National Cancer Institute, AIIMS, New Delhi, India, profile picture
Uploaded byNational Cancer Institute, AIIMS, New Delhi, India
PPTX, PDF26,843 views

Spinal cord tumor

This document provides an overview of spinal cord tumors, including: - They constitute 3-4% of all CNS tumors and 6% of pediatric CNS tumors. - The most common types are astrocytomas and ependymomas. - Treatment involves surgical resection followed by radiation therapy if needed. - Prognostic factors include tumor type/grade, extent, and patient age/function.

Embed presentation

Downloaded 1,016 times
SPINAL CORD TUMOR DR DODUL MONDAL MD, DNB All India Institute of Medical Sciences, New Delhi Dodul Mondal
• INTRODUCTION • ANATOMY • EPIDEMILOGY • NATURAL HISTORY • CLASSIFICATION • ROUTES OF SPREAD • CLINICAL PESENTATION • DIAGNOSTIC WORKUP • PROGNOSTIC FACTOR • DISEASE SPECIFIC MANAGEMENT • CONCLUSION Dodul Mondal
INTRODUCTION • Rare tumor • Constitutes 3-4% of all CNS and 6% of pediatric CNS tumors • Oversimplified anatomical classification • Young children more affected than adults • Lack of RCT • Mainly retrospective series • Surgery and radiation mainstay of treatment • Judicious use of radiation important Dodul Mondal
ANATOMY CSF DURA INTERVERTEBRAL DISC SPINAL CORD VERTEBRAL BODY EPIDURAL SPACE Dodul Mondal
Normal transverse spine Transverse spine with extradural mass Intradural extramedullary mass Intramedullary massDodul Mondal
EPIDEMIOLOGY Primary Spinal Cord Tumors – Uncommon Primary Brain Tumor : Primary Spinal Cord Tumor = 20:1 (children) ** 5:1 (adult) Younger individuals affected more than adults Constitutes 3-4 % of all primary CNS tumors & 6% of CNS tumors of children** **CBTRUS-Statistical Report 2011 Dodul Mondal
EPIDEMIOLOGY cont…  Primary tumor of SC are more frequent in children & more than half occur below 10 years of age*  36% intramedullary 27% extramedullary 24% extradural 75% of intramedullary tumor were astrocytomas* **John K, Howard L. Weiner Pediatric Intramedullary Spinal Cord Tumors: Special Considerations . Journal of Neuro- Oncology Volume 47, Number 3 / May, 2000 Dodul Mondal
NATURAL HISTORY Mostly benign IM tumors produce damage by local invasion & cystic compression EM tumors compress, stretch or distort the cord & nerves May involve focally or entire length of spinal cord Dodul Mondal
CLASSIFICATION SPINAL CORD TUMOR Intra Dural EXTRAMEDULLARY Meningioma Nerve sheath tumor Vascular tumor Ependymoma INTRAMEDULLARY Ependymoma Astrocytoma Oligodendroglioma Extra Dural Metastatic Osteoid osteoma Osteoblastoma ABC Plasmacytoma / Myeloma Chordoma Chondrosarcoma Osteosarcoma Ewing’s sarcoma Epidural hemangioma Lipoma Extradural meningioma Nerve sheath tumor Lymphoma Dodul Mondal
ROUTES OF SPREAD Low Grade-Generally localized High Grade-Spread via CSF Occasionally hematogenous route to Lungs Lymph Node spread is generally not seen as CNS has no lymphatics Dodul Mondal
CLINICAL PRESENTATION Depends on the anatomical location & site of the lesion Local Focal Pain(75%): • In EM tumors pain is more in the night due to venous congestion Distal Neurological: Paresis & Numbness Autonomic Dysfunction Sensory Deficits Muscle Wasting Loss of Reflexes Failure to achieve milestones Gait disturbance Dodul Mondal
DIAGNOSTIC WORK UP GENERAL History Physical examination Complete neurological evaluation IMAGING Plain radiography MRI whole spine with contrast MRI brain CT myelography Intraoperative ultrasound LABORATORY TESTS CSF chemistry CSF cytology Dodul Mondal
RADIOGRAPHY/MYELOGRAPHY • Overall 50% lesions of primary spinal tumors detected with plain X-ray • Features are due to raised ICP • Erosion of pedicles • Increased AP diameter • Scalloping of posterior vertebral body • Scoliosis or kyphosis in children • Calcification in meningioma • Myelography in patients unsuitable for MRI • CT myelography better Dodul Mondal
COMPUTED TOMOGRAPHY • Better for bony lesions and bony extent detection • Extradural pathologic processes • Paraspinal soft tissue masses • Erosion of bone • Calcification of meningioma Dodul Mondal
MRI • Gd-DTPA enhanced MRI imaging modality of choice • CSF, white and gray matter, bone and bone marrow, fat, and flowing blood can be distinguished • MRI brain should also be done • Maximum impact in the field of spinal tumors amongst all spinal pathologies • Preoperative study of choice so as to narrow the differential diagnosis and guide surgical resection. • All spinal cord gliomas enhance • LP should be done after MRI Dodul Mondal
• Cord expansion-Essential imaging criterion for intramedullary spinal neoplasm* • MR sensitive to hemorrhage- can identify intratumoral bleeding • Cysts are common associated finding • Majority of intramedullary neoplasms show at least some enhancement • Contrast study essential: Enhancement useful in focal masses, especially hemangioblastoma and mets Contrast helpful in differentiating suspected neoplasms from other etiologies. e.g. infection, syrinx. Actual lesion smaller than area of cord enlargement-Useful to pinpoint sites for biopsy. • *Epstein et al: IM tumors of spinal cord , Journal of Neurosurgery1993;79:204-209. Dodul Mondal
PROGNOSTIC FACTORS Major factors: Tumor type and grade Tumor extent and location Patient age, presenting neurologic function Treatment-related factors: Tumor resectability Use of radiation therapy for certain tumor types Lower grade, younger age, and surgical resection were associated with significantly better overall survival and cause-specific survival for both astrocytomas and ependymomas* • Milano MT, et al. Primary spinal cord glioma: a Surveillance, Epidemiology, and end results database study. J Neurooncol2010;98(1):83–92 Dodul Mondal
PROGNOSTIC FACTORS…cont  Patients with ependymoma survive longer without recurrence than patients with astrocytoma  Rostral tumors have a worse survival and neurologic outcome  Cervical lesions had a higher surgical risk and complication rate  Tumors affecting the rostral or cervical spinal cord were more likely to be astrocytoma  Tumors in the caudal spinal cord, filum terminale , or cauda equina were more likely to be ependymomas  High histopathologic tumor grade is associated with a high rate of disability and death Extensive involvement of the spinal cord with an ependymoma is associated with a worse outcome Younger age is associated with a better than 5-year recurrence-free survival rate Dodul Mondal
MANAGEMENT OF INTRAMEDULLARY TUMORS • Most common: Astrocytoma, Ependymoma (95%) • Complete surgical excision without compromising neurologic function • Introduction of bipolar forceps • Microsurgical techniques, use of CUSA (Cavitron Ultrasonic Surgical Aspirator ) • CUSA allows aspiration of tissue fragments from within 1 mm of the vibrating tip • Intraoperative ultrasonography:  Localize the lesion  Define its extent  Characterize the tumor as cystic or solid  Facilitates placement of a myelotomy incision and initiation of tumor resection  Assess the progress of tumor resection and adjacent cyst drainage with internal spinal cord decompression • Risk of paralysis after surgery less Dodul Mondal
MANAGEMENT OF INTRAMEDULLARY TUMORS .. cont • Resection of astrocytic tumors begins from within the tumor at the initial midline myelotomy • Removal until interface between tumor and normal spinal cord evident • Complete excision achieved no postoperative therapy • Delaying adjuvant radiation important in children • Complete resection not achieved PORT • PORT can be delayed even after STE till time of recurrence • Recurrence assess for reresection and judicious use of PORT Dodul Mondal
ASTROCYTOMA  Low backache  Painful scoliosis  Thoraciccord (67%)*  Cervical cord (49%)  Entire spinal cord (holocord presentation)common in children (up to 60%) quite rarein adults  Isolated conus medullaris (3%)& rare infilum terminale  Less than 10% of pediatric and 25% of spinal cord astrocytomas are malignant .** *Epstein et al Adult IM Astrocytoma of SC,J of Neurosurgery 77:355-359;2002 **Stein et al.IM tumors in adults.Neurosurgery Clin of N America 1998:1:609-630 Dodul Mondal
