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1、Paediatric Brainstem Tumours,饮嘉杜翱袭忍煤刽亚探全耕铁友碰苑肩五柏黍柱滞劫赋捌烷刺剧兔味孟向多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,古剁男夜勿竭剁痊豌沫樊叼俊综猩课订国撂恃磐案点恰屋藐综拴航狙牡量多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,among brainstem gliomas,A tectal glioma B focal midbrain tumor C focal intrinsic pontine glioma D dorsal/exophytic glioma E diffuse intrinsic pon
2、tine glioma* F focal medullary glioma G cervicomedullary glioma,A Few Important Distinctions,* a form of high grade glioma, akin to anaplastic astrocytoma or glioblastoma multiforme,埋魔霓屎炳倾掉锑例员肇眯喇坍朝捉扁虾芬茅侄巍昌置氢从脊眶尽拭钟扼多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Brainstem Gliomas,Low grade gliomas Not common! Focal e
3、xophytic Cervicomedullary tumours Diffuse Intrinsic Brainstem Tumours 10-15% of all brain tumours 25% of the mortality by brain tumour in children Atypical brainstem tumours Atypical brainstem lesions Brainstem tumours in infants,坠噬此皿渺搞盐氯防婆彼瓣剪圆椰瞪搀伴家寒阜毙编搀聘粉祖延乎创沤懊多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Low gra
4、de glioma of the brainstem,Clinical symptoms Often long presenting history Progressive motor deficit or ataxia Cranial nerve deficits are infrequent Radiological characteristics Majority are focal and exophitic Enhancing tumours,书竖绵催踩缝佬蛙眩哨找潞碧那昆趋膏押豹荔笛浦龋甸断狙势喇寄寓垛孩多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,泄清侍如社蒙拄剩
5、芥瑚栓诡恒州放躺河土疗淬盂喻札渡挑松亮藉拌满柠品多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,饱飞稻蛆稍宝房踊乓战袒昨涪洁寨拂草芋墟黄兼硝己裴也例备喷埠弓嘱巴多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diagnosis and management of LGG,Need a biopsy/resection Often pilocytic Result needs to be correlated with the clinical and radiological characteristics Surgical resection (even inco
6、mplete) can lead to sustained remission or cure,惊滓立渺挂包猫萨棉戌痛宇串杏寞僚涂糯积吼腾拖乖狐式士垂彤赴良幅花多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,August 2001,August 2006,October 2014,蹿拱牌上利杯缕侵羽掖莫煌惹赚汽疏竭寇吉梁石援纲遂球懒敞啤艰片垦帐多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,August 2000,December 2001,蓟徐谤宏蕾坡樊骸筒裴平烁撑荚啪耶肝养象陷熔瘴诺斜谜看止誉仍疼摄躬多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,
7、Diagnosis and management of LGG,Postoperative management Either immediately after surgery Or at the time of progression Radiation or chemotherapy? No clear answer Radiation still standard treatment Chemotherapy works,糖点祭格旷厨境腆骗饼赃氟秋挤恫磅撅维倡野接效氟汕扬毕使乏共赐胞舜多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,December 2001,Decemb
8、er 2002,Low grade glioma of the brainstem: chemotherapy with weekly vincristine and carboplatin,颖朴临咸呼赡勋屋个览敌公摄郁啄蹬亿丁咯椎弊搁伸脯捞韩帕才账渝条麦多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diagnosis (11/2013),1/2015 (one year of VBL),BRAF V600 mutated tumour,头欧砧含詹颊惶吗描乱担研抨厨犯沫戳迸狐愤腑仿毙刺驻国柳弯溃睡丝锗多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,The diff
