Mohammed T. Abou-Saleh

PSYCHIATRIC MANIFESTATIONS OF CNS MALIGNANCIES 337Effects of TreatmentA final very important contributor to the psychiatric morbidity ofpatients with brain tumors is the effect of treatment 138 . Becausepatients are living longer and treatments are becoming moreaggressive, the psychiatric complications of treatment havebecome common. While these ‘‘late effects’’ have traditionallybeen blamed on cranial irradiation, concurrent chemotherapy,corticosteroids and surgery are important contributors. The beststudiedlate effect is cerebral radionecrosis 139 . Typically, anenhancing mass develops at the site of previous cranial irradiationseveral months to several years after the completion of treatment.While headache, seizures and focal neurologic defects are oftenpresent, insidiously progressive personality change, abulia andlethargy may be the only early manifestations. A second latecomplication of cranial irradiation, also developing months toyears after the completion of treatment, has been termed‘‘radiation-related dementia’’ 40 . This is a more diffuse brainprocess, betokened radiographically by cortical atrophy, ventricularenlargement and increased white matter signal on T2-weighted and FLAIR MRI images. Again, gradually progressivecognitive impairment, abulia, short-term memory loss andpersonality change occur. Focal neurologic deficits are uncommon,although gait impairment and incontinence may develop.Frequently the correct diagnosis of a treatment-related complicationis delayed while the diagnoses of depression, Alzheimer’sdisease, Parkinson’s disease or normal pressure hydrocephalus areconsidered.APPROACH TO THE PATIENTThe need for integration of psychiatric, neurologic and oncologicinsights arises in at least three diagnostically different settings inpatients with CNS cancer. In the most common scenario, a patientwith known cancer or a proven primary brain tumor develops newor progressive psychiatric deficits. Frequently the symptom isiatrogenic, and withdrawal of the offending agent or substitutionof some other therapy will be of benefit. Sometimes recurrent orprogressive disease (a new metastasis, regrowth of a treated braintumor) is the cause, and antineoplastic therapy is indicated. Thenew onset of seizures or a paraneoplastic disorder may be at fault,the symptom may have evolved from the patient’s reaction to hisillness. Recognition of these possibilities and an appropriatelydirected evaluation will often be of diagnostic and therapeuticvalue and will improve both the length and quality of life.The patient with known psychiatric disease who develops newsymptoms represents a second type of challenge. If focalneurologic deficits are prominent, a vigorous evaluation usuallyensues. If the earliest or most obvious signs and symptoms arebehavioral, a malignant etiology may be overlooked. Becausepsychiatric disease and cancer are both common, the chancedevelopment of cancer in a behaviorally abnormal patient willaccount for some of the apparent excess of brain tumors arising inpatients in psychiatric hospitals. However, because behavioralchanges are a common manifestation of CNS tumors and areespecially easy to overlook in patients with chronic psychiatricillness, many cases elude early diagnosis. In patients with longstandingpsychiatric illness, therefore, periodic evaluations shouldalso include a detailed neurologic assessment.A third diagnostically difficult situation occurs when an elderlypatient presents with new psychiatric symptoms and no knowncancer. Submitting all such patients to periodic neuroradiographic,electroencephalographic, neurologic and laboratoryevaluations would eliminate most misdiagnoses, but is impracticaland costly. Most secondary psychiatric disturbances in the elderlyare due to toxic-metabolic, endocrine, cerebrovascular orinfectious etiologies 41 . A detailed history supplemented by a fewsimple laboratory tests is usually adequate for diagnosis of thesedisorders. In most patients with CNS cancer, at least subtleneurologic abnormalities are demonstrable at the time ofpsychiatric presentation, although a careful neurologic examinationmay be required 47,52 . If not attributable to another knownetiology (e.g. stroke, trauma, multiple sclerosis), such abnormalitiesshould prompt additional studies. The presence of seizures,evidence of increased intracranial pressure (papilledema, headaches,nausea and vomiting), a disturbed level of consciousness,gradual intellectual decline, ‘‘frontal lobe’’ findings (also seen withtemporal lobe and deep cortical lesions; Table 60.2), or persistent,unexplained headaches should also trigger further evaluation. Insuch patients, neuroimaging or examination of the cerebrospinalfluid (if leptomeningeal disease is suspected) is the best diagnosticapproach.Elderly patients with the new onset of psychoses, mania orhallucinations, suggestive family histories, normal neurologicexaminations and no neurologically worrisome complaints rarelyharbor CNS malignancies. Nevertheless, the number of these‘‘idiopathic’’ cases, after toxic and metabolic etiologies have beenexcluded, will be so few and so unusual that neuroimaging isprobably justified. In contrast, depression is common in theelderly. A careful history and examination are obligatory.REFERENCES1. Eby NL, Grufferman S, Flannelly CM et al. Increasing incidence ofprimary brain lymphoma in the US. Cancer 1988; 62: 2461–5.2. Russell DS, Rubinstein LJ. Pathology of Tumours of the NervousSystem 5th edn. Baltimore, MD: Williams & Wilkins, 1989; 1–6.3. Greenlee RT, Murray T, Bolden S, Wingo PA. Cancer statistics,2000. CA Cancer J Clin 2000; 50: 7–33.4. 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