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Late Effects

Central Nervous System

 

Brain Tumor Late Effects

 

CNS late effects associated with brain tumors:

LATE EFFECTS CAUSE SIGNS & SYMPTOMS

Neurocognitive

Problems

IV/IT MTX

 

Radiation therapy (RT)

 

Surgery

Difficulty with:

  • Reading
  • Language (receptive & expressive)
  • Verbal/non-verbal memory
  • Arithmetic

 

Decreased speed of mental processing

 

Attention deficit

 

Decreased IQ

 

Behavior problems

 

Poor school attendance

 

Poor hand-eye coordination
Focal necrosis

IT or high dose IV MTX, BCNU, CDDP

 

High dose radiation therapy (>50 Gy)

Raised ICP:

  • Headaches
  • Nausea
  • Papilledema

 

Seizures

 

Hemiparesis

 

Speech, learning and memory deficits
Cerebrovascular disease High dose RT (>50 Gy)

Headache

 

Seizure

 

Hemiparesis

 

Aphasia

 

Focal neurological findings

Pituitary

hypothalamic

damage

RT

 

Tumor resection (location dependant)

Pituitary dysfunction

  • Reduced hormone levels
  • Precocious puberty
  • Obesity

 

 

Risk factors for CNS late effects

Patient factors

  • Age
    • The developing brain is very vulnerable3
  • Underlying  genetic problems which impair DNA repair such as ataxia-telangectasia

 

Tumor factors

Location of pediatric CNS tumor and associated late effects:

Location

Histology

Late effects

Supratentorial

Low-grade astrocytoma

 

High-grade astrocytoma

 

Other glioma

 

PNET

Poor cognitive function

 

Poor manual dexterity

 

Emotional difficulties

 

Seizures
Right hemisphere tumor  

Poor cognitive function

 

Visuospatial processing difficulties
Left hemisphere tumor  

Poor cognitive function

 

Tendency to be more affected than patient with a right cerebral hemisphere tumor
Pineal gland  

Visual problems (Parinauds syndrome)

 

affective disorders

 

Disorders of:

  • memory
  • visuospatial attention
  • visuomotor problem solving

Hypothalamic/

Parasellar

Craniopharyngioma

 

Optic pathway glioma

Hypopituitarism with reduced levels of:

  • GH
  • TSH
  • FSH/LH

Cognitive difficulties

  • more severe if anterior third ventricle is involved

Infratentorial

PNET

 

Cerebellar astrocytoma

 

High-grade pontine glioma

 

Ependymoma

Mild cognitive deficits

Hypopituitarism with low levels of : GH, TSH, FSH & LH

 

Cerebellar problems

  • Ataxia

 

Craniospinal RT is associated with:

  • Primary hypothyroidism
  • Primary gonadal failure

 

 

Treatment factors

Surgery

A complete resection helps to ensure local control and the long term outcome in many tumors is determined by the extent of resection (demonstrated in both medulloblastoma and high grade astrocytoma)

Peri-operative complications are associated with an increased risk of cognitive deficits

  • Posterior fossa mutism acquired at the time of surgery can be associated with long term cognitive decline
  • Meningitis
  • Shunt infections
  • The need for repeat surgery

 

Radiation Therapy

 

 

 

 

 

 

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