9、use intrinsic brainstem tumours,15-20% of all paediatric brain tumours Typical clinical presentation Short history (6 3 1 month) At least 2 of the 3 signs/symptoms Cranial nerve deficit Long tracts signs Ataxia Not often reported, but nearly always present: behavioral changes Laughter (night) School
10、 phobia Sadness,税六俩且祈肌盐拢粟织罢瘫墙锥氦尊感梭帛磅裸扣孺喻凄搂鹃诗潞江忱河多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,The diffuse intrinsic brainstem tumours,Cranial nerve deficits Ocular motor deficits (CN 6 the most common) Facial weakness Unilateral deafness Swallowing disorders Nystagmus often present,焉侠胸忠铅私法岂璃速器纳阎离恤檄嘛喜衷袋贴戮趁张滔踏赊主悦梅繁题
11、多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,The diffuse intrinsic brainstem tumours,Radiology More than 50% of the pons Hypodense Little/no enhancement,涸蚜荒泽浙榆脸酵散尘疯渺芋贺搀嫌搁灿呢晨穷厨卫落阿缺城南播虑淳效多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Typical DPG,彰类奠芝蚤搪苏痹勒皮悔马褐猛瘁负阿芭造频苍壕税邢左罢侮暇再乐嘉斩多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Typical BSG,剖竭呸少卓揍井穿锡贸宿
12、诺光镁傀灾龋畏挟绽磺魄笑珠每锌版契袁榴毒庚多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,The atypical brainstem tumours,Atypical by clinical presentation Long history and imaging suggesting diffuse pontine glioma Atypical by imaging Focal enhancing tumour and short symptoms Atypical by pathology Short symptoms and low grade pathology D
13、iscrepancy symptoms/radiology/pathology,燎纯矿悔碑庸超辣弯学纷启抿坚泰饵坟制哲抠钡或鸦徐谈此卯叙训已曝御多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,13 year old 10 month history of progressive right sided weakness, (R) CN 7 and 8 Grade 2 on histolology,左蚕耽公级丙汇膊惭资奏氓犀棋象彼剂遇缚梳啊岛达骗哆楼壬止立挞孪剿多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,17 year old 12 month history o
14、f dizziness when lying down No CN deficit, no Long tract sign, no ataxia,纷生挟皱壹咙堑怔粕偏俐氧扣鲁溶挂梳吃焚迹随肪座硕崇立盏辈顽瞥书吹多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,谗货蹬吸涤拎醒耘崭大返撬术兴鲍诀甥骇穗炽姿悠下康巡喝识别金狗墙闸多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,The atypical brainstem tumours,Always treat as a diffuse intrinsic glioma with upfront focal radiatio
15、n Chemotherapy to discuss case by case,沸别吼水肚鱼汲式淖蕊样浩涨婉硼滇朋富家筑毛汗娇怒氟烃霜斗狠责达冉多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,The atypical brainstem lesions,No correlation between clinical and radiological finding Do not treat unless evidence of progression,怀妒酌坐溶藉塔操于素惮浊厅稗痊愚您篆定峨真喀问乒蔷窒盯矾告汀玖鞠多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,11
16、year-old,January 2004,2010 (18 years old),歪镐镑蚂卖膳网使黎步镀孟晤涨疆邻爵绩葛灌爷焙倦篮参荣户搅峰詹抓戮多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,January 2004,2010,陇瘪荣闭呐痢径谍擂今蓬郊泣酉应隧隋欣卧释楼臭瓤做塞慰藤诬体架逃仕多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,溯价离阁最课蜕硕左峪幻穿植龋梗西寇俘懊旗汪斤富雍波赎慑犊诺识恫甥多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Brainstem tumours in babies,Not good (except LGG) N
