Psychiatric aspects of brain tumors: A review

Drug-resistant schizophrenia-like psychosis associated with temporal non-anaplastic pleomorphic xanthoastrocytoma: unusual revealing symptom of a rare pathology

Introduction and importance

Pleomorphic xanthoastrocytoma (PXA) was first described by Kepes et al. in 1979. Fewer than 200 cases have been reported in the literature. It generally involves the temporoparietal lobe. PXA has a favorable prognosis. The most reported clinical manifestation is epileptic seizures. Revealing psychiatric symptoms have an incidence varying from 50 to 78%. The most common symptoms encountered are anxiety disorders, depression, schizophrenia-like psychosis, cognitive dysfunction or even anorexia nervosa.

Case presentation

Here, the authors report a new case of non-anaplastic pleomorphic xanthoastrocytoma revealed by a drug-resistant schizophrenia-like psychosis in a 26-year-old male patient known with epileptic seizures in whom these two pathologies were intertwined and had been evolving for 5 years. The postoperative course was uneventful, and positive symptoms of schizophrenia were relatively stabilized at discharge.

Clinical discussion

Given the superficial hemispheric location of PXA, the most common clinical presentation is seizures. Psychiatric symptoms revealing brain tumors have an incidence varying from 50 to 78%. Most of these symptoms concern frontal and limbal tumors. In their case, the tumor was located in the right temporal lobe. Surgery was performed and postoperative course was uneventful even though there are conflicting reports regarding the importance of the surgical excision quality.

Conclusion

PXA remains a rare and benign primary CNS tumor. Psychiatric disorders represent a rare revealing mode of this pathology, which must lead to neuroimaging in any patient carrying this type of symptoms.

Why do patients with cancer die?

Cancer is a major cause of global mortality, both in affluent countries and increasingly in developing nations. Many patients with cancer experience reduced life expectancy and have metastatic disease at the time of death. However, the more precise causes of mortality and patient deterioration before death remain poorly understood. This scarcity of information, particularly the lack of mechanistic insights, presents a challenge for the development of novel treatment strategies to improve the quality of, and potentially extend, life for patients with late-stage cancer. In addition, earlier deployment of existing strategies to prolong quality of life is highly desirable. In this Roadmap, we review the proximal causes of mortality in patients with cancer and discuss current knowledge about the interconnections between mechanisms that contribute to mortality, before finally proposing new and improved avenues for data collection, research and the development of treatment strategies that may improve quality of life for patients.

Pharmacological treatment of depression in patients with brain tumors

Patients with brain tumors suffer from intense psychosocial distress. Although the prevalence of depressive symptoms in patients with brain tumors is high, the pharmacological antidepressant treatment of those patients is not well defined and results from clinical trials are largely missing. In this review, we describe the current standard of evidence and clinical guidelines for the pharmacological treatment of depression in brain tumor patients. We present specific side effects and interactions that should guide treatment decisions. Furthermore, we provide evidence for the diagnosis, screening and risk factors for depression in brain tumor patients and we elaborate on potential antineoplastic effects of antidepressant drugs and ongoing clinical trials. Antidepressant drugs should not be withheld from patients with brain tumors. Future clinical trials should explore the effectiveness and side effects of antidepressants in this specific patient population.

A Von Hippel-Lindau Syndrome Case Diagnosed While Hospitalized for Major Depression

Von Hippel-Lindau syndrome (VHL) is a rare genetic disorder inherited in an autosomal dominant manner. It progresses with the presence of cranial and visceral organ tumors. Psychiatric symptoms may be accompanied by tumor location and hormonal changes. However, it is rare for the disease to first appear with psychiatric symptoms, which may delay the diagnosis of the disease. In this article, a case of VHL, first presenting with major depression, is discussed. The diagnosis and treatment of major depression may obscure the diagnosis of VHL due to the similar mean age at diagnosis and the confounding effect of neurovegetative symptoms accompanying depression.

Patients With Hemangioblastoma: Mood Disorders and Sleep Quality

BACKGROUND

Sleep has confirmed physical, psychological, and behavioral benefits, and disruptions can result in disturbances in these states. Moreover, it can be linked bidirectionally with susceptibility to and the subsequent status of brain tumors. The current study examined mood disorders and sleep quality before and after surgery for hemangioblastoma brain tumors.

METHODS

Thirty-two patients diagnosed with hemangioblastoma brain tumors between 2017 and 2023 underwent surgical treatment. The Karnofsky Performance Status and ECOG performance status scales, the Brunel Mood Scale, the Morningness-Eveningness Questionnaire, and the Mini-Sleep Questionnaire were employed to assess the patients.

RESULTS

The findings indicate that after surgery, sleep quality and mood disorders, including tension, vigor, and depression, did not exhibit significant differences in these patients (p>0.05). However, tension, vigor, depression, and sleep quality did have a significant impact on their functional status post-surgery (p<0.05).

CONCLUSION

Depression is the significant mood factor in patients with brain tumors that impact their functional status. In this context, it is recommended that psychological therapies be considered for them, alongside conducting more comprehensive and in-depth studies on psychological disorders in patients with brain tumors.

Diagnostic and Therapeutic Particularities of Symptomatic Melanoma Brain Metastases from Case Report to Literature Review

The recent introduction of immunotherapy and targeted therapy has substantially enriched the therapeutic landscape of metastatic melanoma. However, cerebral metastases remain unrelenting entities with atypical metabolic and genetic profiles compared to extracranial metastases, requiring combined approaches with local ablative treatment to alleviate symptoms, prevent recurrence and restore patients' biological and psychological resources for fighting malignancy. This paper aims to provide the latest scientific evidence about the rationale and timing of treatment, emphasizing the complementary roles of surgery, radiotherapy, and systemic therapy in eradicating brain metastases, with a special focus on the distinct response of intracranial and extracranial disease, which are regarded as separate molecular entities. To illustrate the complexity of designing individualized therapeutic schemes, we report a case of delayed BRAF-mutant diagnosis, an aggressive forearm melanoma, in a presumed psychiatric patient whose symptoms were caused by cerebral melanoma metastases. The decision to administer molecularly targeted therapy was dictated by the urgency of diminishing the tumor burden for symptom control, due to potentially life-threatening complications caused by the flourishing of extracranial disease in locations rarely reported in living patients, further proving the necessity of multidisciplinary management.

Engaging carers in neuropsychological rehabilitation for brain cancer survivors: The "I'm aware: Patients And Carers Together" (ImPACT) program

BACKGROUND

Cognitive impairment is a common late effect in child and adult brain cancer survivors (BCS). Still, there is a dearth of research aimed at therapeutic interventions and no standard treatment options for most BCS.

OBJECTIVE

To describe 1) a novel neuropsychological rehabilitation program for BCS - the "I'm aware: Patients And Carers Together" (ImPACT) program, and 2) two studies that aim to assess the feasibility of the ImPACT program in child and adult BCS, respectively. The program adapts the holistic neuropsychological approach pioneered by Leonard Diller and Yehuda Ben-Yishay to an outpatient setting.

