Neuro-oncology

neu·ro-on·col·o·gy n. The branch of medical science dealing with tumours of the nervous system.

Anmari ReyndersAnne Venter

Annami Havenga

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Definition

Neuro-oncology (brain cancers) can develop from:1. Primary brain cells (membranes, blood vessels)2. Metastatic brain cells (cancers cells spread to the

brain via the bloodstream from other organs)

Brain tumours are growths in the brain, but not all of them are cancerous. Cancer refers to malignant tumours.

“Malignant tumours grow and spread aggressively, overpowering healthy cells by taking their space, blood, and nutrients. Like all cells of the body, tumour cells need blood and nutrients to survive. This is especially a problem in the brain, as the added growth within the closed confines of the skull can lead to an increase in intracranial pressure or the distortion of surrounding vital structures, causing their malfunction.”

Pathophysiology

Cancer is a disease where a specific part of the body undergoes uncontrolled, abnormal tissue growth that leads to tumours. Alteration of the genes cells that control the growth and differentiations will change normal cells into cancer cells.

Pathophysiology

The affected genes are divided into two broad categories. Oncogenes – genes that promote cell growth and reproduction. Tumour suppressor genes -genes that inhibit cell division and survival.

Malignant transformation can occur through the:•formation of novel oncogenes•inappropriate over-expression of normal oncogenes•under-expression or disabling of tumour suppressor genes.

There is a number of mechanisms by which tumours can develop that produces neurological manifestations. Specific neural pathways in the brain may be damaged even by small tumours that are located close to these pathways.

Normal function can be disrupted because tumours can invade, infiltrate and supplant normal parenchamal tissue. Growth of intracranial tumours normally leads to the presence of oedema and this may compress normal tissue and impair normal function.

New blood vessels (ex. angiogenesis) develop due to the tumour growth and this disrupts the normal blood-barrier and then lead to a further increase in oedema. Hydrocephalus may also develop when the flow of cerebrospinal fluid proximal to the third and fourth ventricle are obstructed.

All the above mentioned factors contribute to increase of the intracranial pressure (ICP) which interns also impairs cerebral perfusion.

Medical treatment

It’s unlikely that there will ever be a single "cure for cancer“

Management for cancer includes the following: • chemotherapy• radiation therapy• surgery• immunotherapy• monoclonal antibody therapy

It depends upon the location, type of cancer and the stage of the cancer which treatment is used.

The goal of surgery is always to remove all cancer, if possible.

Medical treatment

Alternative treatmentsThey are used by alternative medicine practitioners. This includes:• herbal preparations• massage• acupuncture• electrical stimulation devices

It has never been proven to be affective at killing cancer cells. These modalities are more used by physicians to manage the symptoms.

Palliative care

It aims to reduce physical,

spiritual, emotional and

psycho-social distress

experienced by patients with

cancer. The goal is to make

the patient feel better.

Causes & Risk factors

The exact cause of primary brain tumours is unknown.

These risk factors that can play a role:• Radiation to the brain (head)• Genetic (inherited risk factor)• HIV infection• Smoking (Cigarette)• Environmental toxins (embalming chemicals, rubber industry chemicals)

Signs and symptoms

Symptoms are caused by a tumour pressing on specific parts of the brain that causes neurological dysfunction. This happens when swelling occur caused by a tumour or its surrounding inflammation.

Most common symptoms:•Headache•Weakness•Clumsiness•Difficulty walking•Seizures

Other nonspecific symptoms and signs:• Altered mental status: changes in concentration, attention, memory or alertness• Nausea, vomiting – especially early in the morning• Abnormalities in vision for example double vision, loss of peripheral vision• Difficulty with speech• Changes in emotional and intellectual capacity.

Signs and symptoms

P.S. In some cases a patient can act as if he or she had a stroke. Symptoms can also be more pronounced if it is in a specific brain lobe. For example: behavioural changes in frontal lobe cancers and difficulty with speech or movements in parietal lobe cancers.

