LINC-02. IMPLEMENTATION OF AN INTEGRATED NEURO-ONCOLOGY SERVICE: CLINICIANS’ PERSPECTIVE ON CONDUCT OF NEURO-ONCOLOGY MULTIDISCIPLINARY TEAM MEETING FROM A SINGLE-INSTITUTION IN MALAYSIA

INTRODUCTION Multidisciplinary Team (MDT) meetings are essential in the management of complex cancer cases. There are limited data regarding clinicians’ perception on conduct of neuro-oncology MDT meetings and its impact on clinical management. In University Malaya Medical Centre (UMMC), weekly neuro-oncology MDT meeting was established since 2013 to discuss adult and paediatric complex central nervous system tumour cases. OBJECTIVE To determine clinicians’ perception and level of satisfaction of neuro-oncology MDT meeting. METHODOLOGY Web-based questionnaire was distributed via e-mail to all neuro-oncology MDT clinicians at UMMC in April 2019. RESULT Eighteen out of 20 clinicians responded to the survey. Respondents were: neurosurgeons (n=5), adult oncologists (n=4), paediatric oncologists (n=3), radiologists (n=2), radiation oncologists (n=2) and pathologists (n=2). Majority of clinicians (65%) agreed at current weekly MDT meeting with maximum length of one hour duration and 75% of them suggested to discuss 5 to 10 cases during each meeting. Almost all of them (94.4%) preferred e-mail as method of communication to disseminate information before and after the meetings. MDT members expected 100% attendance from neurosurgeons. Fourteen (70%) clinicians agreed that patients/ parents/ carers do not receive copy of MDT meeting plans and only seven (35%) clinicians document MDT meeting plans in patients’ medical record. Overall, all clinicians felt that MDT meeting improved decision-making process, enhanced continuity of coordinated care and promoted good communication among team members. CONCLUSION The structure and logistics of neuro-oncology MDT meeting in UMMC are generally agreed upon. However, documentation of post-meeting plan and notification to patients need uniformity.

The many faces of glioblastoma: Pictorial review of atypical imaging features

Glioblastoma is an aggressive primary central nervous system tumour that usually has a poor prognosis. Generally, the typical imaging features are easily recognisable, but the behaviour of glioblastoma multiforme (GBM) can often be unusual. Several variations and heterogeneity in GBM appearance have been known to occur. In this pictorial essay, we present cases of pathologically confirmed GBM that illustrate unusual locations and atypical features on neuroimaging, and review the relevant literature. Even innocuous-looking foci, cystic lesions, meningeal-based pathology, intraventricular and infra-tentorial masses, multifocal/multicentric lesions and spinal cord abnormalities may represent GBM. We aim to highlight the atypical characteristics of glioblastoma, clarify their importance and list the potential mimickers. Although a definitive diagnosis in these rare cases of GBM warrants histopathological confirmation, an overview of the many imaging aspects may help make an early diagnosis.

Reappraisal of haemorrhagic suprasellar pilocytic astrocytoma during adulthood

Pilocytic astrocytomas comprise the most common central nervous system tumour during childhood and have an excellent response to surgical treatment in this population. The tumour incidence decreases with age, whereas more aggressive behaviour tends to increase. Haemorrhage as a presenting feature of pilocytic astrocytomas is a rare phenomenon, especially in the adult population. We present a case of a 55-year-old patient with progressive headaches and dizziness. MRI confirmed a sellar and predominantly retrochiasmal suprasellar lesion with heterogeneous signal, enhancement and blood products. Management via transsphenoidal approach was performed, and histopathology revealed the unexpected diagnosis of haemorrhagic pilocytic astrocytoma. Haemorrhagic pilocytic astrocytoma is an infrequent entity in the adult population and it is essential to recognise the peculiarities regarding diagnostic evaluation and management, which differ from the paediatric population. During adulthood, this tumour carries an overall unfavourable prognosis, with higher rates of progression and recurrence.

Lagophthalmos- A Rare Presenting Sign in a Case of Childhood Pontine Glioma

Brain stem glioma is a rare central nervous system tumour arising from glial cells which occur mostly in children. Diffuse Intrinsic Pontine Gliomas (DIPG) and Focal glioma are the two types of pontine glioma. DIPGs are highly aggressive. The clinical features are not the same in every child. It commonly has a grave prognosis as most children die within 18 months of diagnosis. Hereby, Authors present a case of 10-year-old male child complaining of watering from the left eye for four days. There was no history suggesting involvement of any other cranial nerves and there was no episode of any seizure or similar history. On examination patient was found to have left lagophthalmos. Magnetic Resonance Imaging (MRI) of brain showed features of pontine glioma with mass effect. To prevent exposure keratopathy, the child was started on lubricating drops/gel and lid taping and referred immediately to a cancer centre for further management. Patients with pontine gliomas usually complain of gait disturbance, headache, limb weakness and double vision. To Authors’ knowledge no other documented case has presented with lagophthalmos. This case is presented for the rarity of the presenting symptom and to stress the importance of picking early ophthalmic signs.

How I treat anaplastic glioma without 1p/19q codeletion

Anaplastic astrocytoma without 1p/19q codeletion is a rare primary central nervous system tumour occurring primarily in middle-aged adults and associated with a median survival of 5–10 years. The major corner stone of treatment is maximal safe neurosurgical resection, followed by radiotherapy and chemotherapy. Several clinical trials addressed the optimal adjuvant treatment; however, interpretation has been challenged by the recent molecular marker-based reclassification of tumour. The interim study of the CATNON trial strongly suggests the addition of 12 adjuvant cycles of temozolomide in addition to radiotherapy after maximal safe resection in patients with anaplastic astrocytoma without 1p/19q codeletion. Based on more recently presented data from the second interim analysis of the CATNON trial and from the molecular analysis, benefit from temozolomide during and after radiotherapy is limited to patients with isocitrate dehydrogenase-mutated anaplastic astrocytoma. Given the small patient number in the single subgroups and the so far missing neurocognitive and quality of life data, more mature analyses needs to be awaited to draw final conclusions on the application of concurrent temozolomide treatment for the daily routine in patients who already are scheduled for adjuvant temozolomide. Further molecular analysis is ongoing to define personalised treatment approaches in patients with anaplastic astrocytoma.

Neurocutaneous melanosis with pulmonary metastasis: looking beyond the skin

Neurocutaneous melanosis are neuroectodermal disorders characterized by giant congenital melanocytic nevus or multiple (≥3) nevus’s associated with melanocytic leptomeningeal tumour. Central nervous system tumour can be benign or malignant and usually presents at an early age. The neurological manifestation includes raised intracranial pressure, seizures and spinal cord compression. The dissemination of malignant nevomelanocytes to the peritoneal cavity has been observed with ventriculoperitoneal shunt placement in neurocutaneous melanosis. We report an infant of neurocutaneous melanosis with primary central nervous system melanoma and its metastasis to the lung in view of rarity.