METHODS

Two feasibility studies are described: 1) A single-armed study with 15 child BCS (10-17 years) (ImPACT Child); and 2) a randomized waitlist-controlled trial with 26 adult BCS (>17 years) (ImPACT Adult). In both studies, patients will undergo an 8-week program together with a cohabiting carer. Primary outcomes (i.e., cognitive and neurobehavioral symptoms), and secondary outcomes (i.e., behavioral and psychological symptoms, e.g., quality of life, fatigue) will be assessed at four time points: pre-, mid-, and post intervention, and 8 weeks follow-up. Adult waitlist controls will be assessed at equivalent time points and will be included in the intervention group after all study assessments. Semi-structured interviews will be conducted at follow-up.

EXPECTED OUTCOMES

Results will provide feasibility data in support of future larger scale trials.

DISCUSSION

The findings could potentially improve the management of cognitive impairment in BCS and transform available services. The program can be delivered in-person or remotely and harnesses existing resources in patients' lives.

Seizures, Psychosis, and Cerebral Vascular Malformation: A Rare Chain of Events

Background

In psychiatry, anatomical abnormalities are sometimes forgotten, and this can mislead doctors into thinking that the diagnosis is purely psychiatric. A physical examination is important whenever it is possible. Even though cerebral arteriovenous malformations (cAVMs) are rare and can go unnoticed, in some cases they can cause clinical symptoms, which is a complication. Case Presentation. In this case, we describe a patient with no prior medical or psychiatric history having a cAVM diagnosed after showing psychotic symptoms (delusion and disorganized thoughts and behavior). The deep 4 × 5 cm cAVM was discovered after admitting the patient to psychiatric ward, the neurological cause has been considered after a recorded seizure, which brings the following question: Is the clinical presentation a direct result of the cAVM or is it postictal?

Conclusions

An abnormality leading to another, here is how we could describe our patient's psychopathology leading to psychotic symptoms. The two hypotheses explaining this case report have a low rate of occurring making this a rare case. Either way, neurological cause cannot be overlooked even if the clinical presentation is typical.

Palliative Care and Care Partner Support in Neuro-oncology

ABSTRACT

The journey for a patient with a brain tumor and their loved ones can be extremely challenging due to the high burden of physical symptoms and the emotional distress caused by the diagnosis. Optimizing quality of life by addressing symptoms and reducing this emotional distress can improve treatment tolerance and outcomes and alleviate care partner distress and burden. Symptoms in patients with central nervous system (CNS) tumors can vary in onset and intensity, ranging from headaches, seizures, and focal weakness to emotional distress and cognitive dysfunction. Additionally, care partners may demonstrate distress due to the high burden of care and need appropriate support structures and access to resources to alleviate this stress. Evidence-based recommendations are unfortunately limited given the lack of high-quality research in this area, but patients living with CNS tumors and their loved ones can benefit from early and routine symptom identification and management, compassionate and transparent communication, and practical guidance for the future. These principles are part of palliative care, a field of medicine focused on alleviating suffering in patients with serious, chronic illness. Clinicians involved in the care of patients with CNS tumors must be educated in these important primary palliative care principles. This article focuses on key symptom management, strategies for high-quality communication, a discussion of advance care planning, and an overview of end-of-life care.

Psychiatric presentation in undiagnosed intracranial space-occupying lesions: A case series

Intracranial space-occupying lesions (SOLs) account for about 5-10 deaths per 100,000 in India. They present with physical symptoms such as headache, nausea, vomiting, and weakness; neurological symptoms such as seizures, and focal neurological deficit; and behavioral changes manifesting as depression (15-20%), anxiety (30-50%), psychosis (<5%), and personality changes (16-76%). Therefore, it is necessary to do an appropriate general, neurological, and behavioral examination for proper diagnosis and management. A series of four cases who reported to psychiatric outpatient with behavioural complaints and no focal neurological deficits were reported. The most common presentation of SOLs is seizure, headache, vomiting, and loss of consciousness. Along with this complaint, some patients may present with abnormal behavior. However, it is very rare for a SOL to present solely with psychiatric or behavioral complaints. Therefore, it becomes imperative to keep a close watch on the symptoms and send for timely investigations.

Prevalence of Neuroradiological Abnormalities in First-Episode Psychosis: A Systematic Review and Meta-analysis

Importance

Individuals presenting with first-episode psychosis (FEP) may have a secondary ("organic") etiology to their symptoms that can be identified using neuroimaging. Because failure to detect such cases at an early stage can have serious clinical consequences, it has been suggested that brain magnetic resonance imaging (MRI) should be mandatory for all patients presenting with FEP. However, this remains a controversial issue, partly because the prevalence of clinically relevant MRI abnormalities in this group is unclear.

Objective

To derive a meta-analytic estimate of the prevalence of clinically relevant neuroradiological abnormalities in FEP.

Data Sources

Electronic databases Ovid, MEDLINE, PubMed, Embase, PsychINFO, and Global Health were searched up to July 2021. References and citations of included articles and review articles were also searched.

Study Selection

Magnetic resonance imaging studies of patients with FEP were included if they reported the frequency of intracranial radiological abnormalities.

Data Extraction and Synthesis

Independent extraction was undertaken by 3 researchers and a random-effects meta-analysis of pooled proportions was calculated. Moderators were tested using subgroup and meta-regression analyses. Heterogeneity was evaluated using the I2 index. The robustness of results was evaluated using sensitivity analyses. Publication bias was assessed using funnel plots and Egger tests.

Main Outcomes and Measures

Proportion of patients with a clinically relevant radiological abnormality (defined as a change in clinical management or diagnosis); number of patients needed to scan to detect 1 such abnormality (number needed to assess [NNA]).

Results

Twelve independent studies (13 samples) comprising 1613 patients with FEP were included. Of these patients, 26.4% (95% CI, 16.3%-37.9%; NNA of 4) had an intracranial radiological abnormality, and 5.9% (95% CI, 3.2%-9.0%) had a clinically relevant abnormality, yielding an NNA of 18. There were high degrees of heterogeneity among the studies for these outcomes, 95% to 73%, respectively. The most common type of clinically relevant finding was white matter abnormalities, with a prevalence of 0.9% (95% CI, 0%-2.8%), followed by cysts, with a prevalence of 0.5% (95% CI, 0%-1.4%).

Conclusions and Relevance

This systematic review and meta-analysis found that 5.9% of patients presenting with a first episode of psychosis had a clinically relevant finding on MRI. Because the consequences of not detecting these abnormalities can be serious, these findings support the use of MRI as part of the initial clinical assessment of all patients with FEP.

Left frontal lobe glioblastoma multiforme masquerading as psychosis: A case report

Brain tumours often present with a variety of early subtle, non-specific symptoms. This can obscure an organic origin of the illness, which deters timely referral and management. We report a rare case of psychosis in a patient with a left frontal lobe tumour, preceded by 2 months of lethargy and word- finding difficulty with minimal neurological deficits, who was referred to our psychiatric unit from a primary care facility. Blood investigation findings including tumour marker levels were normal. Prompt neuroimaging revealed a left frontal lobe lesion with findings indicating a glioblastoma. The patient was subsequently referred to the neurosurgical team for surgical resection of the tumour. A high index of suspicion is paramount among atypical sociodemographic groups of patients with atypical psychiatric presentations. The primary care setting, which is often the first point of contact for patients, provides an avenue for early detection of such cases and timely referral to the appropriate healthcare system to ensure an optimal outcome.