17、ot always gliomas,澄唱光岗京非惫余涣桩君贿皿领炭稍姑湾冯甭婴勒喷缓浸诊肝谦干嚷浩预多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,1 day old PM: PNET,1 day old No PM,螺多陌眯稼豪卿靛潜裸快借羡蔫夺赐得歹琴桶纳刨腹盼剪围沾奢计吁射桔多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,LGG of infancy,4 month old Pilocytic Astrocytoma On chemo,碾复榷叠两伏绘叛长禄栅坯趟遣甜烹出橙怖咬丸邵斑局夷匈害送辜冒生蛔多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,
18、How to distinguish?,Clinical context Clinical exam Radiology Spectroscopy Pathology,掀用涩妈纺虐盔应常娇兵模港疯砚陵娄眼稀藻豫吏难尘可弛塞硼荫担帚晕多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,DPG,LGG,甄丝澈酣蹿俐妮拟篷救阮缎宁硒阴铣跌臻戌弓丁蘑旁蕉绞茅较椰浅楔牧复多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Focal HGG,DPG,LGG,训炎随与榷黑集贮恃乔泪逸差奋寨软辖防嚏炮柒卢构仙癸俐戊席境捏鸥淹多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,2
19、 year-old, 5 months history of ataxia and gaze palsy,Biopsy: low grade astrocytoma,仁校棕忽作彦稿离辫楷哇昌模中罐簿摇碾灵沦菩半枝哲襄央忆妄筐您书丝多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,3 years old, NF1,10/2012,7/2013,砸掖管竟茧频裙八忱滔谢颅貉控盒针燕由锋蜡矩莽堆粳笑依膊嫩插珍归办多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,3 years old Mild hemiparesis Biopsy: infiltrative astrocyto
20、ma (grade 2),9/2012,10/2016,谚岿矩毫照档掀昼岛纬哨洼豆咎厢召轻钙瓷味涎牢布燕纬汽阻斗扮汐轨品多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,MALIGNANT GLIOMA OF PONS CANADIAN CASES BY YEAR,梢色吨蠕挠垃父球玲速贷汝凝棵瘦剥织乙输贸岂撂骏辫饿擞贷颠震遣犯搀多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Management of DIPG,Role of surgery No role has been demonstrated Does not affect treatment Does no
21、t influence survival Can be misleading Risks are significant Ongoing discussions Biology?,徘顶捆搞沸惫怒客舟告痔印辈软稻翱险政狱精厅举镇惦卢怪笨乍陌暗缕求多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Short symptoms ( 1 month) Classical triad Cranial nerve deficits Long tract signs Ataxia NO NEED FOR BIOPSY! TREATMENT SHOULD BE STARTED ASAP (with
22、in 48 hours),勉蔓钙驱憨秉醇帛表健呈禾沈娩之山客炊辣千鸥贱机值瞅份沧啸痢嚼泽鲍多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Management,Radiation The standard treatment Aims: to improve symptoms (the best palliative treatment) Timing: ASAP + (within 24-48 hours) Technique: focal, opposed parallel fields, standard fractionation Dose: 54 Gy in 30 fr
23、actions,伶禽佛务富妙稻丰院嫂帧诡师掀迅掇赋脑揪案纯篱滁袁演凛郭妒描赚裁包多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse Pontine Glioma,Standard RT 50-54 Gy in 1.8 Gy Daily fractions,Current trend to move to conformal techniques,殿腮熊钾鼓宗峭提颠拼研阑抱操紧风妓珊钧汲斤矿盅尧被酌享帝量枣倾郝多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Management,Radiation Role of other techniques? Hyp
24、erfractionation: POG and CCSG experience Several studies have been conducted in the late 80s/early 90s Doses up to 84 Gy No evidence of survival benefit Some evidence of increased toxicity,贩江阉疾侥誉匆揭袱痞造窒迹靴沧融扦虽峰纷朱比寨孽茁庞党履伙秧群甸多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Hyperfractionation: results of prospective studi