ASTROCYTOMA Arise from the cord parenchyma not from the central canal, are usuallyeccentric within the cord Usually have poorly defined margins Multisegment involvement of the cord is rule Associated polar and intratumoral cysts. Usually low grade fibrillary Astro is MC type followed by anaplastic Astro GBM is rare. Dodul Mondal
ASTROCYTOMA cont..  Iso- to hypo intense relative to the cord on T1W  Hyper intense on T2W images  Enhancement is seen in all cord astrocytomas, Inhomogenous enhancement  Tumor, syrinx and cysts can be delineated on MR  Rare SC GBM has propensity of leptomeningeal spread in 60% of patients*  Completely resected tumor do not require PORT  Incompletely removed tumor PORT should be considered  Ciappetta et al, Spinal GBM: Report of 7 patients with spinal GBM and Review of literature.Neurosurgery 28:302-306,1991. Dodul Mondal
Treatment Recommendations for Pediatric Spinal Cord Astrocytoma Nadkarni TD,Childs Nerv Syst 1999;15:17-28Dodul Mondal
EPENDYMOMA  Most common intramedullary spinal neoplasm in adults*  Common in young adults  Common in male patients  Location: 2/3rd arise in lumbosacral region 40% arise from filum terminale *Torres et al: Intramedullary ependymoma of spinal cord , J Neurosurgery 62;523-532;1992 Dodul Mondal
 Arise from ependymal cells of the central canal, and symmetric cord expansion is the rule.  Slow growth and tends to compress adjacent spinal cord tissue rather than infiltrate it.  Usually histologically benign and have long and indolent course. EPENDYMOMA Dodul Mondal
HISTOLOGICAL TYPES  Cellular Ependymoma - mostly in cervical cord  Myxopapillary Ependymoma - exclusively in conus medullaris and cauda equina  Primary Anaplastic Ependymoma of spinal cord are rare  Other histological types:  Subependymal  Epithelial  Mixed Dodul Mondal
MR Imaging characteristics:  Iso or hypointense relative to spinal cord on T1.  Occasional hyperintense mass secondary to hemorrhage.  Hyperintense relative to spinal cord on T2.  Cap sign, a rim of extreme hypointensity (hemosiderin) seen at the poles of the tumor on T2W (20%—30%) …. thought to be secondary to hemorrhage.  Cord edema around the masses (60%). Dodul Mondal
Cysts In Ependymoma Cysts are a common feature Mostly non tumoral (polar) (70-80%) NON TUMORAL CYSTS Located at the poles of the solid portion of the tumor . Reactive dilatation of the central canal (syringomyelia). Not part of the tumor itself . No enhancement. TUMORAL CYSTS Contained within the tumor itself. Peripheral enhancement More in astrocytomas than ependymomas. Dodul Mondal
Filum Terminale Ependymoma (Myxopapillary) Dodul Mondal
EPENDYMOMA T 1W-HYPO to ISO T 2W-HYPERINTENSE T 1W- CONTRAST Dodul Mondal
EPENDYMOMA WITH BLEED Plain T1W sagittal  Iso to Hypo on T1  Hyper on T2  Bleeding-Hyper on T1  Enhancement  Homogeneous  Cap sign seen BLEED Dodul Mondal
Nadkarni TD. Childs Nerv Syst 1999;15:17-28 Treatment Recommendations for Pediatric Spinal Cord Ependymoma Dodul Mondal
Difference Between Astrocytoma and Ependymoma ASTROCYTOMA EPENDYMOMA Cervical & Thoracic cord LS spine, Cauda equina & conus medullaris Centrally located in cord Eccentric Hemorrhage uncommon Hemorrhage common Infiltrative with poorly defined margins(multiple segment inv.) Well defined due to pseudocapsule Heterogenous enhancement Homogenous enhancement Dodul Mondal
RADIOTHERAPY FOR INTRAMEDULLARY TUMORS • Dose: 50.4 Gy. 1.8 Gy per fraction for low grade tumor • 5 fractions per week • Dose for high grade tumor is 54Gy in 1.8Gy/fx • Limited data for dose response • Dose below 50Gy is associated with high failure rate • Where CSI is indicated, entire Craniospinal axis receives 36Gy to 45 Gy followed by boost to gross tumor to a dose of 50.4-54 Gy Dodul Mondal
RADIOTHERAPY TECHNIQUE CONVENTINOAL TECHNIQUE  Position: Supine/Prone  Usually direct posterior field  Superior and inferior border: Myelography defined gross tumor plus 2 vertebrae above and below  Lateral border: To include tip of the lateral process of vertebral body  Field placement should be judicious to avoid exit dose to vital OAR s  Cervical vertebra can be treated with bilateral parallel opposed fields  Lumbar region tumors can be treated with antero posterior field arrangement  Oblique wedge pairs can also be used for thoracolumbar region For female patients lateral fields may be better for lumbosacral spine  Dose distribution should be homogenous and toxicity minimal Combination of low and high energy depending on site Image courtesy: Unknown contributor Dodul Mondal
RA D I O T HE RA P Y T EC HN I Q U E Image taken from Principles and Practice of Radiation Oncology, 6th Ed, Perez and Brady Dodul Mondal
RADIOTHERAPY TECHNIQUES cont..  For Low grade:  CTV= GTV+ 0.5 to 1 cm margin  CTV includes pre op tumor seen on MRI with intratumoral cysts  Not necessary to include syrinx, unless radiographically or Sx evidence of tumor  For High grade:  CTV= GTV +1.5 to 2 cm margin craniocaudally  Should encompass inter vertebral foramina (IVF) if involved  If cauda equina involved - CTV should include entire thecal sac to cover meningeal sleeves in the IVF  Myxopapillary ependymomas involving the conus, a 1.5-cm CTV margin cephalad and caudal to the GTV is used  Not beyond the thecal sac, which is typically at the level of S2-3 Dodul Mondal
Pioneering work by Merchant and Thompson et al from St.Judes on EBRT in pediatrics Spinal cord tumors. In a retrospective study of High grade tumors with a post op margin to GTV less than 1.5 cm yielded increase local failure rate.(13% vs. 39%) P-signicant.* *Merchant TE,Thompson SJ et al.High grade pediatrics spinal cord tumors. Pediatrics Neurosurgery 1999;39:1-5. Dodul Mondal
STEREOTACTIC RADIOSURGERY • Single fraction high dose radiation to the target and reduced dose to normal tissue to reduce toxicity • Most experiences in metastatic disease • Intradural benign tumors • 16-18 Gy in single fraction to 24-30Gy in 4-5 fractions • Spinal Cord tolerance • 13Gy/1fx, V10<10%(2-3mm above and below the target) Dodul Mondal
Dodul Mondal
CRANIOSPINAL IRRADIATION IN SPINAL TUMOR Multifocal dissemination Leptomeningeal spread CSF positive for malignant cells Dose: 36-45 Gy to whole spine followed by boost Radiation dose de-escalation not discussed Dodul Mondal
Craniospinal Irradiation cont.. • one of the most complex radiotherapy techniques • The CTV for CSI has an irregular shape that consists of the whole of the brain and spinal cord and overlying meningeal coverings Dodul Mondal
Patient Positioning and Immobilization • Traditionally prone position • Supine position also safe • More comfortable • If anesthesia is required, allows better control of the airway • Immobilization is essential and involves the use of a head shell or full-body immobilization Dodul Mondal
Target Volume Definition • Coverage of the entire target volume is critical • CT simulation is invaluable for target volume definition - adequate coverage of the CTV in the subfrontal region, cribriform plate, anterior and temporal lobes are more easily ensured • CT is also helpful in identifying the lateral aspect of CTV for the spine field that includes the extensions of the meninges along the spinal nerve roots • MRI is better to determine the lower limit of CTV for the spine field. • Traditionally the lower border of the spine field was placed at the lower border of the S2 (it is below S2 in 7% of children) Dodul Mondal
Treatment Planning and Delivery • Photons ( 6 to 10 MV range) - provide satisfactory PTV coverage • Blocks are used in the lateral fields to shield facial structures and teeth • The field must be wide enough to encompass the intervertebral foramina • Block heart, lung, kidney, gonad • Compensators may be needed to achieve dose homogeneity throughout the target volume. Dodul Mondal
The use of CT simulation with contouring of the cord and overlying meninges that extend laterally to the lateral aspect of the spinal ganglia results in a field width that is narrower than one based on bony anatomy. The addition of shielding reduces even further the volume of normal tissues included in the treated volume Treatment planning by DobbsDodul Mondal