Incidence of clinically relevant psychiatric symptoms during glioblastoma treatment: an exploratory study

PURPOSE

In addition to neurological symptoms glioblastoma (GBM) patients can experience psychiatric complaints, which are often hard to recognize and difficult to treat. Research on psychiatric symptoms during glioblastoma treatment is limited, but can have significant impact on quality of life, treatment processes and even survival. The aim of this study is to explore the incidence of clinically relevant psychiatric symptoms, during glioblastoma treatment and active surveillance.

METHODS

Medical records of 302 GBM patients were reviewed from diagnostic surgery until discontinuation of treatment or active surveillance. Clinical relevance was defined as psychiatric symptoms that interfered with the oncological treatment and required referral to a psychiatrist. "Referred" versus "non-referred" GBM patients were compared using the Pearson Chi-Square test, Fisher's Exact Test or Mann Whitney-U test.

RESULTS

Psychiatric symptoms occurred in 11.5% of patients during glioblastoma treatment or active surveillance, most often mood or behavioral symptoms, followed by psychotic symptoms. Referral occurred mainly during concomitant chemoradiation or adjuvant chemotherapy (64.3%). In 28.6% of patients psychiatric symptoms were thought to be attributive to medication. Treatment was discontinued in 17.9% of patients and temporarily interrupted in 3.6%. Possible risk factors included male gender, history of psychiatric disorder, postoperative delirium, non-frontal tumor location, anti-epileptic drug use at baseline and corticosteroid initiation during treatment.

CONCLUSION

The found incidence of 11.5% and the high number of patients discontinuing treatment due to psychiatric symptoms justify more research in this, to date, understudied topic in scientific literature. Further prospective studies are needed to identify risk factors and unravel possible effects on survival.

Psychiatric disorders associated with immune checkpoint inhibitors: a pharmacovigilance analysis of the FDA Adverse Event Reporting System (FAERS) database

Background

With the increasing use of immune checkpoint inhibitors (ICIs) for tumour immunotherapy, the immune-related adverse events (irAEs) caused by their collateral effect on the immune system pose a key challenge for the clinical application of ICIs. Psychiatric adverse events are a class of adverse events associated with ICIs that are realistically observed in the real world. We aim to provide a comprehensive study and summary of psychiatric adverse events associated with ICIs.

Methods

We obtained ICI adverse reaction reports during January 2012-December 2021 from the FDA Adverse Event Reporting System (FAERS) database. ICI reports underwent screening to minimize the influence of other adverse reactions, concomitant medications, and indications for medication use that may also contribute to psychiatric disorders. Disproportionality analysis was performed to find psychiatric adverse events associated with ICIs by comparing ICIs with the full FAERS database using the reporting odds ratio (ROR). Influencing factors were explored based on univariate logistic regression analysis. Finally, the Cancer Genome Atlas (TCGA) pan-cancer transcriptome data were combined to explore the potential biological mechanisms associated with ICI-related pAEs.

Findings

Reports of psychiatric adverse events accounted for 2.71% of the overall ICI adverse event reports in the FAERS database. Five categories of psychiatric adverse events were defined as ICI-related psychiatric adverse events (pAEs). The median age of reports with ICI-related pAEs was 70 (interquartile range [IQR] 24-95), with 21.54% of reports having a fatal outcome. Cases with indications for lung cancer, skin cancer and kidney site cancer accounted for the majority. The odds of ICI-related pAEs increased in older patients (65-74: OR = 1.44 [1.22-1.70], P < 0.0001: ≥75: OR = 1.84 [1.54-2.20], P < 0.0001). The occurrence of ICI-related pAEs may be related to NOTCH signalling and dysregulation of synapse-associated pathways.

Interpretation

This study investigated psychiatric adverse events highly associated with ICI treatment, their influencing factors and potential biological mechanisms, which provides a reliable basis for further in-depth study of ICI-related pAEs. However, as an exploratory study, our findings need to be further confirmed in a large-scale prospective study.

Funding

This work was supported by the Natural Science Foundation of Guangdong Province (2018A030313846 and 2021A1515012593), the Science and Technology Planning Project of Guangdong Province (2019A030317020) and the National Natural Science Foundation of China (81802257, 81871859, 81772457, 82172750 and 82172811). Guangdong Basic and Applied Basic Research Foundation (Guangdong - Guangzhou Joint Fouds) (2022A1515111212). This work was supported by Key Research and Development Projects of Sichuan Science and Technology (2022YFS0221, 2022YFS0074, 2022YFS0156 and 2022YFS0378). Sichuan Provincial People's Hospital Hospital Young Talent Fund (2021QN08).

Unraveling the Complexity of Multicentric Gliomas: Insights Into Chronicity and Genetic Aberrations

Gliomas are among the most common primary tumors of the brain. Discrimination among tumors of more than one focus has segregated the latter into two groups: multifocal gliomas and multicentric gliomas (MCGs). In this case series, outcomes among three patients are described and discussed in light of the findings present in the literature. Ideally, it is crucial to consider genetic testing for categorizing each tumor. This can help determine the original genetic mutations of MCGs and allow to establish necessary screening testing for early detection. We present the cases of three patients diagnosed with cranial gliomas. The first case showed two synchronous gliomas at different loci in the right hemisphere. The second patient showed synchronous lesions on cranial magnetic resonance imaging in each hemisphere. The third case was of a patient with metachronous lesions appearing at different times with similar radiological findings at different loci of the same hemisphere. Discrimination among multifocal and multicentric gliomas requires genetic workup because radiological and temporal findings may fail to allow adequate discrimination.

Predictive models and survival analysis of postoperative mental health disturbances in adult glioma patients

Background and Objectives

Patients with primary malignant brain tumors may experience mental health disturbances that can significantly affect their daily life. This study aims to identify risk factors and generate predictive models for postoperative mental health disturbances (PMHDs) in adult glioma patients in accordance with different clinical periods; additionally, survival analyses will be performed.

Methods

This longitudinal cohort study included 2,243 adult patients (age at diagnosis ≥ 18 years) with nonrecurrent glioma who were pathologically diagnosed and had undergone initial surgical resection. Six indicators of distress, sadness, fear, irritability, mood and enjoyment of life, ranging from 0-10, were selected to assess PMHDs in glioma patients in the third month after surgery, mainly referring to the M.D. Anderson Symptom Inventory Brain Tumor Module (MDASI-BT). Factor analysis (FA) was applied on these indicators to divide participants into PMHD and control groups based on composite factor scores. Survival analyses were performed, and separate logistic regression models were formulated for preoperative and postoperative factors predicting PMHDs.

Results

A total of 2,243 adult glioma patients were included in this study. Based on factor analysis results, 300 glioma patients had PMHDs in the third postoperative month, and the remaining 1,943 were controls. Candidate predictors for PMHDs in the preoperative model were associated with age, clinical symptoms (intracranial space-occupying lesion, muscle weakness and memory deterioration), and tumor location (corpus callosum, basal ganglia and brainstem), whereas age, clinical symptoms (nausea and memory deterioration), tumor location (basal ganglia and brainstem), hospitalization days, WHO grade 4, postoperative chemotherapy or radiotherapy and postoperative Karnofsky Performance Scale (KPS) served as important factors in the postoperative model. In addition, the median overall survival (OS) time for glioma patients with PMHDs was 19 months, compared to 13 months for glioblastoma, IDH-wild type (GBM) patients with PMHDs.

