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Treatment Protocol



Treatment Protocols at the Brain Tumour Foundation of India

Assessment, Investigations and the Decision making process



Initial Investigations and Assessment

1. Full history and physical examination as outlined in the Neuro Oncology Data Sheet (NDS). A copy of NDS can be obtained by writing to us.

2. Baseline investigations: a) Laboratory (we do not carry out any baseline investigations except when indicated as in unknown primary with brain metastases.) b) Imaging review of all previous imaging

3. Review of histology: Submit slides with full details to our pathology department Attach outside histopathology report. In cases of NHL, round cell tumors and PNETs or where the diagnoses is doubtful or not correlating with radiological diagnoses, we ask for paraffin blocks or 4-6 unstained slides for immunohistochemistry.

4. Evaluation of physical, functional and psychological status: All new patients seen in the NeuroOncology Clinics are also evaluated in the simultaneously running BTF clinics, where patients are evaluated for their physical, functional and psychological assessments. Special emphasis is laid on identifying their potential needs during and after treatment and a plan of action charted detailing appropriate steps to meet their and family's needs.


The Decision Making Process

All new cases are evaluated by a consultant and a treatment plan is formalized. Patients requiring multidisciplinary postoperative management, those with a diagnostic or therapeutic problem, interesting cases and patients eligible for trial are discussed in the weekly Joint NeuroOncology Meeting (JNOM). JNOM is held every Thursday at 2 pm at ‘Dr. Sirsat Room’, Dept of Pathology, 8th floor, Annexe Bldg.

Guidelines for Medical Decompressive Therapy



Starting dose of Dexamethasone / Mannitol:

A) Headache (not severe*) and or vomiting (not severe#):

Dexamethasone 6mg daily (2mg, 8 hourly).

B) Headache (not severe*) and or vomiting (not severe#) WITH new or worsening focal neurological deficit:

Dexamethasone 12mg daily (4mg, 8 hourly).

C)*Severe Headache OR #Severe vomiting OR deteriorating consciousness:

Dexamethasone 24mg daily (8mg, 8 hourly) with 20% Mannitol, 1g/kg, 6-8 hourly.

*Severe Headache: perceived as severe or incapacitating by patient
#Severe vomiting: persistent for >12 hours, unable to retain any food


Tapering schedule :

If no improvement is seen within 24 hours, increase dose to the next level/s (B or C) and stop steroids if no improvement even after 48 hours of 24mg dexamethasone with mannitol. If symptoms improve and then stabilize or continue improving, taper dexamethasone every 48 hours: 24,20,16,12,8,6,4,2mg/day and stop. For deterioration while tapering, revert to the previous dose/s every 48 hours, and then attempt tapering. If escalation is required twice (steroid dependence), attempt tapering every 5th day.

Intensity Modulated Radiotherapy (IMRT)


Indications: Mainly for base of skull meningiomas, chordomas.

Rationale: To try to deliver higher doses to chordomas and atypical or malignant meningiomas

Technical policies: To use rigid positioning device only. CT and MR fusion for tumour delineation. CTV and PTV are contoured as for individual sites. Libraries for dose constraints for individual sites devised.

Stereotactic Irradiation (SRS and SRT)


Stereotactic Conformal Radiotherapy (SCRT)

Immobilisation in BrainLAB mask/frame system

Imaging

  • Localisation/planning CT scan in the frame (Double contrast, 3/3mm in the tumour bearing are and 5/6mm outside)
  • Planning MRI with 1-3 mm cuts. Contrast enhanced 3DFSPGR axial sequence only.
  • Fusion of planning CT and MRI on Brain LAB

Target Delineation

  • GTV = enhancing mass including areas presumed to contain active tumour Critical structures including eyes, optic nerves/chiasm (and hypothalamus) and brain stem to be outlined
  • CTV margin = 0 to 5 mm and edited appropriately
  • PTV margin = 2 mm

Planning technique: 6-8 non-coplanar fields, individually shaped with microMLC of the BrainLAB.

Dose Prescription: Dose prescribed at isocentre (plans normalised to 100% at isocentre) with PTV covered by 95% isodose line as per ICRU 50 guidelines

  • Pituitary adenoma 45Gy in 25# in 5 weeks
  • Craniopharyngioma 54Gy in 30# in 6 weeks
  • Meningioma and Acoustic neuroma 54Gy in 30# in 6 weeks
  • Optic nerve meningioma 50.4 Gy in 30# in 6 weeks

Trial Consider patients between 6-25 years with low-grade glioma, craniopharyngioma and meningioma for SCRT Trial (conventional vs SCRT).