Field matching • To cover the clinical target volume for CSI, lateral opposed fields upto the lower border of C3-4, are used to treat the brain and a direct posterior field is used to cover the spinal axis • Precise matching of beam divergence is required – cranial fields with a collimator rotation of 7–10° are used to match the divergence of the posterior spinal beam • The field junction may be shifted or feathered by 1 to 2 cm once or twice to avoid any excessive overlap of dose over the cervical spine – moving junction/ feathering technique Dodul Mondal
• The field junction, which is over the cervical cord (C3), usually is moved weekly to avoid over- or under dosage Treatment planning by DobbsDodul Mondal
Dose solutions in conventional planning • Whole brain - • Treatment is given isocentrically using a linear accelerator and opposing lateral beams as defined in the simulator. • The position of the lower cranial border is shifted by 1cm every wk to change the level of the junction with the spinal field. • Spinal field - • Despite the use of an FSD extended up to 140 cm, two adjacent fields are commonly required to cover the spinal cord in adults and older children. • Both this and the craniospinal beam junction are moved caudally every wk Dodul Mondal
Technique for calculating the gap at spinal beam junctions • Half beam blocking using shielding or independent collimator jaws can be used to eliminate divergence up to the match line, but accuracy is then dependent on precise immobilisation and reliability of skin marks • It can also be done by using a gap between beams so that the beam edges converge at a planned depth Dodul Mondal Image from Principles and Practice of Radiation Oncology, 6th Ed, Perez and Brady
MENINGIOMA • Usually benign • Well-encapsulated • Easily separated from the spinal cord • Most can be completely excised • Rare • May arise anywhere within the intradural space • Found in the thoracic region in approximately 80% of patients • Uncommon in the lumbar region • Rare in the sacrum • At least 80% of meningiomas occur in women 40 years of age or older Dodul Mondal
• Maximal surgical excision with preservation of neurologic function • Posterior approach with a standard posterior laminectomy • As much as 15% of spinal meningiomas • Prognosis is excellent for most patients • Rarely recur after total excision • Subtotally resected meningiomas may recur late after surgery • Some advocated postoperative radiation using either conventional fractionated external-beam radiotherapy or stereotactic radiosurgery Dodul Mondal
METASTASIS • Common complication in advanced malignancy • Not every metastasis is emergency • Malignant epidural spinal cord compression (MESCC) is emergency • Acute neurologic deterioration • Prompt decision making necessary • Pretreatment neurologic function most important determinant • Pain is most common presentation (85-95%) • Motor deficit 60-80% • Sensory deficit 40-60% • MRI gold standard investigation modality Dodul Mondal
Treatment Corticosteroids In a randomized trial 96mg loading dexamethasone followed by 96mg/d x3d followed by taper before RT vs. no steroid showed increased ambulatory rates at 3m , 6m* Dose: Two different dose schedules *Sorensen S et al. Eur J Cancer 1994:30A:22-7 100 mg loading dose followed by 96mg/d 10 mg loading followed by 16mg/d Dodul Mondal
Surgical decompression Life expectancy important determinant Laminectomy Reserved for posterior lesion Anterior approach with immediate stabilization for anterior lesion Combination of anterior and posterolateral approach Surgery followed by RT provides higher overall ambulatory rate (85% vs 64%, P<0.001)* *Klimo et al. Neuro Oncol 2005:7:64-76 Dodul Mondal
RADIOTHERAPY • Standard of care since 1950 • Preservation or improvement of neurologic function • Palliation of pain • Predictors of outcome: • Extent of functional limitation at the beginning • Tumor type • Rapidity of neurologic deterioration • Dose/fractionation: • Different dose schedules used • 30Gy/10fx/2wk • 16Gy/2fx/2d • 8Gy/1fx/1d • PROTRACTED SCHEDULE REDUCES RISK OF NECESSITY OF REPEAT RADIATION • SINGLE FRACTION MORE SUITABLE FOR PATIENTS WITH LIMITED LIFE EXPECTANCY Dodul Mondal
OPTIMUM RT DOSE SCHEDULE?? Dodul Mondal
NEWER TECHNIQUES Dodul Mondal
PROTON THERAPY • Conventional photon/X-ray therapy produces tissue damage in the entry and exit path • More dose deposited in the entry track • Radiation induced normal tissue damage • Proton therapy gives high dose to the tumor tissue with reduced dose to entry and exit path • Positively charged hydrogen atoms • High energy produced by acceleration in cyclotron/synchrotron • Bragg peak effect Dodul Mondal
Dodul Mondal
PROTON THERAPY cont.. • Lack of RCT of proton vs. photon in spinal cord tumor • Dosimetric advantage in reducing exit dose to vital anterior structures • Particularly promising in radiation of entire craniospinal axis • Exit dose to the thyroid, heart, lung, gut, and gonads can be reduced with proton therapy Dodul Mondal Treatment planning by Dobbs
SRS (STEREOTACTIC RADIO SURGERY) • Accurate delivery of high dose of radiation to the target • Use of multiple highly targeted radiation • Reduced dose to surrounding normal tissue • Most spine SRS used in metastatic disease • Limited data in intradural tumor METASTATIC DISEASE:  1-2 Session 8-18 Gy Improved pain control Better quality of life due to reduced toxicity Less side effects Dodul Mondal
SRS IN INTRADURAL TUMOR • Only few reports on intradural tumor • Largest series treated 73 benign tumor • Used CyberknifeTM • Dose 16-30 Gy • 1-5 fx • Median FU of 37 • Local control rate 98% • Pain improved in: • 70% of meningiomas • 50% of schwannomas • 0% of neurofibromas. • Three patients developed radiotherapy-related spinal cord toxicity 5 to 13 months after treatment • Overall radiographic response rates for benign intradural tumors in the series reported to date range from 28% to 39 Neurosurgery. 2008 Apr;62(4):887-95Dodul Mondal
SRS IN INTRADURAL TUMOR cont… • 7 patients with intramedullary hemangioblastoma and ependymoma treated at Stanford University showed good result* • Dose used 16-30Gy in 1-5 fx or 18-25 Gy in 1-3 fx • Early results promising *Ryu SI, Kim DH, Chang SD. Stereotactic radiosurgery for hemangiomas and ependymomas of the spinal cord. Neurosurg Focus 2003;15(5):E10 Dodul Mondal
Stereotactic radiosurgery for an L1 hemangioblastoma. A single dose of 20 Gy was delivered with CyberKnife using 87 noncoplanar beams Perez, Sixth Ed Dodul Mondal
CHEMOTHERAPY IN INTRAMEDULLARY LOW GRADE ASTROCYTOMA AND EPENDYMOMA To delay radiation in young children Of no proven value till now  Lack of large RCT  Mostly extrapolated from intracranial tumor  Platinum and Etoposide mostly considered Temozolomide showed response in a retrospective series of 22 patients with recurrent GrII gliomas* *Chamberlain MC. Cancer 2008;113(5):1019–1024 Dodul Mondal
• 16-month polychemotherapy regimen • Seven cycles of carboplatin 15 mg/kg or 450 mg m2 on day D1 • Procarbazine 4 mg/kg or 200 mg m2 on D 1–7 • Etoposide 5 mg/kg or 150 mg m2 on D2 and 23 • Cisplatin 1 mg/kg or 30 mg m2 on D22 and 23 • Vincristine 0.05 mg/kg or 1.5 mg m2 on D 43C • Cyclophosphamide 50 mg/kg or 1500 mg m2 on D 43 • For children over 3, doses were calculated in mg/m2 /day • Doireau V. Br J Cancer 1999;81(5):835–840 Dodul Mondal
Chemotherapy should be considered for children with a poor prognosis due to relapse or metastasis of an intramedullary tumour Chemotherapy could even be the first line of treatment for metastatic and unresectable tumours (e.g. holocord tumours) and replace extensive irradiation Dodul Mondal
Children’s Cancer Group 945 • N=13 • High-grade astrocytic spinal cord neoplasms • Two cycles of “8-drugs-in-1-day” chemotherapy before radiation therapy • Eight additional cycles thereafter • 5 years PFS=46% • 5 year OS=54% • Conclusion: More intensive therapy necessary Dodul Mondal
SUMMARY • Rare tumors • Children are more affected • Intramedullary tumor mainly astrocytoma and ependymoma • Contrast enhanced MRI investigation of choice • Biopsy for histopathology confirmation • Surgery mainstay of treatment • Completely resected low grade intramedullary astrocytoma/ependymoma do not require adjuvant treatment • High grade tumors require adjuvant radiation • Radiation to be delayed if possible • Chemotherapy role still not defined • Judicious treatment policy and technique of paramount importance Dodul Mondal
THANK YOU Dodul Mondal