Conclusion

The risk factors for PMHDs were identified. These findings may provide new insights into predicting the probability of PMHD occurrence in glioma patients in addition to aiding effective early intervention and improving prognosis based on different clinical stages.

Clinical Presentation and Prognosis

Over the past three decades, the care for patients with meningioma has steadily improved as a result of a better understanding of the natural history, molecular biology, and classification of these tumors. Surgical frameworks for management have been established and validated with more options for adjuvant and salvage treatment available for patients with residual or recurrent disease. Overall these advances have improved clinical outcomes and prognosis.Alongside the improved clinical management has come an increase in biological understanding of these tumors. The number of publications within the field of meningioma research continues to expand and biological studies identifying molecular factors at the cytogenic and genomic level offer exciting potential for more personalized management strategies. As survival and understanding have increased, treatment outcomes are moving from traditional metrics, which describe the morbidity and mortality to more patient-centered measures. The subjective experiences of patients with meningioma are gaining interest among clinical researchers and it is recognized that even supposedly mild symptoms arising from meningioma can have a significant effect on a patient's quality of life.This chapter reviews the varied clinical presentations of meningioma, which in the modern era of widespread brain imaging must include a discussion of incidental meningioma. The second part examines prognosis and the clinical, pathological, and molecular factors that can be used to predict outcomes.

Psychiatric Symptoms in Patients with Cerebral Endometriosis: A Case Report and Literature Review

Endometriosis is a systemic medical condition characterized by endometrial tissue that is abnormally implanted in extrauterine sites, including the central nervous system. In this article, we reported the case of a patient with presumed cerebral endometriosis who was diagnosed with bipolar disorder and panic disorder and systematically reviewed the literature for previously reported neuropsychiatric symptoms in patients with cerebral and cerebellar endometriosis. The PubMed, Scopus, and Web of Science bibliographic databases were searched according to the PRISMA guidelines. Seven previous case reports were found and described. While neurological disturbances dominated the clinical picture in the cases retrieved from the literature, our patient represented the first case to show both neurological and psychiatric manifestations. Atypical features of bipolar disorder including chronic mood instability, mixed episodes, and excitatory interepisodic symptoms were highlighted. During the neuropsychological evaluation, a dysexecutive profile consistent with frontal lobe pathology was evidenced. We hypothesized that the course and features of the illness were largely influenced by the presence of documented brain lesions compatible with endometrial implants, especially in the frontal region. Accordingly, patients with endometriosis who exhibit neurological as well as mental symptoms should be investigated for cerebral lesions.

The effect of anticonvulsants on survival among patients with GBM brain tumors undergoing radiation: A SEER-Medicare analysis

BACKGROUND

Patients with glioblastoma multiforme (GBM) who undergo radiation often require anticonvulsants during treatment. The aim of this study was to determine the effects of anticonvulsants on GBM clinical outcomes.

METHODS

A retrospective analysis was performed using the SEER-Medicare database. All patients with GBM who were treated with radiation and concurrently taking an anticonvulsant were included in final analysis. Each class of medication was further subdivided by mechanism of action. Descriptive statistics were performed for all variables. Kaplan Meier survival curves were generated for each class of medication and Cox regression analysis was performed to assess the effect of each individual variable on survival.

RESULTS

There were 1561 patients available for final analysis. On multivariate Cox regression analysis, GBM patients taking sodium/calcium (Na/Ca) channel blocker anticonvulsants during radiation therapy demonstrated both improved overall survival (OS) (HR, 0.799; 95% CI [0.716, 0.891]; P < 0.001) and cancer specific survival (CSS) (HR, 0.814; 95% CI [0.727, 0.911]; P < 0.001).

CONCLUSION

OS was significantly better in patients taking NA/Ca channel blockers among patients with GBM who were concurrently undergoing radiation therapy.

The Use of Psychotropic Medication in Pediatric Oncology for Acute Psychological and Psychiatric Problems: Balancing Risks and Benefits

Severe acute behavioral and emotional problems represent one of the most serious treatment-related adverse effects for children and adolescents who have cancer. The critical and severe nature of these symptoms often makes necessary the use of psychotropic drugs. A working group composed of experts in multiple disciplines had the task of creating an agreement regarding a management plan for severe acute behavioral and emotional problems (SABEPs) in children and adolescents treated for cancer. To obtain global information on the use of psychotropic drugs in pediatric oncology, the working group first developed and mailed a 15-item questionnaire to many Italian pediatric oncology centers. Overall, an evident lack of knowledge and education regarding the use of psychotropic medications for the treatment of SABEPs was found. Thus, by referring to an adapted version of the Delphi method of consensus and standard methods for the elaboration of clinical questions (PICOs), the working group elaborated evidence-based recommendations for psychotropic drugs in the pediatric oncology setting. Furthermore, based on a thorough multivariate analysis of needs and difficulties, a comprehensive management flow was developed to optimize therapeutic interventions, which allows more accurate and efficient matching of the acute needs of patients while guiding treatment options.

Socioeconomic and demographic determinants of radiation treatment and outcomes in glioblastoma patients

Introduction

Poor outcomes in glioblastoma patients, despite advancing treatment paradigms, indicate a need to determine non-physiologic prognostic indicators of patient outcome. The impact of specific socioeconomic and demographic patient factors on outcomes is unclear. We sought to identify socioeconomic and demographic patient characteristics associated with patient survival and tumor progression, and to characterize treatment options and healthcare utilization.

Methods

A cohort of 169 patients with pathologically confirmed glioblastomas treated at our institution was retrospectively reviewed. Multivariable cox proportional hazards analysis for overall survival (OS) and cumulative incidence of progression was performed. Differences in treatment regimen, patient characteristics, and neuro-oncology office use between different age and depressive disorder history patient subgroups were calculated two-sample t-tests, Fisher's exact tests, or linear regression analysis.

Results

The median age of all patients at the time of initiation of radiation therapy was 60.5 years. The median OS of the cohort was 13.1 months. Multivariable analysis identified age (Hazard Ratio 1.02, 95% CI 1.00–1.04) and total resection (Hazard Ratio 0.52, 95% CI 0.33–0.82) as significant predictors of OS. Increased number of radiation fractions (Hazard Ratio 0.90, 95% CI 0.82–0.98), depressive disorder history (Hazard Ratio 0.59, 95% CI 0.37–0.95), and total resection (Hazard Ratio 0.52, 95% CI 0.31–0.88) were associated with decreased incidence of progression. Notably, patients with depressive disorder history were observed to have more neuro-oncology physician office visits over time (median 12 vs. 16 visits, p = 0.0121). Patients older than 60 years and those with Medicare (vs. private) insurance were less likely to receive as many radiation fractions (p = 0.0014) or receive temozolomide concurrently with radiation (Odds Ratio 0.46, p = 0.0139).

Conclusion

Older glioblastoma patients were less likely to receive as diverse of a treatment regimen as their younger counterparts, which may be partially driven by insurance type. Patients with depressive disorder history exhibited reduced incidence of progression, which may be due to more frequent health care contact during neuro-oncology physician office visits.

