Oncology management of CNS tumours Neil Burnet

1. Oncology management of CNS tumoursNeil Burnet University of Cambridge Department of Oncology & Oncology Centre, Addenbrooke’s Hospital ECRIC CNS study day 7th April 2009

2. Introduction • Treatment modalities for cancer • What data do oncologists want? • Examples of uses of Registry data

4. Cancer treatment modalities

5. Cancer treatment modalities • Modalities • (Surgery) • Radiotherapy • Chemotherapy • Consider efficacy • Consider costs

6. Oncology management

8. Radiotherapy • Radiotherapy is an anatomical treatment • Treats a specific area • Localising the tumour target is crucial • Imaging is key • Better localisation – better outcome • Localising normal structures allows avoidance

9. CT – the technology advance Late 1970s 1980s 2003

10. Glioblastoma imaging • T2 • T1 • T1 + Gd contrast MR (magnetic resonance) imaging

11. Radiotherapy • Immobilise the patient • Relate today's patient position to tumour imaging

12. Radiotherapy • High precision positioning • Relocatable stereotactic frame

13. Radiotherapy

14. Radiotherapy imaging CT MRI

15. GBM planning • Using CT +MR together MRI CT

16. Radiotherapy imaging • Post-op planning CT • Pre-op CT

17. Target volume delineation

18. Radiotherapy • Planning and delivery technology now very different • Old ‘square’ planning • Was conventional in 1960s – 1990s • Conformal (dose conforms to shape of target in 3D) • ‘Ultra-conformal’ (includes concave shape) • known as IMRT (intensity modulated radiotherapy) • 21st century technology

19. Treatment volumes compared Conformal Ultra-conformal IMRT ‘Square’ plan

20. Old ‘square’ planning

21. Some shielding with ‘lead’ blocks

22. Treatment volumes compared Conformal Ultra-conformal IMRT ‘Square’ plan

23. Conformal RT plan

24. IMRT plan (TomoTherapy) • Ca nasopharynx • 68 Gy to primary (34#) • 60 Gy to nodes (34#) • Cord dose < 45 Gy • No field junctions • No electrons

25. IMRT plan • Skull base meningioma • Shaping of dose around optic nerves and chiasm • Tumour ~60 Gy • Optic chiasm 50 Gy

27. Radiotherapy dose • Biological effect depends on • Total dose • Number of fractions (Dose per fraction) • Overall treatment time Complex relationship

28. Radiotherapy dose • Single fraction • Very destructive • Known as radiosurgery • Must physically avoid normal tissue • Multiple fractions • Spare normal tissue • Enhances therapeutic radio • Allows treatment including normal tissue

29. RT dose and fractions • For a given dose, and overall time, biological effect depends on number of # • Actually depends on dose/#

30. Chemotherapy • Use in accordance with NICE Guidelines • At first presentation, with (surgery &) RT • Temozolomide • Also at relapse • PCV • Monitor • Blood count, nausea, liver function (+ other s/e) • Progression

31. Chemotherapy • Most chemo for CNS tumours is oral • Temozolomide • Invented in UK • Revolutionised treatment of GBM

32. RT + TMZ for GBM EORTC Randomised trial results P<0.001

33. Cancer cure and cost

34. Cancer cures by modality • References • SBU. The Swedish council on technology assessment in health care: Radiotherapy for Cancer. 1996 • Cancer Services Collaborative 2002

35. The Cancer Reform Strategy Prof. Mike Richards 2007

36. Effectiveness and cost % cures % of cancer Ratio care cost • Radiotherapy 40% 5% 8.0 • Chemotherapy 11% 18% 0.6 • Surgery 49% 22% 2.2

37. What data do oncologists really want?

38. What data do oncologists really want? • What data do oncologists really want or need? • Types of CNS tumour • Prognostic factors • Treatment intent • Treatment details • Dates

39. Tumour types in oncology clinic • Note ~20% with benign tumours

40. CNS tumour types - 1 • Glial tumours • Astrocytoma (inc Pilocytic & Juvenile Pilocytic) • Oligodendroglioma • Oligo-astrocytoma • Glioblastoma (GBM) • Ependymoma (+ subependymoma) • Meningioma • Pituitary adenoma + Craniopharyngioma

41. CNS tumour types - 2 • Vestibular schwannoma (aka acoustic neuroma) • Medulloblastoma • Germinoma + teratoma • Lymphoma • Neurocytoma + Ganglioglioma • Pineoblastoma • Primitive neuro-ectodermal tumour (PNET) • (Chordoma + chondrosarcoma) • (Metastases)

42. CNS tumour types - 3 • Many tumour types • Prognosis varies enormously • Survival from “days to weeks” to cure • Affected by tumour type • Grade (ie how malignant) • Essential to know detail • Detail must be collected

43. Grade affects prognosis • High grade glioma • Grade III • Grade IV = GBM - Surgery + RT only - Radical treatment - Addenbrooke’s data

44. Grade affects prognosis • Histology is not the only tumour feature which affects outcome

45. Radiotherapy & Oncology 2007; 85:371-378 • Radiology adds to pathology grade • Need to include information from imaging

46. What data do oncologists really want? • Prognostic factors • Age • Performance status • ? Size • Extent of surgical resection (hard to evaluate) • Treatment intent • Radical • Palliative

47. What data do oncologists really want? • Treatment intent • Might be clear from treatment • GBM – RT 60 Gy (30#) = radical 30 Gy (6#) = palliative • Need to know if intent changes • eg due to progression

48. Radiotherapy details • Area treated • Total dose • Number of fractions • Overall treatment time • Dates • Time (delay) to start RT • Overall time (duration) of RT

49. Chemotherapy details • Drug(s) • Dose • Number of cycles given • Dates