More Related Content

PPTX
INTRAMEDULLARY TUMOR OF SPINAL CORD
bysuresh Bishokarma
 
PPTX
Spinal cord tumors
byANILKUMAR BR
 
PPT
Spinal tumors lecture
bytest
 
PPTX
Spinal neoplasm
bySayali Gujjewar
 
PPTX
Spinal tumour lecture - copy
bywasek_bd
 
PPT
Spinal tumors
bysayf aldeen kassab bashi
 
PPTX
Spinal Tumors: approach and management
byAmit Agrawal
 
PPTX
SPINAL TUMOR
byDr. Darshan Parmar
 
INTRAMEDULLARY TUMOR OF SPINAL CORD
bysuresh Bishokarma
 
Spinal cord tumors
byANILKUMAR BR
 
Spinal tumors lecture
bytest
 
Spinal neoplasm
bySayali Gujjewar
 
Spinal tumour lecture - copy
bywasek_bd
 
Spinal tumors
bysayf aldeen kassab bashi
 
Spinal Tumors: approach and management
byAmit Agrawal
 
SPINAL TUMOR
byDr. Darshan Parmar
 

What's hot

PPTX
Spinal cord tumors
byAhmed Debes
 
PPT
Brain tumor
byMuhammad Eimaduddin
 
PPTX
SPINAL TUMORS PPT
byssuser2f50ef
 
PPTX
Brain Tumors
byDrhardik Patel
 
PPTX
Dbs final
byDr. Shahnawaz Alam
 
PPTX
Meningioma of brain
bysuresh Bishokarma
 
PPT
Spinal Cord Syndrome
byRobert J Miller MD
 
PPTX
Meningioma
byNeurologyKota
 
PPTX
Chiari malformation
byUsman Haqqani
 
PPTX
Spina bifida
byDr KAMBLE
 
PPTX
Dandy-Walker Malformation: Classification and Management
byDr. Shahnawaz Alam
 
PPTX
Brain abscess (dr. mahesh)
byBangabandhu Sheikh Mujib Medical University (BSMMU)
 
PPTX
Dandy Walker syndrome
bysuresh Bishokarma
 
PPTX
Chiari malformation
bySourabh Jain
 
PPTX
Aneurysm clips /clipology
byGopalSedain
 
PPT
BRAIN ABSCESS
byjas sodhI
 
PPTX
Spinal dysraphism
byairwave12
 
PPTX
Craniovertebral anomalies
byShivshankar Badole
 
PPTX
Cvj anomalies
byNavni Garg
 
PPT
Neurogenic Bladder
byBharat Bhushan
 
Spinal cord tumors
byAhmed Debes
 
Brain tumor
byMuhammad Eimaduddin
 
SPINAL TUMORS PPT
byssuser2f50ef
 
Brain Tumors
byDrhardik Patel
 
Dbs final
byDr. Shahnawaz Alam
 
Meningioma of brain
bysuresh Bishokarma
 
Spinal Cord Syndrome
byRobert J Miller MD
 
Meningioma
byNeurologyKota
 
Chiari malformation
byUsman Haqqani
 
Spina bifida
byDr KAMBLE
 
Dandy-Walker Malformation: Classification and Management
byDr. Shahnawaz Alam
 
Brain abscess (dr. mahesh)
byBangabandhu Sheikh Mujib Medical University (BSMMU)
 
Dandy Walker syndrome
bysuresh Bishokarma
 
Chiari malformation
bySourabh Jain
 
Aneurysm clips /clipology
byGopalSedain
 
BRAIN ABSCESS
byjas sodhI
 
Spinal dysraphism
byairwave12
 
Craniovertebral anomalies
byShivshankar Badole
 
Cvj anomalies
byNavni Garg
 
Neurogenic Bladder
byBharat Bhushan
 

Similar to Spinal cord tumor

PPT
Brain spinal tumors
byMan B Paudyal
 
PPTX
Spinal tumors
byJavid Akhgar
 
PPTX
Brain tumor in children
bySharminNaharNabila
 
PDF
Spinal tumors- Imaging
byshefaliMeshram
 
PPTX
Spinal tumors
byFarhad Hussain
 
PPTX
Spinal cord lesions and its radiological imaging finding.
byNavneet Ranjan
 
PPTX
Imaging in spinal tumors
byGirendra Shankar
 
PPT
Intramedullary Spinal Cord Tumors
byLeslieHutchinsMD
 
PPTX
Spinal neoplasms
byfahad shafi
 
PPTX
Tumor of spine and spinal cord
byHong Sothea
 
PPTX
IMAGING OF SPINAL TUMORS
byaasrithakotha2
 
PPT
A systematic approach to possible case of brain
byREKHAKHARE
 
PPT
Dr.mumtaz ali
byNeurosurgeon Mumtaz Ali Narejo
 
PPTX
Neuroradiology primary spinal cord tumours
byRoopchand Ps
 
PPTX
Neoplastic disorders of spinal cord
byMilan Silwal
 
PPTX
Spinal cord tumors seminar presentation.pptx
bydrpraneethpremkumar
 
PPTX
spinal cord tumors.pptx intra dural intra
bysaroj336886
 
PDF
Intramedullary Diffuse Astrocytoma of The Spinal Cord in a 3-Year-Old Patient...
byCrimsonPublishersTNN
 