Study of Association of Various Psychiatric Disorders in Brain Tumors

Background  Brain tumors may be associated with high morbidity, and psychiatric symptoms may be an early manifestation. It is important to address mental symptoms as early as possible because they are prone to develop psychiatric comorbidities in future. If untreated, these situations may worsen and lead to burden upon caregivers. Methods  A total of 176 brain tumor patients between January 2021 and January 2022 constituted the sample size. All recently diagnosed cases of brain tumor with age equal to or more than 18 years who can comprehend and answer questionnaires were included. Patients with a long history of brain tumor or who had a history of a psychiatric illness other than presenting symptoms or any other serious medical illness were excluded. Results  Twenty-seven percent of brain tumor patients had psychiatric symptoms. Depressive symptoms were the most common, associated with 24% of patients, followed by anxiety disorders. Psychiatric disorders were more common in supratentorial compared to infratentorial tumors. Psychiatric symptoms seem to be associated more commonly with malignant tumors and peritumoral edema. Among malignant tumors, depressive symptoms tend to be related with high-grade glioma, and among benign tumors, they were more common in meningioma. No predilection to laterality and anatomical lobe involvement is reported. Conclusion  Screening of psychiatric disorders should be a routine in brain tumor patients. An integrated approach is required to treat brain tumor patients. Healthcare professionals should be more vigilant about the onset of psychiatric symptoms and the need of palliative care to improve the quality of life.

Predictors of functional outcomes in adults with brain tumor undergoing rehabilitation treatment: a systematic review

INTRODUCTION

The number of diagnosed brain tumors (BT) has increased in recent years. The results of treatment of patients with surgery, chemotherapy and radiotherapy are also improving and their survival rate has increased significantly. Symptoms of the disease and side effects of oncological treatment may reduce the functional performance of patients. It is so important to conduct rehabilitation in this group of patients. The aim of this systematic review is to identify predictors of effective rehabilitation in aspects of physical functioning of BT patients. The study was registered with health and social care, welfare, public health, education, crime, justice and international development departments, where there is a health-related interest outcome PROSPERO. We have received registration number is: CRD42021269398.

EVIDENCE ACQUISITION

To find relevant publications, the algorithm of keywords ("brain tumor") AND (rehabilitation OR "physical activity" OR exercise OR "physical therapy") was used. The search was conducted in PubMed, Web of Science, PEDro, ClinicalTrials.gov and Cochrane Library. Information was extracted using the PICO format (i.e., participants, intervention, comparison, outcomes).

EVIDENCE SYNTHESIS

the initial search identified a total of 1122 results, and 21 articles met the criteria and were selected for analysis.

CONCLUSIONS

The results present that rehabilitation is an important and safe cancer encouraging therapy, brings functional benefits. The type of rehabilitation program, especially in BT patients, depends on many factors such as time and type of oncological treatment, general conditions which is strongly related to the general functioning of the patient. It still is a need for clinical research into the safety and effectiveness of rehabilitation interventions already during radio or chemotherapy in this group of cancer patients.

Schizophrenia-Like Psychosis Presented in a Patient With a Temporal Lobe Tumor: A Case Report

Psychiatric symptoms caused by brain lesions are not uncommon nowadays, caused by several different pathologies such as Alzheimer's, dementia, vascular and oncological diseases, etc. and they are known as neuropsychiatric or neurobehavioral symptoms, overlapping as mental health disorders. The most common primary brain tumors are gliomas, and the most common neuropsychiatric symptoms caused by them are depression, anxiety disorder, schizophrenia-like psychosis, anorexia nervosa, or cognitive dysfunction. We present a case of a 46-year-old male with no psychiatric familial history who started with a schizophrenia-like psychosis with hallucinations and, in consequence, killed his mother, symptoms which, after almost eight years, were known to be caused by a brain tumor.

CSCO expert consensus on the diagnosis and treatment of breast cancer brain metastasis

Breast cancer is one of the most common malignancies among women worldwide. According to the International Agency for Research on Cancer, breast cancer affected more Chinese women than any other cancer in 2020. The brain is an increasingly common metastatic sites of breast cancer. Although the risk of developing brain metastases (BMs) is lower in breast cancer than in lung cancer and melanoma, due to its high prevalence, it is the second most common cause of BM among solid tumors, being second only to lung cancer. The incidence of breast cancer brain metastasis (BCBM) differs by molecular subtype. Half of patients with advanced human epidermal growth factor receptor-2 (HER2)-positive and one-third of patients with triple-negative breast cancer (TNBC) develop BM. The clinical manifestations of leptomeningeal metastasis (LM) are often non-specific and may manifest as a variety of signs and symptoms, mainly including brain parenchyma involvement and meningeal irritation syndromes cranial nerve involvement, increased intracranial pressure, and progressive brain dysfunction. Therefore, the Chinese Society of Clinical Oncology (CSCO) Breast Cancer Committee has developed this expert consensus on BM, in an effort to improve the overall prognosis of BCBM and promote the standardized diagnosis and treatment of this disease. During the development of this expert consensus, we carried out a comprehensive literature review and referred to some of the most authoritative guidelines in China and abroad. In this consensus, we will discuss clinical manifestations, imaging examinations, pathological diagnosis, treatments, prognosis, follow-up and monitoring. We hope this consensus will be of help to all the clinicians majored in breast cancer and other similar professions.

Cognitive evaluation following the evolution of brain myofibroblastic tumor in the adolescence: a case study report

ABSTRACT Objective To report the case of a teenager (12 years old) diagnosed with a brain tumor in the right frontal-parietal region emphasizing the main characteristics observed in neuropsychological examinations. Methods In the pre-surgical evaluation, the patient presented behavioral alterations, including deficits in verbal comprehension, perceptual organization, working memory, processing speed, and slight alterations regarding constructive praxis. Results A reevaluation after two years surgery revealed significant improvement in verbal and perceptual comprehension and constructive praxis while remaining a slight change in processing speed. These results suggest that the tumor’s surgical resection produced significant improvements in the patient’s neurocognitive context, especially in executive functions. This study also indicates that Neuropsychological evaluation are useful for pre- and post- surgical evaluation of cognitive functioning and its evolution. Conclusion Brain tumor causes cognitive and behavioral changes and its resection can result in improvements in the patient’s quality of life.

Psychiatric mimics of neurosurgical disorders

Every year there are about 22.6 million people in need of neurosurgical care around the world, and one or several interventions are required to save lives and restore functional losses in more than half of these cases (13.8 million). Most neurosurgical interventions are performed in patients with traumatic brain and spinal cord injuries, strokes, central nervous system (CNS) tumors, hydrocephalus, and epilepsy. In addition to neurological symptoms, many CNS disorders are often accompanied by cognitive and/or behavioral changes. Physical and psychological symptoms can be intertwined as follows: 1) neurological symptoms may be manifested as a result of complex psychological processes; 2) psychological disorders may be manifested as neurological symptoms; 3) neurological disorders commonly cause secondary psychological responses; 4) psychological disorder may be induced more or less directly by an organic brain disease. In the present paper, we focus on the psychiatric conditions occurring in the patients with neurosurgical disorders who either get prepared for surgery or have already received it.

Machine learning models to predict neuropsychiatric disorders in various brain tumors

OBJECTIVE

Neuropsychiatric disorders in brain tumor patients are commonly observed. It is difficult to anticipate these disorders in different types of brain tumors. The goal of the study was to see how well machine learning (ML)-based decision algorithms might predict neuropsychiatric problems in different types of brain tumors.