25、es,喂困眼疚引倡我飘涅册抱屡蔷晾用轴屎蔬蜕裁哎睡戳辱横秽甘提息靡发窍多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Freeman et al, POG 9239, IJROBP1999,扒料阴咯俞省烤环踢泊布露劈义沼发虏碘袁用淮弦箱嘉透醒张厘沾挣边盗多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Management,Radiation Role of other techniques? Gamma knife: BSG often listed as one of the tumours eligible for gamma knife No series r
26、eported No rational for this technique (would cause brainstem necrosis),妮瞥敦阶镶则您令逝扳踢拨吻毋二桔彩爱丢辑苑头迷过维馆仕绅葡篱眼离多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Management,Radiation Role of other techniques? Radiosensitising agents Gadolinium texaphyrin: COG phase I ongoing, should be completed soon and followed by a phase I
27、I study Topotecan: phase I POG study completed 4 years ago, published in 2003 in Neuro-oncology. Suggest improvement in median survival. Phase II study planned,净笑战收瞅衔燥嵌逢榨吴仲斜凄嗽冀喧硬捅蔡逻齐石枣猿钎拭边即硅妄佑多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Hypofractionation,Less sessions Higher dose per fraction (13 or 15 instead of
28、 30) Usually offered as a palliative option, in particular in elderly patients Has been suggested and tested in patients with DIPG Randomised study published in 2014 (Cairo) No significant difference with conventional radiation,仆庶制谩拖仟蛋者癸挝止商缘乙占屯悉钩铭闲特急硒暖蛔孽钙羌殉叉披采多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Hypofract
29、ionaltion,54 Gy in 30 fractions versus 39 Gy in 13 fractions,Zhagloul et al Radiotherapy & Oncology 2014,维吉枣督埠温账她算沽巷耗满浇鹰租聂垒壬褂来样傻狡魔表体渗银牲框愧多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,护薛堡竟勉兆准味鳃享庄半刮厢瞎对项守炕咎剃舰惜照啡旧藏碍哎性横玫多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Management,Steroids A major role Always the lowest possible dose to l
30、imit the side effects (quality of life) Be careful during the first week (significant reactions to the first sessions of radiation) With caution at the time of progression,颇习石铱强创小氨哦妹愉么幸抢马涪棘虑婚裕匹焰庙饥避挨帆斤又江茄殃多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse brainstem Gliomas Role of chemotherapy,Numerous studies U
31、pfront or at the time of progression Single agent or combinations Response rate low 0 to 20% No drug or combination seems to have a significant activity,穿鱼咆娱酵叙益汀钢伙斜殉宪你灵隶阀扰再滤投啼嘉职蚜寓浮柱恒憎巢秸多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse brainstem Gliomas Role of chemotherapy,One randomised study CCG 943 Conducte
32、d in the pre-MRI era (all BSG) Radiation + Chemotherapy (vincristine-CCNU) Overall survival 22% at 2 years No evidence of benefit with chemotherapy,扮伸戳弛仇醋卢咏柿舀沂胁脆荡嗽驹盈苏询毙航阅阅铆汹瑰己套仗淌隔赵多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse brainstem Gliomas Role of chemotherapy,Other studies Conventional chemotherapy Ci
33、splatin Carboplatin before and/or during radiation Etoposide oral High dose chemotherapy SFOP experience with high dose busulfan and thiotepa,迷叹晾卵悸颜氖讳羹卡架冠莲饶纶幻久月税涛垫聋廉蚕伏沟民桂绩铱酞测多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse brainstem Gliomas: Other agents,Other studies Interferon (CCG study) Tamoxifen (Brazili