PPTX
SPINAL CORD TUMORS MRI AND CT FEATURES.pptx
byNagasai Pelala
 
PDF
Case record...Intramedullary ependymoma
byProfessor Yasser Metwally
 
Brain spinal tumors
byMan B Paudyal
 
Spinal tumors
byJavid Akhgar
 
Brain tumor in children
bySharminNaharNabila
 
Spinal tumors- Imaging
byshefaliMeshram
 
Spinal tumors
byFarhad Hussain
 
Spinal cord lesions and its radiological imaging finding.
byNavneet Ranjan
 
Imaging in spinal tumors
byGirendra Shankar
 
Intramedullary Spinal Cord Tumors
byLeslieHutchinsMD
 
Spinal neoplasms
byfahad shafi
 
Tumor of spine and spinal cord
byHong Sothea
 
IMAGING OF SPINAL TUMORS
byaasrithakotha2
 
A systematic approach to possible case of brain
byREKHAKHARE
 
Dr.mumtaz ali
byNeurosurgeon Mumtaz Ali Narejo
 
Neuroradiology primary spinal cord tumours
byRoopchand Ps
 
Neoplastic disorders of spinal cord
byMilan Silwal
 
Spinal cord tumors seminar presentation.pptx
bydrpraneethpremkumar
 
spinal cord tumors.pptx intra dural intra
bysaroj336886
 
Intramedullary Diffuse Astrocytoma of The Spinal Cord in a 3-Year-Old Patient...
byCrimsonPublishersTNN
 
SPINAL CORD TUMORS MRI AND CT FEATURES.pptx
byNagasai Pelala
 
Case record...Intramedullary ependymoma
byProfessor Yasser Metwally
 

Recently uploaded

PDF
quick review in robbin's basic pathology
bymohammed Alahmadi‬‏
 
PDF
Dr.Pothireddy Surendranath Reddy explains the Management of Neck Pain.pdf
bybvsubbareddy1
 
PPTX
CONNECTIVE TISSUE (Classification, Structure, Location and Functions).pptx
byPranaliChandurkar2
 
PDF
Human Anatomy and Physiology - I Practical Manual.pdf
bySreenivasa Reddy Thalla
 
PPTX
Understanding-Disease-Causation-Epidemiological-Triad-and-Multifactorial-Mode...
bydrasifk
 
PPTX
Progesterone primed Ovarian stimulation- PPOS
byRudriAgrawal
 
PPTX
Biochemistry
byDr. Sankalp Bhargava
 
PDF
PECTORAL REGION . Prof.Dr.N.Mugunthan.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
PPTX
BRAINSTEM & MIDBRAIN: BASICS OF NEUROANATOMY.pptx
byRAMA UNIVERSITY
 
PPTX
Human Organ Transplantation Act 2014, THOTA- 2014 Legal basics by Dr MB Singh...
byBalajiSinghM
 
PPTX
ASCENDING TRACTS OF SPINAL CORD- ROUTE & FUNCTIONS.pptx
byRAMA UNIVERSITY
 
PPT
2.Approach to apatient with acute abdomen.ppt
byhikaemi8
 
PPTX
Levothyroxine-Dosing-Principles-and-Clinical-Application.pptx
byamarnath970868
 
PPTX
IMMUNOLOGY presentation by Sangeena_8004ef7e-aa99-4199-bd66-dd1fece8edc0.pptx
byAshmitaDhital
 
PPTX
Drug Induced Liver Disease- Pharm-D Therapy
byAnusha Are
 
PPTX
Virginia_Henderson_theory_group_B_2.pptx
byMedical PPT
 
PDF
Top 5 Places to Buy Aged LinkedIn Accounts and Should ....pdf
byche3h5jojp4zk2gkv4s
 
PDF
Medicinal Plants: Uses, Benefits and Mechanisms of Action
byazamsaleembilgrami
 
PDF
Key Tasks Third Party Claims Administrators Perform for Insurers
byDataGenix
 
PPTX
A Detailed Description of Raktagulma wrt PTSR
byDr Chandrika Kulkarni
 
quick review in robbin's basic pathology
bymohammed Alahmadi‬‏
 
Dr.Pothireddy Surendranath Reddy explains the Management of Neck Pain.pdf
bybvsubbareddy1
 
CONNECTIVE TISSUE (Classification, Structure, Location and Functions).pptx
byPranaliChandurkar2
 
Human Anatomy and Physiology - I Practical Manual.pdf
bySreenivasa Reddy Thalla
 
Understanding-Disease-Causation-Epidemiological-Triad-and-Multifactorial-Mode...
bydrasifk
 
Progesterone primed Ovarian stimulation- PPOS
byRudriAgrawal
 
Biochemistry
byDr. Sankalp Bhargava
 
PECTORAL REGION . Prof.Dr.N.Mugunthan.pdf
byKanyakumari Medical Mission Research Center, Muttom
 
BRAINSTEM & MIDBRAIN: BASICS OF NEUROANATOMY.pptx
byRAMA UNIVERSITY
 
Human Organ Transplantation Act 2014, THOTA- 2014 Legal basics by Dr MB Singh...
byBalajiSinghM
 
ASCENDING TRACTS OF SPINAL CORD- ROUTE & FUNCTIONS.pptx
byRAMA UNIVERSITY
 
2.Approach to apatient with acute abdomen.ppt
byhikaemi8
 
Levothyroxine-Dosing-Principles-and-Clinical-Application.pptx
byamarnath970868
 
IMMUNOLOGY presentation by Sangeena_8004ef7e-aa99-4199-bd66-dd1fece8edc0.pptx
byAshmitaDhital
 
Drug Induced Liver Disease- Pharm-D Therapy
byAnusha Are
 
Virginia_Henderson_theory_group_B_2.pptx
byMedical PPT
 
Top 5 Places to Buy Aged LinkedIn Accounts and Should ....pdf
byche3h5jojp4zk2gkv4s
 