METHODS

145 histopathologically-confirmed primary brain tumors of both gender aged 25-65 years of age, were included for neuropsychiatric assessments. The datasets of brain tumor patients were employed for building the models. Four different decision ML classification trees/models (J48, Random Forest, Random Tree & Hoeffding Tree) with supervised learning were trained, tested, and validated on class labeled data of brain tumor patients. The models were compared in order to determine the best accurate classifier in predicting neuropsychiatric problems in various brain tumors. Following categorical attributes as independent variables (predictors) were included from the data of brain tumor patients: age, gender, depression, dementia, and brain tumor types. With the machine learning decision tree/model techniques, a multi-target classification was performed with classes of neuropsychiatric diseases that were predicted from the selected attributes.

RESULTS

86 percent of patients were depressed, and 55 percent were suffering from dementia. Anger was the most often reported neuropsychiatric condition in brain tumor patients (92.41%), followed by sleep disorders (83%), apathy (80%), and mood swings (76.55%). When compared to other tumor types, glioblastoma patients had a higher rate of depression (20%) and dementia (20.25%). The developed models Random Forest and Random Tree were found successful with an accuracy of up to 94% (10-folds) for the prediction of neuropsychiatric disorders in brain tumor patients. The multiclass target (neuropsychiatric ailments) accuracies were having good measures of precision (0.9-1.0), recall (0.9-1.0), F-measure (0.9-1.0), and ROC area (0.9-1.0) in decision models.

CONCLUSION

Random Forest Trees can be used to accurately predict neuropsychiatric illnesses. Based on the model output, the ML-decision trees will aid the physician in pre-diagnosing the mental issue and deciding on the best therapeutic approach to avoid subsequent neuropsychiatric issues in brain tumor patients.

Should Neurosurgeons Try to Preserve Non-Traditional Brain Networks? A Systematic Review of the Neuroscientific Evidence

The importance of large-scale brain networks in higher-order human functioning is well established in neuroscience, but has yet to deeply penetrate neurosurgical thinking due to concerns of clinical relevance. Here, we conducted the first systematic review examining the clinical importance of non-traditional, large-scale brain networks, including the default mode (DMN), central executive (CEN), salience (SN), dorsal attention (DAN), and ventral attention (VAN) networks. Studies which reported evidence of neurologic, cognitive, or emotional deficits in relation to damage or dysfunction in these networks were included. We screened 22,697 articles on PubMed, and 551 full-text articles were included and examined. Cognitive deficits were the most common symptom of network disturbances in varying amounts (36–56%), most frequently related to disruption of the DMN (n = 213) or some combination of DMN, CEN, and SN networks (n = 182). An increased proportion of motor symptoms was seen with CEN disruption (12%), and emotional (35%) or language/speech deficits (24%) with SN disruption. Disruption of the attention networks (VAN/DAN) with each other or the other networks mostly led to cognitive deficits (56%). A large body of evidence is available demonstrating the clinical importance of non-traditional, large-scale brain networks and suggests the need to preserve these networks is relevant for neurosurgical patients.

Psychiatric symptoms in children with low-grade glioma and craniopharyngioma: A systematic review

The presentation of psychiatric symptoms in pediatric low-grade brain tumors is challenging because this can delay proper diagnosis and treatment. We performed a systematic review of psychiatric presenting symptoms of low-grade brain tumors in pediatric patients. We searched the PubMed and Web of Science databases of studies published in English from 1977 until 2019 reporting patients aged ≤21 years at the time of tumor diagnosis who exhibited psychiatric/behavioral symptoms before diagnosis of low-grade glioma (LGG), pilocytic astrocytoma (PA), or craniopharyngioma (CP). Our systematic search strategy coupled each tumor type with patient age and presenting symptoms by using different variations of the search terms "childhood" and "psychiatric symptoms" or "behavioral symptoms." We identified six unique articles that met our inclusion criteria in the LGG search, 27 in the PA search, and 32 in the CP search. Six patients were included in the LGG articles (age range, 3-16 years), 75 in the PA articles (age range, 0.5-21 years), and 87 in the CP articles (age range, 0.67-21 years). The most common presenting symptoms included eating disorders (n = 64) and behavioral changes (n = 49). Our findings demonstrate the need to establish clear criteria for neuroimaging indications for pediatric patients exhibiting eating disorders.

Levetiracetam Prophylaxis Therapy for Brain Tumor-Related Epilepsy (BTRE) Is Associated With a Higher Psychiatric Burden

Purpose: Brain tumor-related epilepsy (BTRE) is a condition characterized by the development of seizures in the context of an undergoing oncological background. Levetiracetam (LEV) is a third-generation anti-seizure medication (ASM) widely used in BTRE prophylaxis. The study evaluated LEV neuropsychiatric side effects (SEs) in BTRE prophylaxis.

Method: Twenty-eight patients with brain tumors were retrospectively selected and divided into two groups. In one group, we evaluated patients with a BTRE diagnosis using LEV (BTRE-group). The other group included patients with brain tumors who never had epilepsy and used a prophylactic ASM regimen with LEV (PROPHYLAXIS-group). Neuropsychiatric SEs of LEV were monitored using the Neuropsychiatric Inventory Questionnaire (NPI-Q) at the baseline visit and the 6- and 12-month follow-up.

Results: Eighteen patients of the BTRE-group and 10 patients of the PROPHYLAXIS-group were included. Compared to the BTRE-group, the PROPHYLAXIS-group showed a higher severity of neuropsychiatric symptoms. According to Linear Mixed Models (LMM), a multiplicative effect was observed for the interaction between group treatment and time. For the caregiver distress score (CDS), only a time-effect was observed.

Conclusion: Prophylactic ASM with LEV is associated with an increased frequency of neuropsychiatric SE. Accurate epileptological evaluations in patients with brain tumors are mandatory to select who would benefit most from ASM.

Cut it out or wait it out? Case series of middle fossa arachnoid cysts presenting with psychiatric symptoms and a discussion of the ethics of neurosurgical management

Arachnoid cysts have been linked to neuropsychiatric morbidity. We describe two patients presenting with dissociative and manic symptoms believed to be associated with middle fossa arachnoid cysts. They were managed medically and remitted eventually, but symptoms were resistant. We briefly review the literature to discuss mechanisms by which cysts could cause symptoms and consider whether neurosurgical management would be appropriate. Although neurosurgery can be considered, its role is currently limited by practical and ethical considerations.

Reforming support systems of newly diagnosed brain cancer patients: a systematic review

PURPOSE

Despite the increasing incidence of currently incurable brain cancer, limited resources are placed in patients' support systems, with reactive utilisation late in the disease course, when physical and psychological symptoms have peaked. Based on patient-derived data and emphasis on service improvement, this review investigated the structure and efficacy of the support methods of newly diagnosed brain cancer patients in healthcare systems.

METHODS

This systematic review was performed following the Preferred Reporting Items for Systematic Reviews and Meta-Analysis Protocols. Articles from PubMed, Embase, and CENTRAL databases were screened with six pre-established eligibility criteria, including assessment within 6 months from diagnosis of a primary malignant brain tumour. Risk of bias was evaluated using the Newcastle-Ottawa Scale and Critical Appraisal Skills Program (CASP) Qualitative Studies Checklist.

