Neurological complications of radiation


Introduction

Cognitive abilities in glioma patients are influenced by a myriad of factors: the tumor itself, depression and anxiety, fatigue, sleep dysfunction, pre–brain tumor cognitive baseline (e.g., premorbid functioning), pain, and brain tumor treatments themselves (e.g., surgery, chemotherapy, and radiation). Most often, attention, working memory, and information processing speed are affected in brain tumor patients but a wide array of cognitive symptoms can be seen. Roughly 30% or more of patients alive at 4 months after chemoradiation have deficits in cognitive functioning and the proportion of patients with impairment continues to rise as a function of time after treatment. The Radiation Therapy Oncology Group (RTOG) 0525 and RTOG 0825 arguably provide the best prospectively collected neurocognitive data of high-grade glioma patients.

RTOG 0825 was a prospective, randomized phase III trial in newly diagnosed patients with glioblastoma comparing standard radiation and temozolomide (TMZ) therapy with and without bevacizumab. RTOG 0825 also prospectively collected extensive neurocognitive data on all enrolled patients. In RTOG 0525, 27% of patients were classified as “declined” using the reliable change index on Hopkins verbal learning test (HVLT)-R scores at 4 months post-radiation.

Patients often experience cognitive dysfunction at baseline and following treatment that can range from mildly to severely affecting functional independence, return to work, and quality of life. Tucha et al. found cognitive impairment in over 90% of patients with supratentorial brain tumors prior to treatment. The domains affected can vary but mainly include difficulties in attention/executive functioning, learning and retrieval, and motor speed. The rate of tumor growth is a predictor of cognitive impairment. In general, rapidly growing tumors like high-grade gliomas present with greater dysfunction and more widespread cognitive deficits than slow-growing, low-grade gliomas. However, the specific tumor type and tumor volume have not been shown to predict cognitive performance. After chemoradiation, risk factors for the development of radiotherapy (RT)-related cognitive dysfunction include greater volume of irradiated tissue, a higher dose of RT (>2 Gy per fraction), adjuvant chemotherapy, and older age. ,

Corticosteroids and antiseizure medications can also impact cognitive functioning. Although corticosteroids can improve cognitive deficits due to cerebral edema, they can also be associated with transient emotional/behavioral disturbance and attention/concentration difficulties. , Some studies show poor working memory in patients treated with antiepileptic drugs (AEDs). Others show no difference in performance when evaluating patients on newer versus older AEDs versus no AED medications.

Clinical cases

Case 25.1
Management of Neurocognitive Dysfunction in a Patient With Diffuse Glioma and Associated Depression and Anxiety

Case . A 48-year-old, right-hand dominant Caucasian female with a master’s degree presented with headache and imaging revealed a right parietal lesion measuring 2.2 × 2.3 cm on T2 fluid attenuated inversion recovery (FLAIR) imaging without enhancement or mass effect. She underwent gross total resection. Pathology revealed a WHO grade III anaplastic astrocytoma. She underwent concurrent chemotherapy (TMZ) and radiation (59.4 Gy). Pre-radiation neuropsychologic testing was performed after surgery and before chemoradiation. At baseline, she had high-average functioning and demonstrated difficulties with attention, concentration, executive functioning, verbal memory, and verbal fluency ( Table 25.1 ). In addition, she had symptomatic anxiety, mild depression, and fatigue. At 3 months posttreatment, her attention and verbal memory performance had improved. However, other cognitive impairments remained stable and she continued to have symptoms of depression and anxiety. Unfortunately, she lost her job during treatment and was required to find alternative employment, exacerbating her perceived stress. Neuropsychology recommended pharmacologic intervention for treatment of her mood, referral to cancer support services for psychosocial support, and discussion of employment options. At 6 months posttreatment, impairment was noted in all areas, but her symptoms of depression and anxiety were much improved (due to pharmacologic intervention).