Stereotactic Radiosurgery

Common Indications: Solitary brain metastasis and AVM

Immobilisation and Imaging: as in SCRT

Target Delineation

  • TGTV = enhanced lesion
  • PTV = GTV + 2mm in 3D

Planning technique: 6-9 non-coplanar individually conformed fixed fields

Dose Prescription

  • Solitary brain metastasis 15-20 Gy in single fraction, prescribed at 90-95% isodose (plans normalised to 100% at isocentre).
  • Recurrent high grade glioma 30-35Gy in 6-7 daily fractions
  • AVM- assess the suitability of SRS after discussing in the JNOM. Check size, location and supply of the lesion. Planning MRI and MRA a few days before actual day of the procedure. Dose- 12-25 Gy (individualised).

Performance Scales Follow-Up Policy



KPS (Karnofsky Performance Score)

  • 100% = Normal; no complaint; no evidence of disease.
  • 90% = Able to carry on normal activity; minor signs of disease.
  • 80% = Normal activity with effort, some signs or symptoms of disease.
  • 70% = Cares for self, unable to carry out normal activity or to do active work.
  • 60% = Requires occasional assistance, but is able to care for most of own needs.
  • 50% = Requires considerable assistance and frequent medical care.
  • 40% = Disabled, requires special care and assistance.
  • 30% = Severely disabled, hospitalization is indicated although death not imminent.
  • 20% = Hospitalization necessary, very sick, active supportive treatment necessary.
  • 10% = Moribund, fatal processes progressing rapidly.

Neurological Performance Scale (MRC)

  • 0 = No neurologic deficit.
  • 1 = Some neurologic deficit but function adequate for useful work.
  • 2 = Neurologic deficit causing moderate functional impairment, e.g. ability to move limbs only with difficulty, moderate dyphasia, moderate paresis, some visual disturbance (e.g. field defect).
  • 3 = Neurologic deficit causing major functional impairment, e.g. inability to use limb/s, gross speech or visual disturbances.
  • 4 = No useful function - inability to make conscious responses

CPS Scale (WHO)

  • 0 = Able to carry out all normal activity without restriction.
  • 1 = Restricted in physically strenuous activity but ambulatory and able to carry out light work.
  • 2 = Ambulatory and capable of all self-care but unable to carry out any work; up and about more than 50% of waking hours.
  • 3 = Capable only of limited self-care; confined to bed or chair more than 50% of waking hours.
  • 4 = Completely disabled; cannot carry out any self-care; totally confined to bed or chair.

Barthel Activities of Daily Living (ADL) Index

This is based on the following factors:


Bowels
0 = incontinent
1 = occasional accident
2 = continent

Bladder
0 = incontinent or catheterised and unable to manage
1 = occasional accident (maximum 1x per 24 hours)
2 = continent (for over 7 days)

Grooming
0 = dependent
1 = needs some help, but can do something
2 = independent but with some difficulty
3 = normal

Toilet needs
0 = unable
1 = needs help cutting, spreading butter etc.
2 = independent but slow
3 = normal

Feeding
0 = unable
1 = major help (1-2 people, physical)
2 = minor help (verbal or physical)
3 = independent but slow
4 = normal

Transfer
0 = immobile
1 = wheel chair independent including corners etc.
2 = walks with help of 1 person (verbal or physical)
3 = independent but slower than before
4 = normal

Mobility
0 = dependent
1 = needs help, but can do about half unaided
2 = independent but has difficulties
3 = normal

Dressing
0 = unable
1 = needs help (verbal, physical, carrying aid)
2 = independent up and down but slow and with difficulty
3 = normal

Stairs
0 = dependent
1 = independent

Astrocytic Tumors (Gliomas) Ependymomas

The diagnosis of a brain tumour comes with a host of problems - fear of the future, readjustments in life, loss of job, change of lifestyle, anxiety about treatment or commitments, practical coping problems, depression, a sense of isolation or weariness caused by the disease and the side effects of the treatment. There may also be concerns regarding treatment, fears of relapse, coping with pain and a host of questions which you will have. To help you cope better, discuss these concerns with trained counsellors at the BTF. They will guide you through options, and search out ways to ease your problems - whether physical, psychological or social - and help in equipping you to face the uncertainties of life.