Medicinal Plants: Uses, Benefits and Mechanisms of Action
byazamsaleembilgrami
 
Key Tasks Third Party Claims Administrators Perform for Insurers
byDataGenix
 
A Detailed Description of Raktagulma wrt PTSR
byDr Chandrika Kulkarni
 

Spinal cord tumor

  • 1.
    SPINAL CORD TUMOR DRDODUL MONDAL MD, DNB All India Institute of Medical Sciences, New Delhi Dodul Mondal
  • 2.
    • INTRODUCTION • ANATOMY •EPIDEMILOGY • NATURAL HISTORY • CLASSIFICATION • ROUTES OF SPREAD • CLINICAL PESENTATION • DIAGNOSTIC WORKUP • PROGNOSTIC FACTOR • DISEASE SPECIFIC MANAGEMENT • CONCLUSION Dodul Mondal
  • 3.
    INTRODUCTION • Rare tumor •Constitutes 3-4% of all CNS and 6% of pediatric CNS tumors • Oversimplified anatomical classification • Young children more affected than adults • Lack of RCT • Mainly retrospective series • Surgery and radiation mainstay of treatment • Judicious use of radiation important Dodul Mondal
  • 4.
  • 5.
    Normal transverse spineTransverse spine with extradural mass Intradural extramedullary mass Intramedullary massDodul Mondal
  • 6.
    EPIDEMIOLOGY Primary Spinal CordTumors – Uncommon Primary Brain Tumor : Primary Spinal Cord Tumor = 20:1 (children) ** 5:1 (adult) Younger individuals affected more than adults Constitutes 3-4 % of all primary CNS tumors & 6% of CNS tumors of children** **CBTRUS-Statistical Report 2011 Dodul Mondal
  • 7.
    EPIDEMIOLOGY cont…  Primarytumor of SC are more frequent in children & more than half occur below 10 years of age*  36% intramedullary 27% extramedullary 24% extradural 75% of intramedullary tumor were astrocytomas* **John K, Howard L. Weiner Pediatric Intramedullary Spinal Cord Tumors: Special Considerations . Journal of Neuro- Oncology Volume 47, Number 3 / May, 2000 Dodul Mondal
  • 8.
    NATURAL HISTORY Mostly benign IMtumors produce damage by local invasion & cystic compression EM tumors compress, stretch or distort the cord & nerves May involve focally or entire length of spinal cord Dodul Mondal
  • 9.
    CLASSIFICATION SPINAL CORD TUMOR IntraDural EXTRAMEDULLARY Meningioma Nerve sheath tumor Vascular tumor Ependymoma INTRAMEDULLARY Ependymoma Astrocytoma Oligodendroglioma Extra Dural Metastatic Osteoid osteoma Osteoblastoma ABC Plasmacytoma / Myeloma Chordoma Chondrosarcoma Osteosarcoma Ewing’s sarcoma Epidural hemangioma Lipoma Extradural meningioma Nerve sheath tumor Lymphoma Dodul Mondal
  • 10.
    ROUTES OF SPREAD LowGrade-Generally localized High Grade-Spread via CSF Occasionally hematogenous route to Lungs Lymph Node spread is generally not seen as CNS has no lymphatics Dodul Mondal
  • 11.
    CLINICAL PRESENTATION Depends onthe anatomical location & site of the lesion Local Focal Pain(75%): • In EM tumors pain is more in the night due to venous congestion Distal Neurological: Paresis & Numbness Autonomic Dysfunction Sensory Deficits Muscle Wasting Loss of Reflexes Failure to achieve milestones Gait disturbance Dodul Mondal
  • 12.
    DIAGNOSTIC WORK UP GENERAL History Physicalexamination Complete neurological evaluation IMAGING Plain radiography MRI whole spine with contrast MRI brain CT myelography Intraoperative ultrasound LABORATORY TESTS CSF chemistry CSF cytology Dodul Mondal
  • 13.
    RADIOGRAPHY/MYELOGRAPHY • Overall 50%lesions of primary spinal tumors detected with plain X-ray • Features are due to raised ICP • Erosion of pedicles • Increased AP diameter • Scalloping of posterior vertebral body • Scoliosis or kyphosis in children • Calcification in meningioma • Myelography in patients unsuitable for MRI • CT myelography better Dodul Mondal
  • 14.
    COMPUTED TOMOGRAPHY • Betterfor bony lesions and bony extent detection • Extradural pathologic processes • Paraspinal soft tissue masses • Erosion of bone • Calcification of meningioma Dodul Mondal
  • 15.
    MRI • Gd-DTPA enhancedMRI imaging modality of choice • CSF, white and gray matter, bone and bone marrow, fat, and flowing blood can be distinguished • MRI brain should also be done • Maximum impact in the field of spinal tumors amongst all spinal pathologies • Preoperative study of choice so as to narrow the differential diagnosis and guide surgical resection. • All spinal cord gliomas enhance • LP should be done after MRI Dodul Mondal
  • 16.
    • Cord expansion-Essentialimaging criterion for intramedullary spinal neoplasm* • MR sensitive to hemorrhage- can identify intratumoral bleeding • Cysts are common associated finding • Majority of intramedullary neoplasms show at least some enhancement • Contrast study essential: Enhancement useful in focal masses, especially hemangioblastoma and mets Contrast helpful in differentiating suspected neoplasms from other etiologies. e.g. infection, syrinx. Actual lesion smaller than area of cord enlargement-Useful to pinpoint sites for biopsy. • *Epstein et al: IM tumors of spinal cord , Journal of Neurosurgery1993;79:204-209. Dodul Mondal
  • 17.
    PROGNOSTIC FACTORS Major factors: Tumortype and grade Tumor extent and location Patient age, presenting neurologic function Treatment-related factors: Tumor resectability Use of radiation therapy for certain tumor types Lower grade, younger age, and surgical resection were associated with significantly better overall survival and cause-specific survival for both astrocytomas and ependymomas* • Milano MT, et al. Primary spinal cord glioma: a Surveillance, Epidemiology, and end results database study. J Neurooncol2010;98(1):83–92 Dodul Mondal
  • 18.
    PROGNOSTIC FACTORS…cont  Patientswith ependymoma survive longer without recurrence than patients with astrocytoma  Rostral tumors have a worse survival and neurologic outcome  Cervical lesions had a higher surgical risk and complication rate  Tumors affecting the rostral or cervical spinal cord were more likely to be astrocytoma  Tumors in the caudal spinal cord, filum terminale , or cauda equina were more likely to be ependymomas  High histopathologic tumor grade is associated with a high rate of disability and death Extensive involvement of the spinal cord with an ependymoma is associated with a worse outcome Younger age is associated with a better than 5-year recurrence-free survival rate Dodul Mondal
  • 19.
    MANAGEMENT OF INTRAMEDULLARYTUMORS • Most common: Astrocytoma, Ependymoma (95%) • Complete surgical excision without compromising neurologic function • Introduction of bipolar forceps • Microsurgical techniques, use of CUSA (Cavitron Ultrasonic Surgical Aspirator ) • CUSA allows aspiration of tissue fragments from within 1 mm of the vibrating tip • Intraoperative ultrasonography:  Localize the lesion  Define its extent  Characterize the tumor as cystic or solid  Facilitates placement of a myelotomy incision and initiation of tumor resection  Assess the progress of tumor resection and adjacent cyst drainage with internal spinal cord decompression • Risk of paralysis after surgery less Dodul Mondal
  • 20.
    MANAGEMENT OF INTRAMEDULLARYTUMORS .. cont • Resection of astrocytic tumors begins from within the tumor at the initial midline myelotomy • Removal until interface between tumor and normal spinal cord evident • Complete excision achieved no postoperative therapy • Delaying adjuvant radiation important in children • Complete resection not achieved PORT • PORT can be delayed even after STE till time of recurrence • Recurrence assess for reresection and judicious use of PORT Dodul Mondal
  • 21.
    ASTROCYTOMA  Low backache Painful scoliosis  Thoraciccord (67%)*  Cervical cord (49%)  Entire spinal cord (holocord presentation)common in children (up to 60%) quite rarein adults  Isolated conus medullaris (3%)& rare infilum terminale  Less than 10% of pediatric and 25% of spinal cord astrocytomas are malignant .** *Epstein et al Adult IM Astrocytoma of SC,J of Neurosurgery 77:355-359;2002 **Stein et al.IM tumors in adults.Neurosurgery Clin of N America 1998:1:609-630 Dodul Mondal
  • 22.
    ASTROCYTOMA Arise from thecord parenchyma not from the central canal, are usuallyeccentric within the cord Usually have poorly defined margins Multisegment involvement of the cord is rule Associated polar and intratumoral cysts. Usually low grade fibrillary Astro is MC type followed by anaplastic Astro GBM is rare. Dodul Mondal
  • 23.