RESULTS

Of 5057 original articles, 14 were eligible for qualitative synthesis. Four studies were cross-sectional and ten were descriptive. Information given to patients was evaluated in seven studies, communication with patients in nine, and patient participation in treatment decisions in eight. Risk of bias was low in ten studies, moderate in two, and high in two.

CONCLUSIONS

Techniques promoting individualised care increased perceived support, despite poor patient-physician communication and complexity of the healthcare system. Extracted data across 14 included studies informed a set of guidelines and a four-step framework. These can help evaluate and reform healthcare services to better accommodate the supportive needs of this patient group.

The need for neuroimaging in first manifestations of psychiatric symptoms

Background

Brain imaging in psychiatry, especially by first-episode psychiatric symptoms, is unfortunately not a standard procedure in psychiatric clinics and is recommended only if indicated by history or if associated with neurological findings. As a result, the most serious diagnoses can be delayed or missed.

Case Description

We describe a patient who presented with psychiatric symptoms admitted initially to a psychiatric clinic. Thanks to routine imaging the diagnosis of a brain tumor could be made with prompt transfer to neurosurgery.

Conclusion

Brain imaging should be a mandatory procedure upon admission to a psychiatric clinic also in patients who present with exclusive psychiatric symptoms.

Anti-N-Methyl-D-Aspartate Receptor (NMDAR) Encephalitis in Children and Adolescents: A Systematic Review and Quantitative Analysis of Reported Cases

OBJECTIVE

This pooled analysis, from a systematic review, examines anti-N-Methyl D-Aspartate Receptor (NMDAR) encephalitis presentation in children and adolescents.

METHOD

A comprehensive literature search from database inception through December 31, 2019, using PubMed, PsycInfo, and OVID was performed. Case reports and case series were included. Sample characteristics are described. Prodromal and presenting symptoms between partial recovery and full recovery are compared. The association between presenting symptoms and abnormal MRI, abnormal EEG, and tumor presence are determined.

RESULTS

The sample (n=283) had a mean age of 10.8 years with 75.3% females. The most common prodromal and presenting symptom was seizure (29.7% and 63.3%, respectively). Partial and full recovery did not differ for prodromal and presenting symptoms. Multivariate logistic regression analysis found that (1) delusion were significantly associated with higher odds and aggressive behavior was associated with lower odds for abnormal findings on magnetic resonance imaging (MRI); (2) waxing and waning of symptoms were significantly associated with higher odds for abnormal electroencephalograms (EEG), and (3) increased age and psychosis were each significantly associated with increased odds, and sleep disturbance and orofacial dyskinesia with lower odds for tumor presence.

CONCLUSION

Given the pattern of findings, routinely obtaining MRI and EEG should be considered for anti-NMDAR encephalitis in children and adolescents presenting with delusion and waxing and waning of symptoms, respectively. Investigation of tumors should be considered in patients with anti-NMDAR encephalitis especially when psychosis is present.

Right frontal meningioma presenting as delusional parasitosis

Central nervous system tumours can occasionally present with psychiatric symptoms as the only manifestation and can often pose diagnostic challenges. A man in his early 60s presented to the psychiatry outpatient department with delusional parasitosis. His old age and an episode of urinary and faecal incontinence made the clinician consider neuroimaging at the very first visit itself. He was detected to have a right frontal meningioma with features of intracranial hypertension with midline shift, and he underwent emergency surgery. His delusional symptoms completely resolved after surgery and did not recur during the follow-up period of 2.5 years. A right frontal meningioma presenting as delusional parasitosis has probably not been reported in the literature before, and the case is being reported to highlight the rarity of its presentation, the importance of eliciting a detailed clinical history and the need for early neuroimaging in these cases.

Brain tumors and indications for brain imaging in patients with psychiatric manifestations: a case report

Background

Studies on the relationship between psychiatric symptoms and brain tumors are ambiguous, as it is not clear whether these symptoms are due to the direct effect of the tumor or a secondary psychological response to stress, resulting from the diagnosis and treatment of the disease; therefore, it is difficult to analyze and retrieve relevant information.

Case presentation

We present the case of a 43-year-old male patient, who was admitted to a psychiatric emergency room with psychiatric symptoms, such as restlessness and extreme talkativeness, but normal neurological examinations. He showed no response to outpatient treatment and had no history of psychiatric disorders. The onset of symptoms was 2 months before his visit. On neuroimaging, a brain tumor was observed in the right temporal and occipital lobes. Accordingly, the patient was transferred to the neurosurgery ward.

Conclusion

Factors, such as increased internal pressure on the brain due to a brain tumor or the effect of tumor area, contribute to the occurrence of symptoms, such as restlessness and talkativeness. However, further studies are needed to confirm these findings.

Mortality from cancer in people with severe mental disorders in Emilia Romagna Region, Italy

Objective

To examine cancer‐related mortality in patients with severe mental disorders (SMI) in the Emilia Romagna (ER) Region, Northern Italy, during the period 2008–2017 and compare it with the regional population.

Methods

We used the ER Regional Mental Health Registry identifying all patients aged ≥18 years who had received an ICD‐9CM system diagnosis of SMI (i.e., schizophrenia or other functional psychosis, mania, or bipolar affective disorders) during a 10‐year period (2008–2017). Information on deaths (date and causes of death) were retrieved through the Regional Cause of Death Registry. Comparisons were made with the deaths and cause of deaths of the regional population over the same period.

Results

Amongst 12,385 patients suffering from SMI (64.1% schizophrenia spectrum and 36.9% bipolar spectrum disorders), 24% (range 21%–29%) died of cancer. In comparison with the general regional population, the mortality for cancer was about 50% higher among patients with SMI, irrespective if affected by schizophrenia or bipolar disorders. As for the site‐specific cancers, significant excesses were reported for stomach, central nervous system, respiratory, and pancreas cancer with a variability according to psychiatric diagnosis and gender.

Conclusions

Patients suffering from SMI had higher mortality risk than the regional population with some differences according to cancer type, gender, and psychiatric diagnosis. Proper cancer preventive and treatment interventions, including more effective risk modification strategies (e.g., smoking cessation, dietary habits) and screening for cancer, should be part of the agenda of all mental health departments in conjunction with other health care organizations, including psycho‐oncology.

Brain Tumor Causes, Symptoms, Diagnosis and Radiotherapy Treatment

The strategy used for the treatment of given brain cancer is critical in determining the post effects and survival. An oncological diagnosis of tumor evaluates a range of parameters such as shape, size, volume, location and neurological complexity that define the symptomatic severity. The evaluation determines a suitable treatment approach chosen from a range of options such as surgery, chemotherapy, hormone therapy, radiation therapy and other targeted therapies. Often, a combination of such therapies is applied to achieve superior results. Radiotherapy serves as a better treatment strategy because of a higher survival rate. It offers the flexibility of synergy with other treatment strategies and fewer side effects on organs at risk. This review presents a radiobiological perspective in the treatment of brain tumor. The cause, symptoms, diagnosis, treatment, post-treatment effects and the framework involved in its elimination are summarized.

A Case of Lung Cancer with Brain Metastasis following Late-Onset Bipolar Disorder

Objective

To describe a case of lung cancer with brain metastasis in a patient who developed new late-onset bipolar disorder 2 years previously.

Background

The typical onset age of bipolar disorder is approximately 20, and the first episode is usually a depressive episode. It is still not clear which age-specific factors contribute to the underlying risk.