Children with brain tumour have a different set of coping problems and need sensitive and careful handling. It is essential that all those concerned and affected seek comfort during this physically demanding and confusing period. The BTF counsellor can be very useful at this time.
Financial Assistance: BTF will assess patients who cannot afford necessary investigations or treatment and if appropriate, refer them to the hospital social worker or other support agencies for help.

Craniospinal Radiotherapy

Brain tumour patients have reported varying degrees of psychological and sometimes physical relief from alternative or complimentary systems such as Ayurveda, homeopathy, reiki, accupuncture, meditation and yoga. In our scientific opinion, these complimentary systems of medicine cannot cure a brain tumour but we also realise that a lot of our patients do try these.A word of caution though: Many of these alternative therapists make tall claims of "Sure Cure" treatments in order to extort large sums of money from patients and families desperately looking for hope.

Consult your doctor or the BTF staff, if you decide to undergo any alternative therapies. This will help in ensuring that:

  • you are not exploited.
  • the therapy does not conflict with our hospital treatment.
  • the efficacy of the treatment is evaluated by experts.

Pituitary Tumors, Craniopharyngiomas, Meningiomas, Chordomas

At times, the illness can compel you to remain at home. If you are unable to reach the hospital, you can ask your family member to inform BTF, who will try to arrange home visits of professionals and volunteers from BTF and the Palliative Care Team of Tata Hospital to help you.


If a patient needs terminal care outside the home:

Should the family find that adequate care cannot be arranged for a terminally ill patient at home, a hospice that is equipped with medical facilites can be arranged by BTF. A list of hospices is with the BTF staff and they can help you arrange one. Here are a couple of such hospices in Mumbai.

Shanti Avendna Ashram
216, Mount Mary Road
Bandra (W)
Mumbai - 400 050
Phone : 642 1889 ; 642 7464

Amrita Kripa Sagar
Badlapur
Contact : A P S Krishnan
Deonar
Mumbai 400088
Phone : 5516050

Primary CNS Lymphomas

The treatment of brain tumour involves a lengthy process, which requires you to be close to the hospital. This can be a problem if you do not live, or have relatives, in Mumbai. Often those affected may face difficulties in movement, especially travelling in buses and trains while commuting to and from the hospital. Talk to the BTF staff and your hospital social workers about your problems. They will advise you about special buses organised by the hospital, and also suggest places you and your family can stay during the course of your treatment - of course, depending on your need and affordability.A list of accommodations, their addresses, name of person to contact, and charges, if any, are with the BTF staff.

If a patient needs terminal care outside the home:

Dr. Ernest Borges Memorial Home (With free transport to hospital)
Near Guru Nanak Hospital
Kalanagar Bandra (East)
Mumbai - 400 051
Phone : 26441404

GADGE MAHARAJ Dharamshala Mission Trust
Badlapur
Dadasaheb Phalke Marg,
Gadge Baba Street
Dadasaheb Phalke Marg,
Dadar (East), Mumbai 400 014
Phone: 24222496, 24134598

Bharat Sevashram Sangha (With free transport to hospital)
Vashi Gaon, New Mumbai
Swami Prshantananda
Phone : 27826625

Ahuja Dharamshala
Behind Hindmata Cinema
Parel, Mumbai 400 012

The Bombay Mother and Child Welfare Trust
Mhaskars Nursing Home
B. D. D. Chawl No 31
Near Delisle Road, Police Station
Mumbai 400 013
Phone: 2411 0561

Bharat Seva Sadan Trust
18-A Dadasaheb Phalke
Near Ranjeet Studio
Dadar (East), Mumbai 400 014
Phone: 24110561

Shri Kumavat Seva Trust
Sita Niwas Hall
Opp. Railway Ground
Parel, Mumbai 400012
8. Tilak Hospital 50 B. D. D. Chawl
Dr. G. M. Bhosle Marg
Near Jambori Maidan
Worli, Mumbai
Phone: 2493 1930

Nana Palkar Samruti Samiti
158, Chamar Baug Cross Street
Off Ambedkar Road
Mumbai
Phone: 2417 2167

Brain Metastasis

Cancer Patients Aid Association
Phone: 2492 4000/ 24928775

Swati Ambulance Service
Phone : 2386 9215
Bombay City Corp
Phone: 2201 4295

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