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This chapter addresses the following Geriatric Curriculum Fellowship Milestone: #21

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LEARNING OBJECTIVES

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Learning Objectives

  • Learn the epidemiology, natural history, clinical presentations, diagnosis, and treatment of common brain neoplasms in older adults.

  • Recognize the benefits, adverse effects, and limitations of common treatment modalities, including surgery, radiation therapy (RT), and chemotherapy for common brain tumors in older patients.

  • Understand the determinants of prognosis and factors driving treatment decisions for intracranial neoplasms in the older population.

  • Learn the significance and indications of symptomatic treatments for brain tumors in older adults.

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Key Clinical Points

  1. Metastases are the most common intracranial neoplasms in older adults.

  2. It is important to differentiate metastases from primary brain tumors. In many patients the primary source of metastases remains unknown.

  3. Glioblastoma multiforme (GBM) is the most common primary tumor of the brain and is uniformly fatal.

  4. Patients with vestibular schwannoma (VS), also known as acoustic neuroma, require follow-up for throughout their entire life.

  5. Symptomatic treatment of brain tumors includes corticosteroids to reduce or prevent cerebral edema, antiepileptics to control seizures, and antidepressants to manage depression, commonly seen in patients with brain tumors.

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INTRODUCTION

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Despite making up 13% of the US population, people aged 65 and older make up 61% of new cancer diagnoses each year, and 37% of new central nervous system (CNS) cancer diagnoses. Regardless of tumor type, nearly all brain tumors present one of four ways: elevated intracranial pressure, seizures, focal neurologic deficits, or cognitive dysfunction. While these symptoms raise red flags that trigger extensive work-ups in younger patients, in older adults, they can be masked by dementia, depression, or sometimes just attributed to “getting old,” and can delay diagnosis significantly. CNS tumors in older adults present unique diagnostic, treatment, ethical, and social challenges. We review here the various CNS neoplastic diseases and their treatment in the older population.

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METASTATIC DISEASE

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Metastatic tumors to the brain are by far the most common intracranial neoplasm in adults (Figure 101-1A and B). They occur in 20% to 30% of all patients with systemic cancer. Though intracranial metastases are still an ominous portent, advances in surgery and systemic therapy for specific cancer types have shown that long-term survival is possible. Karnofsky Performance Scale (KPS) is crucially important when deciding upon treatment and prognosticating outcome. KPS greater than or equal to 70, that is, the patient is able to care for himself, seems to be the most significant factor for improved outcome—age less than 65 and controlled systemic disease are also important. In this case advanced age may affect survival by affecting the patient’s ability to tolerate treatments.

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FIGURE 101-1.

(A) Axial and (B) coronal contrast magnetic resonance sequences of metastatic squamous cell carcinoma. Note the lesion is round and well circumscribed, and occurs at the junction of the gray matter and white matter typical of metastatic ...

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