Materials and Methods

A 65-year-old male patient presented with a new-onset manic episode characterized by labile mood, impulsivity, decreased need for sleep, and grandiosity. He was diagnosed with late-onset bipolar disorder after excluding other possible physiological conditions. He was hospitalized in the acute psychiatric ward, and a combination of mood stabilizers and antipsychotics was prescribed. His mental condition improved, and he remained stable for 2 years. However, he experienced abrupt cognitive decline for 2 months and was referred to the emergency room for physiological examination.

Results

The patient was diagnosed with lung cancer with brain metastasis by brain magnetic resonance imaging and whole-body positron emission tomography.

Conclusion

In geriatric patients, who are at high risk of multiple medical conditions, excluding secondary causes of bipolar disorder is important.

Presenting Psychiatric and Neurological Symptoms and Signs of Brain Tumors before Diagnosis: A Systematic Review

Brain tumors can present with various psychiatric symptoms, with or without neurological symptoms, an aspect that complicates the clinical picture. However, no systematic description of symptoms that should prompt a neurological investigation has been provided. This review aims to summarize available case reports describing patients with brain tumors showing psychiatric symptoms before brain tumor diagnosis, in order to provide a comprehensive description of these symptoms as well as their potential relationship with delay in the diagnosis. A systematic literature review on case reports of brain tumors and psychiatric symptoms from 1970 to 2020 was conducted on PubMed, Ovid, Psych Info, and MEDLINE. Exclusion criteria comprised tumors not included in the World Health Organization (WHO) Classification 4th edition and cases in which psychiatric symptoms were absent or followed the diagnosis. A total of 165 case reports were analyzed. In a subset of patients with brain tumors, psychiatric symptoms can be the only manifestation or precede focal neurological signs by months or even years. The appearance of focal or generalized neurological symptoms after, rather than along with, psychiatric symptoms was associated with a significant delay in the diagnosis in adults. A timely assessment of psychiatric symptoms might help to improve early diagnosis of brain tumors.

Lorlatinib in pretreated ALK- or ROS1-positive lung cancer and impact of TP53 co-mutations: results from the German early access program

Introduction:

We report on the results of the German early access program (EAP) with the third-generation ALK- and ROS1-inhibitor lorlatinib.

Patients and Methods:

Patients with documented treatment failure of all approved ALK/ROS1-specific therapies or with resistance mutations not covered by approved inhibitors or leptomeningeal carcinomatosis were enrolled and analyzed.

Results:

In total, 52 patients were included [median age 57 years (range 32–81), 54% female, 62% never smokers, 98% adenocarcinoma]; 71% and 29% were ALK- and ROS1-positive, respectively. G1202R and G2032R resistance mutations prior to treatment with lorlatinib were observed in 10 of 26 evaluable patients (39%), 11 of 39 patients showed TP53 mutations (28%). Thirty-six patients (69%) had active brain metastases (BM) and nine (17%) leptomeningeal carcinomatosis when entering the EAP. Median number of prior specific TKIs was 3 (range 1–4). Median duration of treatment, progression-free survival (PFS), response rate and time to treatment failure were 10.4 months, 8.0 months, 54% and 13.0 months. Calculated 12-, 18- and 24-months survival rates were 65, 54 and 47%, overall survival since primary diagnosis (OS2) reached 79.6 months. TP53 mutations were associated with a substantially reduced PFS (3.7 versus 10.8 month, HR 3.3, p = 0.003) and were also identified as a strong prognostic biomarker (HR for OS2 3.0 p = 0.02). Neither prior treatments with second-generation TKIs nor BM had a significant influence on PFS and OS.

Conclusions:

Our data from real-life practice demonstrate the efficacy of lorlatinib in mostly heavily pretreated patients, providing a clinically meaningful option for patients with resistance mutations not covered by other targeted therapies and those with BM or leptomeningeal carcinomatosis.

The importance of specialized sleep investigations in children with a suprasellar tumor

PURPOSE

Disruption of sleep has great impact on quality of life. In children with a suprasellar tumor and hypothalamic-pituitary dysfunction, the circadian rhythm may be disturbed causing sleep problems. However, also other factors may influence sleep. Awareness of these different etiologies and careful history taking with appropriate additional diagnostics will aid in restoring sleep quality.

METHODS

We present the workup of 4 cases with a suprasellar tumor and disturbances of sleep initiation, sleep maintenance, and daytime sleepiness. In parallel, we developed a flowchart, to aid clinicians in the diagnostics of sleep problems in children after treatment for a (supra) sellar brain tumor.

RESULTS

All four patients, known with hypopituitarism, presented with sleep complaints and increased daytime sleepiness. In all four, the cause of sleep problems showed to be different. In the first case, sleep evaluation revealed a severe obstructive sleep apnea, whereupon nocturnal ventilation was started. The second case revealed poor sleep hygiene in combination with an obsessive compulsive disorder. Sleep hygiene was addressed and psychiatric consultation was offered. Dexamphetamine treatment was started to reduce her obsessive compulsive complaints. The third case showed a delayed sleep phase syndrome, which improved by educational support. The fourth case revealed a secondary organic hypersomnia for which modafinil treatment was started.

CONCLUSION

Sleep disturbances in children with hypopituitarism due to a (supra) sellar tumor can have different entities which require specific therapy. Awareness of these different entities is important to enable appropriate counseling. Referral to an expertise sleep center may be advised, if standard educational support is insufficient.

Depression among adult patients with primary brain tumour: a cross-sectional study of risk factors in a low-middle-income country

OBJECTIVE

The prevalence of depression among patients with primary brain tumour ranges from 15% to 40% globally. Several individual and clinical factors contribute to the development of depression. However, their association with depression in Pakistani setting has not yet been assessed. Thus, we aim to study the factors associated with depression among adult patients with primary brain tumour at a tertiary care hospital in Karachi, Pakistan.

STUDY DESIGN

A prospective cross-sectional study.

SETTING

This study was conducted at a tertiary care hospital of Karachi, Pakistan.

PARTICIPANTS

This study included 132 patients with confirmed diagnosis of primary brain tumour (initially diagnosed on MRI of the brain with contrast and later confirmed on histology of surgical specimen) in various stages of treatment.

PRIMARY OUTCOME

The primary outcome of this study was to assess depression and its associated factors among adult patients with primary brain tumour. Depression was assessed using a validated screening tool Patient Health Questionnaire-9 (PHQ-9). Scores of 10-27 on PHQ-9 were indicative of screen positive for depressive symptoms. A set of the structured pre-tested questions was used to evaluate patient-related, tumor-related and treatment-related factors.

RESULTS

Fifty-one (39%, CI: 33.33-46.94) patients in our study screened positive for depressive symptoms on PHQ-9. There was a significant association between depressive symptoms and Karnofsky Performance Scores (KPS) (prevalence ratio: 3.25 and CI: 1.87-5.62) after controlling covariates. Propensity scores predicted a positive association between KPS (functional status) and unemployment, treatment stage, and tumour recurrence. Tumor-related and treatment-related factors including tumour grade, location, type and hemispheric lateralisation were found insignificant.

CONCLUSION

Depression is common in patients with primary brain tumour. Impaired functional status has a direct impact on depression in these patients. Incorporating the psychosocial domain earlier in the course of treatment needs to be considered for better neuro-oncology management of patients with primary brain tumour.