    ASTROCYTOMA cont..  Iso-to hypo intense relative to the cord on T1W  Hyper intense on T2W images  Enhancement is seen in all cord astrocytomas, Inhomogenous enhancement  Tumor, syrinx and cysts can be delineated on MR  Rare SC GBM has propensity of leptomeningeal spread in 60% of patients*  Completely resected tumor do not require PORT  Incompletely removed tumor PORT should be considered  Ciappetta et al, Spinal GBM: Report of 7 patients with spinal GBM and Review of literature.Neurosurgery 28:302-306,1991. Dodul Mondal
  • 24.
    Treatment Recommendations forPediatric Spinal Cord Astrocytoma Nadkarni TD,Childs Nerv Syst 1999;15:17-28Dodul Mondal
  • 25.
    EPENDYMOMA  Most commonintramedullary spinal neoplasm in adults*  Common in young adults  Common in male patients  Location: 2/3rd arise in lumbosacral region 40% arise from filum terminale *Torres et al: Intramedullary ependymoma of spinal cord , J Neurosurgery 62;523-532;1992 Dodul Mondal
  • 26.
     Arise fromependymal cells of the central canal, and symmetric cord expansion is the rule.  Slow growth and tends to compress adjacent spinal cord tissue rather than infiltrate it.  Usually histologically benign and have long and indolent course. EPENDYMOMA Dodul Mondal
  • 27.
    HISTOLOGICAL TYPES  CellularEpendymoma - mostly in cervical cord  Myxopapillary Ependymoma - exclusively in conus medullaris and cauda equina  Primary Anaplastic Ependymoma of spinal cord are rare  Other histological types:  Subependymal  Epithelial  Mixed Dodul Mondal
  • 28.
    MR Imaging characteristics: Iso or hypointense relative to spinal cord on T1.  Occasional hyperintense mass secondary to hemorrhage.  Hyperintense relative to spinal cord on T2.  Cap sign, a rim of extreme hypointensity (hemosiderin) seen at the poles of the tumor on T2W (20%—30%) …. thought to be secondary to hemorrhage.  Cord edema around the masses (60%). Dodul Mondal
  • 29.
    Cysts In Ependymoma Cystsare a common feature Mostly non tumoral (polar) (70-80%) NON TUMORAL CYSTS Located at the poles of the solid portion of the tumor . Reactive dilatation of the central canal (syringomyelia). Not part of the tumor itself . No enhancement. TUMORAL CYSTS Contained within the tumor itself. Peripheral enhancement More in astrocytomas than ependymomas. Dodul Mondal
  • 30.
  • 31.
    EPENDYMOMA T 1W-HYPO toISO T 2W-HYPERINTENSE T 1W- CONTRAST Dodul Mondal
  • 32.
    EPENDYMOMA WITH BLEED PlainT1W sagittal  Iso to Hypo on T1  Hyper on T2  Bleeding-Hyper on T1  Enhancement  Homogeneous  Cap sign seen BLEED Dodul Mondal
  • 33.
    Nadkarni TD. ChildsNerv Syst 1999;15:17-28 Treatment Recommendations for Pediatric Spinal Cord Ependymoma Dodul Mondal
  • 34.
    Difference Between Astrocytomaand Ependymoma ASTROCYTOMA EPENDYMOMA Cervical & Thoracic cord LS spine, Cauda equina & conus medullaris Centrally located in cord Eccentric Hemorrhage uncommon Hemorrhage common Infiltrative with poorly defined margins(multiple segment inv.) Well defined due to pseudocapsule Heterogenous enhancement Homogenous enhancement Dodul Mondal
  • 35.
    RADIOTHERAPY FOR INTRAMEDULLARYTUMORS • Dose: 50.4 Gy. 1.8 Gy per fraction for low grade tumor • 5 fractions per week • Dose for high grade tumor is 54Gy in 1.8Gy/fx • Limited data for dose response • Dose below 50Gy is associated with high failure rate • Where CSI is indicated, entire Craniospinal axis receives 36Gy to 45 Gy followed by boost to gross tumor to a dose of 50.4-54 Gy Dodul Mondal
  • 36.
    RADIOTHERAPY TECHNIQUE CONVENTINOAL TECHNIQUE Position: Supine/Prone  Usually direct posterior field  Superior and inferior border: Myelography defined gross tumor plus 2 vertebrae above and below  Lateral border: To include tip of the lateral process of vertebral body  Field placement should be judicious to avoid exit dose to vital OAR s  Cervical vertebra can be treated with bilateral parallel opposed fields  Lumbar region tumors can be treated with antero posterior field arrangement  Oblique wedge pairs can also be used for thoracolumbar region For female patients lateral fields may be better for lumbosacral spine  Dose distribution should be homogenous and toxicity minimal Combination of low and high energy depending on site Image courtesy: Unknown contributor Dodul Mondal
  • 37.
    RA D I O T HE RA P Y T EC HN I Q U E Image taken fromPrinciples and Practice of Radiation Oncology, 6th Ed, Perez and Brady Dodul Mondal
  • 38.
    RADIOTHERAPY TECHNIQUES cont.. For Low grade:  CTV= GTV+ 0.5 to 1 cm margin  CTV includes pre op tumor seen on MRI with intratumoral cysts  Not necessary to include syrinx, unless radiographically or Sx evidence of tumor  For High grade:  CTV= GTV +1.5 to 2 cm margin craniocaudally  Should encompass inter vertebral foramina (IVF) if involved  If cauda equina involved - CTV should include entire thecal sac to cover meningeal sleeves in the IVF  Myxopapillary ependymomas involving the conus, a 1.5-cm CTV margin cephalad and caudal to the GTV is used  Not beyond the thecal sac, which is typically at the level of S2-3 Dodul Mondal
  • 39.
    Pioneering work byMerchant and Thompson et al from St.Judes on EBRT in pediatrics Spinal cord tumors. In a retrospective study of High grade tumors with a post op margin to GTV less than 1.5 cm yielded increase local failure rate.(13% vs. 39%) P-signicant.* *Merchant TE,Thompson SJ et al.High grade pediatrics spinal cord tumors. Pediatrics Neurosurgery 1999;39:1-5. Dodul Mondal
  • 40.
    STEREOTACTIC RADIOSURGERY • Singlefraction high dose radiation to the target and reduced dose to normal tissue to reduce toxicity • Most experiences in metastatic disease • Intradural benign tumors • 16-18 Gy in single fraction to 24-30Gy in 4-5 fractions • Spinal Cord tolerance • 13Gy/1fx, V10<10%(2-3mm above and below the target) Dodul Mondal
  • 41.
  • 42.
    CRANIOSPINAL IRRADIATION INSPINAL TUMOR Multifocal dissemination Leptomeningeal spread CSF positive for malignant cells Dose: 36-45 Gy to whole spine followed by boost Radiation dose de-escalation not discussed Dodul Mondal
  • 43.
    Craniospinal Irradiation cont.. •one of the most complex radiotherapy techniques • The CTV for CSI has an irregular shape that consists of the whole of the brain and spinal cord and overlying meningeal coverings Dodul Mondal
  • 44.
    Patient Positioning andImmobilization • Traditionally prone position • Supine position also safe • More comfortable • If anesthesia is required, allows better control of the airway • Immobilization is essential and involves the use of a head shell or full-body immobilization Dodul Mondal
  • 45.
    Target Volume Definition •Coverage of the entire target volume is critical • CT simulation is invaluable for target volume definition - adequate coverage of the CTV in the subfrontal region, cribriform plate, anterior and temporal lobes are more easily ensured • CT is also helpful in identifying the lateral aspect of CTV for the spine field that includes the extensions of the meninges along the spinal nerve roots • MRI is better to determine the lower limit of CTV for the spine field. • Traditionally the lower border of the spine field was placed at the lower border of the S2 (it is below S2 in 7% of children) Dodul Mondal
  • 46.
    Treatment Planning andDelivery • Photons ( 6 to 10 MV range) - provide satisfactory PTV coverage • Blocks are used in the lateral fields to shield facial structures and teeth • The field must be wide enough to encompass the intervertebral foramina • Block heart, lung, kidney, gonad • Compensators may be needed to achieve dose homogeneity throughout the target volume. Dodul Mondal
  • 47.
    The use ofCT simulation with contouring of the cord and overlying meninges that extend laterally to the lateral aspect of the spinal ganglia results in a field width that is narrower than one based on bony anatomy. The addition of shielding reduces even further the volume of normal tissues included in the treated volume Treatment planning by DobbsDodul Mondal
  • 48.
    Field matching • Tocover the clinical target volume for CSI, lateral opposed fields upto the lower border of C3-4, are used to treat the brain and a direct posterior field is used to cover the spinal axis • Precise matching of beam divergence is required – cranial fields with a collimator rotation of 7–10° are used to match the divergence of the posterior spinal beam • The field junction may be shifted or feathered by 1 to 2 cm once or twice to avoid any excessive overlap of dose over the cervical spine – moving junction/ feathering technique Dodul Mondal
