey: CEA, AFP, CA-199.

2. We will arrange 3DCT for preparing 3DCRT for this patient firstly. RT will be given after histologically proven, if any. Or, empiric RT may be given under current clinical diagnosis if patient's family agreed it.

Q6: What is your Radiotherapy Plan for this case?

(Please reply with the following form: Indication/Contraindication, Goal, Target & Volume, Technique, and Dose & Fractionation.)

A6: RT Plan may be designed as the following one: (1). Indication: RT may be indicted in current condition under the clinical diagnosis of malignant brain tumor with mass effect; however, RT is best indicated after a histologic diagnosis. (2). Goal: potentially curative in definitive RT setting (could be palliative only; depending on family’s decision) (3). Target & Volume: brain tumor with adequate margin (4). Technique: CT-based 3DCRT (5). Dose & Fractionation: 5400-6300 cGy in 30-35 fractions.

Further Readings & References: NCCN 2009 & Perez 2008 & AJCC 2006

Radiation Oncologist Hon-Yi Lin 2009/05/25

Key Image(s): (with marked) Fig. 1.

Fig. 2.

Fig. 3.

Fig. 2. The brain tumor shows heterogeneous enhancement in the MRI with T1 sequence and contrast (as the white arrow); the brain stem shows torsion appearance that is secondary induced by the brain tumor (as the white arrow head).

Fig. 3. The brain tumor shows heterogeneous enhancement in the MRI with T1 sequence and contrast (as the white arrow); the brain stem shows torsion appearance that is secondary induced by the brain tumor (as the white arrow head).

Fig. 1. The brain tumor shows heterogeneous enhancement in the MRI with T1 sequence and contrast (as the white arrows); and, in this cut, it seems that two tumors are in place with attached tightly each other.