Physiotherapy problems

Problems:•Fatigue•Pain•Maintaining and regaining fitness (exercise tolerance) •Muscles weakness due to staying in bed for long periods•Decreasing in joint mobility•Cord compression

Physiotherapy treatment

Treatment for pain:•Specific exercises : relaxation exercises•Postural re-education•Massage•Soft tissue mobilisation•TENS•Heat and cold packs

pain

Treatment for regaining mobility after treatment by physiotherapists:•Exercise programs specifically for patient•For those who cannot walk: Asses for appropriate walking aids and advice on transfers to wheelchair or chair.

mobilityfatigue

cord compression

Physiotherapy treatment

Treatment for fatigue and muscle weakness and regaining fitness:Radiotherapy and chemotherapy cause a lot of tiredness.Coping with cancer is psychologically drainingIn the past standard advice has been to rest but current evidence shows that it is better to do moderate aerobic exercises – walking, cycling or treadmill.It will combat fatigue and rebuild muscle strength and fitness.

Treatment for patients with cord compression:• Carefully planned exercise regime for improving exercise tolerance and building up towards walking.•If not – transfers from bed to wheelchair using sliding board.

Hydrotherapy:Very useful for some patients.Contraindicated in patients who are immunosuppressed

It is very important to discuss the care of patient with other members of the multidisciplinary team regarding mobilisation, discharging planning and continuing care after discharge.

Specific treatment of patients with brain tumours:Physiotherapy will focus on: •Respiratory care, especially when ventilated•Exercises and stretches for maintain normal ROM•Neurological rehabilitation exercises: - sitting balance, walking re-education

JOURNAL OF PALLIATIVE MEDICINEVolume 6, Number 1, 2003© Mary Ann Liebert, Inc.The Utilization of Physical Therapyin a Palliative Care UnitMARCOS MONTAGNINI, M.D.,1,2 MOHAMMED LODHI, M.D.,1,2and WENDI BORN, Ph.D.2ABSTRACTBackground: In the supportive oncology and palliative care settings, rehabilitation interventionsare often overlooked and underutilized, despite high levels of functional disability inthese patients. As a result, little is known about the utilization or effectiveness of rehabilitationinterventions in palliative care populations.Objective: To assess the utilization of physical therapy (PT) in a hospital-based palliative careunit, to characterize functional disabilities in patients who received PT, and to identify factorsrelated to functional improvement following a course of PT.Methods: Retrospective chart review of 100 patients (mean age 70 years, 97% male) dischargedfrom the Milwaukee Veterans Hospital Palliative Care unit over 15 months. Activities of dailyliving (ADL) performance scores were recorded on admission, at 2 weeks, and at completionof the PT program and correlated with demographic and disease-related variables.Results: Thirty-seven patients received a formal PT assessment, and 18 patients underwentPT. The most common functional disabilities in patients who received PT were deconditioning,pain, imbalance, and focal weakness. Ten patients demonstrated improvement in ADLfunction at 2 weeks. Six patients completed the course of PT. Albumin was significantly correlatedwith functional improvement. When controlling for albumin, patients with diagnosisof dementia were more likely to show improvement in functional status than patients withouta dementia diagnosis.Conclusion: PT assessment and utilization were uncommon in this group. When utilized, PTbenefited 56% of patients. Factors related to functional improvement following a PT coursewere a higher albumin level and a diagnosis of dementia. Prospective trials of PT in palliativecare patients are needed to better define response rate and predictors of response.

References

1. www.emedicinehealth.com/brain_cancer/article_em.htm2. www.estroric.org/GENERALINFORMATION/Pages/Physiotherapyandcancercareaspx.htm3. http://www.rehab.research.va.gov/jour/99/36/3/taub.htm4. http://emedicine.medscape.com/article/779664-overview#a01045. JOURNAL OF PALLIATIVE MEDICINE, Volume 6, Number 1, 2003, The Utilization of Physical Therapy in a Palliative Care Unit

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