  • 49.
    • The fieldjunction, which is over the cervical cord (C3), usually is moved weekly to avoid over- or under dosage Treatment planning by DobbsDodul Mondal
  • 50.
    Dose solutions inconventional planning • Whole brain - • Treatment is given isocentrically using a linear accelerator and opposing lateral beams as defined in the simulator. • The position of the lower cranial border is shifted by 1cm every wk to change the level of the junction with the spinal field. • Spinal field - • Despite the use of an FSD extended up to 140 cm, two adjacent fields are commonly required to cover the spinal cord in adults and older children. • Both this and the craniospinal beam junction are moved caudally every wk Dodul Mondal
  • 51.
    Technique for calculatingthe gap at spinal beam junctions • Half beam blocking using shielding or independent collimator jaws can be used to eliminate divergence up to the match line, but accuracy is then dependent on precise immobilisation and reliability of skin marks • It can also be done by using a gap between beams so that the beam edges converge at a planned depth Dodul Mondal Image from Principles and Practice of Radiation Oncology, 6th Ed, Perez and Brady
  • 52.
    MENINGIOMA • Usually benign •Well-encapsulated • Easily separated from the spinal cord • Most can be completely excised • Rare • May arise anywhere within the intradural space • Found in the thoracic region in approximately 80% of patients • Uncommon in the lumbar region • Rare in the sacrum • At least 80% of meningiomas occur in women 40 years of age or older Dodul Mondal
  • 53.
    • Maximal surgicalexcision with preservation of neurologic function • Posterior approach with a standard posterior laminectomy • As much as 15% of spinal meningiomas • Prognosis is excellent for most patients • Rarely recur after total excision • Subtotally resected meningiomas may recur late after surgery • Some advocated postoperative radiation using either conventional fractionated external-beam radiotherapy or stereotactic radiosurgery Dodul Mondal
  • 54.
    METASTASIS • Common complicationin advanced malignancy • Not every metastasis is emergency • Malignant epidural spinal cord compression (MESCC) is emergency • Acute neurologic deterioration • Prompt decision making necessary • Pretreatment neurologic function most important determinant • Pain is most common presentation (85-95%) • Motor deficit 60-80% • Sensory deficit 40-60% • MRI gold standard investigation modality Dodul Mondal
  • 55.
    Treatment Corticosteroids In a randomizedtrial 96mg loading dexamethasone followed by 96mg/d x3d followed by taper before RT vs. no steroid showed increased ambulatory rates at 3m , 6m* Dose: Two different dose schedules *Sorensen S et al. Eur J Cancer 1994:30A:22-7 100 mg loading dose followed by 96mg/d 10 mg loading followed by 16mg/d Dodul Mondal
  • 56.
    Surgical decompression Life expectancyimportant determinant Laminectomy Reserved for posterior lesion Anterior approach with immediate stabilization for anterior lesion Combination of anterior and posterolateral approach Surgery followed by RT provides higher overall ambulatory rate (85% vs 64%, P<0.001)* *Klimo et al. Neuro Oncol 2005:7:64-76 Dodul Mondal
  • 57.
    RADIOTHERAPY • Standard ofcare since 1950 • Preservation or improvement of neurologic function • Palliation of pain • Predictors of outcome: • Extent of functional limitation at the beginning • Tumor type • Rapidity of neurologic deterioration • Dose/fractionation: • Different dose schedules used • 30Gy/10fx/2wk • 16Gy/2fx/2d • 8Gy/1fx/1d • PROTRACTED SCHEDULE REDUCES RISK OF NECESSITY OF REPEAT RADIATION • SINGLE FRACTION MORE SUITABLE FOR PATIENTS WITH LIMITED LIFE EXPECTANCY Dodul Mondal
  • 58.
    OPTIMUM RT DOSESCHEDULE?? Dodul Mondal
  • 59.
  • 60.
    PROTON THERAPY • Conventionalphoton/X-ray therapy produces tissue damage in the entry and exit path • More dose deposited in the entry track • Radiation induced normal tissue damage • Proton therapy gives high dose to the tumor tissue with reduced dose to entry and exit path • Positively charged hydrogen atoms • High energy produced by acceleration in cyclotron/synchrotron • Bragg peak effect Dodul Mondal
  • 61.
  • 62.
    PROTON THERAPY cont.. •Lack of RCT of proton vs. photon in spinal cord tumor • Dosimetric advantage in reducing exit dose to vital anterior structures • Particularly promising in radiation of entire craniospinal axis • Exit dose to the thyroid, heart, lung, gut, and gonads can be reduced with proton therapy Dodul Mondal Treatment planning by Dobbs
  • 63.
    SRS (STEREOTACTIC RADIOSURGERY) • Accurate delivery of high dose of radiation to the target • Use of multiple highly targeted radiation • Reduced dose to surrounding normal tissue • Most spine SRS used in metastatic disease • Limited data in intradural tumor METASTATIC DISEASE:  1-2 Session 8-18 Gy Improved pain control Better quality of life due to reduced toxicity Less side effects Dodul Mondal
  • 64.
    SRS IN INTRADURALTUMOR • Only few reports on intradural tumor • Largest series treated 73 benign tumor • Used CyberknifeTM • Dose 16-30 Gy • 1-5 fx • Median FU of 37 • Local control rate 98% • Pain improved in: • 70% of meningiomas • 50% of schwannomas • 0% of neurofibromas. • Three patients developed radiotherapy-related spinal cord toxicity 5 to 13 months after treatment • Overall radiographic response rates for benign intradural tumors in the series reported to date range from 28% to 39 Neurosurgery. 2008 Apr;62(4):887-95Dodul Mondal
  • 65.
    SRS IN INTRADURALTUMOR cont… • 7 patients with intramedullary hemangioblastoma and ependymoma treated at Stanford University showed good result* • Dose used 16-30Gy in 1-5 fx or 18-25 Gy in 1-3 fx • Early results promising *Ryu SI, Kim DH, Chang SD. Stereotactic radiosurgery for hemangiomas and ependymomas of the spinal cord. Neurosurg Focus 2003;15(5):E10 Dodul Mondal
  • 66.
    Stereotactic radiosurgery foran L1 hemangioblastoma. A single dose of 20 Gy was delivered with CyberKnife using 87 noncoplanar beams Perez, Sixth Ed Dodul Mondal
  • 67.
    CHEMOTHERAPY IN INTRAMEDULLARYLOW GRADE ASTROCYTOMA AND EPENDYMOMA To delay radiation in young children Of no proven value till now  Lack of large RCT  Mostly extrapolated from intracranial tumor  Platinum and Etoposide mostly considered Temozolomide showed response in a retrospective series of 22 patients with recurrent GrII gliomas* *Chamberlain MC. Cancer 2008;113(5):1019–1024 Dodul Mondal
  • 68.
    • 16-month polychemotherapyregimen • Seven cycles of carboplatin 15 mg/kg or 450 mg m2 on day D1 • Procarbazine 4 mg/kg or 200 mg m2 on D 1–7 • Etoposide 5 mg/kg or 150 mg m2 on D2 and 23 • Cisplatin 1 mg/kg or 30 mg m2 on D22 and 23 • Vincristine 0.05 mg/kg or 1.5 mg m2 on D 43C • Cyclophosphamide 50 mg/kg or 1500 mg m2 on D 43 • For children over 3, doses were calculated in mg/m2 /day • Doireau V. Br J Cancer 1999;81(5):835–840 Dodul Mondal
  • 69.
    Chemotherapy should beconsidered for children with a poor prognosis due to relapse or metastasis of an intramedullary tumour Chemotherapy could even be the first line of treatment for metastatic and unresectable tumours (e.g. holocord tumours) and replace extensive irradiation Dodul Mondal
  • 70.
    Children’s Cancer Group945 • N=13 • High-grade astrocytic spinal cord neoplasms • Two cycles of “8-drugs-in-1-day” chemotherapy before radiation therapy • Eight additional cycles thereafter • 5 years PFS=46% • 5 year OS=54% • Conclusion: More intensive therapy necessary Dodul Mondal
  • 71.
    SUMMARY • Rare tumors •Children are more affected • Intramedullary tumor mainly astrocytoma and ependymoma • Contrast enhanced MRI investigation of choice • Biopsy for histopathology confirmation • Surgery mainstay of treatment • Completely resected low grade intramedullary astrocytoma/ependymoma do not require adjuvant treatment • High grade tumors require adjuvant radiation • Radiation to be delayed if possible • Chemotherapy role still not defined • Judicious treatment policy and technique of paramount importance Dodul Mondal
  • 72.