Table 25.1
Cognitive performance of patient in Case 25.1
Pretreatment Three months posttreatment Six months posttreatment
Premorbid 86th percentile 86th percentile 86th percentile
Attention 1st percentile 4th percentile 9th percentile
Learning 21st percentile 10th percentile 2nd percentile
Memory 2nd percentile 14th percentile 1st percentile
Lexical fluency 1st percentile 3rd percentile 3rd percentile
Semantic fluency 4th percentile 1st percentile 1st percentile
Set-shifting 1st percentile 1st percentile 1st percentile
BDI-2 16/63 32/63 23/63
BAI 33/63 19/63 4/63
Fatigue 6.4/7 5.8/7 7.0/7
Lower percentiles indicate worse cognitive functioning; higher percentiles indicate better cognitive performance.
BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory.

Teaching Points . This case highlights the multifactorial nature of neurocognitive dysfunction in patients with brain tumors. Cognition may be influenced not only by the tumor and its treatment but also by associated mood symptoms, treatment-induced fatigue, psychosocial stressors, and other factors, all of which likely contributed to the deficits in this patient. She reported significant anxiety and depressive symptoms following her diagnosis. Treatment of her mood symptoms with selective serotonin reuptake inhibitor (SSRI) therapy resulted in considerable benefit on her neurocognitive performance.

Clinical Pearls

  • 1.

    The neuropsychologic evaluation should include an assessment of fatigue and depression as both occur at high rates within the brain tumor patient population and can impact cognitive functioning.

  • 2.

    Neuropsychologic evaluation should be performed by a board-certified neuropsychologist who is experienced in working with brain tumor patients.

  • 3.

    Neurologists and neuro-oncologists should use the neuropsychology report to guide treatment interventions which can include pharmacologic and nonpharmacologic interventions.

Case 25.2
Management of NeurocognitiveDysfunction in a Patient With Glioblastoma and Sleep Dysfunction

Case . A 62-year-old, right-hand dominant Caucasian male presented after a fall and was found on imaging to have an enhancing 6.5 × 5.5 × 4.8 cm mass in the right frontal lobe. He underwent a right frontal craniotomy and pathology revealed glioblastoma. He subsequently underwent standard Stupp-style chemoradiation. Postsurgical, pre-radiation cognitive testing showed difficulties with effortful encoding and retrieval of novel verbal information as well as impaired visual abstract reasoning, and impaired lexical verbal fluency ( Table 25.2 ). He had average consolidation, attention and set-shifting, and semantic verbal fluency. During his treatment course, he required prolonged corticosteroid use for management of cerebral edema and complained of severe treatment-associated fatigue and excessive daytime sleepiness. His weight increased by approximately 20 pounds during the 6 months of adjuvant chemotherapy and he developed steroid-induced myopathy and steroid-induced diabetes mellitus requiring initiation of metformin. He was found to have elevated thyroid stimulating hormone (TSH) at 10.5 IU/mL and low free thyroxine (free T4) of 2.1 ng/dL and was started on levothyroxine 50 mcg/day with improvement in thyroid studies. He was also sent for a polysomnogram which revealed obstructive sleep apnea and he was recommended to initiate home continuous positive airway pressure treatment.

Table 25.2
Cognitive performance by patient in Case 25.2
Pretreatment Six months posttreatment
Premorbid 34th percentile 34th percentile
Attention 37th percentile 21st percentile
Learning 13th percentile 61st percentile
Memory 16th percentile 55th percentile
Lexical fluency 2nd percentile 4th percentile
Semantic fluency 93rd percentile 42nd percentile
Set-shifting 34th percentile 68th percentile
BDI-2 6/63 5/63
BAI 0/63 0/63
Fatigue 4.11/7 2.11/7
BAI, Beck Anxiety Inventory; BDI, Beck Depression Inventory.

At his 6-month examination, his encoding skills improved, as did his retrieval for novel verbal information though his attention and verbal fluency skills declined. He did not have any emotional/behavioral disturbance at either visit and his self-reported fatigue levels were low. Currently, he is not bothered enough by the deficits in attention or verbal fluency so no empiric treatment has been pursued.

Teaching Points . This case highlights many of the factors and their management that can be considered in high-grade glioma patients with neurocognitive dysfunction. The patient in this case developed endocrinopathy, corticosteroid-associated side effects, and was found to have newly diagnosed obstructive sleep apnea. These comorbid conditions, in combination with his underlying glioma and prior treatment, presumably contributed to the findings on neurocognitive assessment. Despite this, he was managed with minimal decline or changes in overall neurocognitive status after treatment and was able to continue to live and work independently.

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