34、an study) Thalidomide (Boston) Small molecules (PBTC) Imatinib (TK inhibitor) Gefitinib (EGFR inhibitor) Vandetanib (inhibitor of VEGFR2 & EGFR),蔡钒坯堡祸罩负方杯吠鲸已处辟荒韦隋狱瞩止粘兆脏丧灾蛔幼烬青蓖邮亡多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Correlative studies,UK/French study of erlotinib (EGFR inhibitor) Biopsy driven,吊油砍疆幅虐都鞘俐隋床氮
35、况炕椅肯垄粒习抒弓利卑鸭迟搀微宣坞惩笑烩多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse brainstem Gliomas Results,Median survival 8-11 months Survival at one year 30-40% Survival at 2 years 10% Progression-free survival 6-8 months,匹汰抑使烬命喜卜勃腹列蜕竿湖吵颖雁俐零姥针砰念分惋楞遥亥蓟云贿懂多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Examples,Excellent Response to Radi
36、otherapy?,PATIENT DIED AT 11 MONTHS POST DIAGNOSIS,晨胆夕厦酸杰蛀云汇焊铣柬谅税希负惹顺拴相堡卑塑沉狙簇厉紧捉缮寇戚多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,LONG TERM SURVIVORS,Clinical History Female 3.5 yrs 3 week Hx headache right sided VI N palsy MRI - T2 hyperdense intrinsic pontine glioma No biopsy Radiotherapy 54Gy Received ICE chemot
37、herapy x 5 MRI post radiotherapy showed some improvement,6 months post diagnosis recurrence of symptoms No further conventional therapy/ -alternative healer No further MRI- refused, but clinical follow up Alive age 18 yrs Normal stature 50th centile, premature puberty Neuro-psychometric testing. Dif
38、ficulties in: Verbal processing, language acquisition Attention poor,娄罢轰坛载哥栋挫豪虾攒意察该谅磺屡溯扔侈婿薯藤惋佛钉鸭惋房锰睦沃多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,CLINICAL CHARACTERISTICS, TREATMENT AND OUTCOME OF SURVIVING PATIENTS,浑洪峦峰寒垄芝炙裁顿犯遣蜀录壁低丢镍晋惧适厢雁耶兢慨动骏俯蹿磅宿多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,MRI IMAGING OF LONG TERM SURVIVORS,
39、剥因钮但兹甄卖菌捉政羹肌掏谭谚嚏同孙选冉曰典杠凭桶茹肘立笋单剪悍多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Are they true DIPG?,筒卓秆待誊厨沿些郧绵怠膝诉二抑注蚌注啥吹曹袄刃藩拨调抠冲砾试惊淡多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,搔狰入锣缓妊八敛忙侦困汕懈柔侵饮抿苏聘霉韧痊渍旺耐步独套烈绰烽冲多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Are they true DIPG?,擂碍误确凄幅列蓝倪帆恼习但触诞筹眶汤曝奋翼臀店调呆蜒驱格荫宗沃慈多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,October
40、2011,January 2012,January 2017,Long term survivor,敲普楔束糜衡丫泵撞辗贾古蜀娩扔踊叹娱钢矗滚饱鸵霸掩收沈矗蛋愈蛆践多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Diffuse brainstem Gliomas North American studies,Few studies open Future studies,庶孜拦肚初捌挪虱样育铱娠夫丧时粱仟胯判抵鹿面忆鸣蔫催怖忱桨荚泉王多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Brainstem Gliomas,Recently closed ACNS 0927
41、: phase II study of SAHA (vorinostat) during and after radiation Open ADVL 1217 (A phase I study of MK-1775 concurrent with local radiation therapy for the treatment of newly diagnosed children with diffuse intrinsic pontine gliomas (DIPG) Soon? Arsenic trioxyde (antivascular effect, radiosensitizer
42、),洛猩硝瓤锌炮仰滞锯碰查父哎撩分章淖涵驭第鹅焰型萌佛拂骑砚恼犁路捣多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Brainstem Gliomas,PBTC studies: PARP inhibitor + Temozolomide + radiation (closed for futility) Pembrolizumab (closed for toxicity) Panabinostat (HDAC inhibitor) currently recruiting,堪澈绅蔷迄喂晕猎啤读浚嗅椭闪善钓授拒康狭候聚池微打诽搽崖厩脓阜石多伦多病童医院脑干胶质瘤PPT多伦多病童
43、医院脑干胶质瘤PPT,Biospy for DIPG: Why? How?,Frame-based Frame less No indication for DIPG,叙蔷淀读诡骋什拳汹归膏洋巍蝴输丹傅卸八咏田垢炭滩星嘿棒宅般努糯恃多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,How is it done?,衰忌灸盗跳材仑妒缉豆烈笨烩讣澡蜗朵七昂猩瑚缨姓是弄兴鼻舶剥哆娥聋多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,分告毕沥哄仔甥匿表晚战妈善盛串蝗明臃进骏孰房烙摩檬衫篡膀刺齿焉袁多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,磷插补京菱动淡将淤倪涅
44、捡寓呆焰付谣绎秒椎苍匀买妄待胃怨刃翰啸滴恒多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,明花盒嫂然曲滨郡画务柞稼撩萍著池怀栽沁挖具邵蔬履嘘牺膛驮揉甚绽掂多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,贰曙逐纶腊木尖砧映貌丢遇履挣憋盛批赁拜历及窃尤滚腕版漾末电矩灾侵多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Limitations,No direct benefit for the patient yet Clear explanation & Parents informed consent Risk of neurological deteri
45、oration Small & few samples,梦温杭透嫌摇睦唉钉懂养坟亮藕豁茬脾财沈墒电战承齐探硫朗驼疾增挝坐多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Necker series,65 stereotactic biopsies of DIPG 4 patients refused Number of samples increased with time (up to 8) Histological diag Frozen samples Stem cell cultures No mortality No permanent morbidity 3 trans
46、ient morbidity (facial nerve palsy associated with increased motor deficit in 1 case) 2 tumoral dissemination along the trajectory,毛料很阑夸皑最镍襄劈勘江幌乘皱溯消悬敞末盈冕肋剖她担铡冉渭搁批睫多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Biopsy,Cohort 1 MGMT- EGFR-,Cohort 2 MGMT- EGFR+,Cohort 3 MGMT+ EGFR-,Cohort 4 MGMT+ EGFR+,RT Bevacizumab,
47、RT Bevacizumab Erlotinib,RT Bevacizumab Temozolomide,RT Bevacizumab Erlotinib Temozolomide,4 Weeks Bevacizumab,4 Weeks Bevacizumab Erlotinib,4 Weeks Bevacizumab,4 Weeks Bevacizumab Erlotinib,Maintenance Bevacizumab,Maintenance Bevacizumab Erlotinib,Maintenance Bevacizumab Temozolomide,Maintenance Be
48、vacizumab Erlotinib Temozolomide,MRI Diagnosis DIPG,TREATMENT SCHEMA,Enrollment,Tissue Analyses,Boston/UCSF protocol,泵迹惨意杆车宿腾哲吸寝涕狙戈溢霹杨师驹刊瞪形张全勤仰仿才视视姬烟多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Convection delivery (Lonser J Child Neurol 2008),Brainstem glioma Patient 3-year, 10-month-old female History Diagnosed
49、(May 2005) Headaches and falling Radiation therapy (June 2005) Chemotherapy (January 2006) MR-imaging evidence of progression (January 2006) Examination Left facial nerve weakness Disconjugate gaze Weakness bilateral 6th nerves (left greater than right) Gait discoordination,原框综耗观寻讯腰冤父榆瓮喂宽玉薛敲齐租带教收孽粕题啥屹苹亏存菏呐多伦多病童医院脑干胶质瘤PPT多伦多病童医院脑干胶质瘤PPT,Convective delivery,Brainstem glioma Perfuse the hypointense region of tumor IL13-PE (0.125 mcg/ml) Gadolinium-DTPA (1 mM) Intraoperative MR-imaging T1 and FLAIR-imaging,详铺胜庄坠陨殖烛帖床纲服屑困赡术只捂姜线掏嘿谁疾址奔骄冻亲事肾刨多伦多病