Brain Neoplasms (Lauren🌭) Flashcards
Overall, brain tumors come from ________ cells
glial
What are the 4 types of glial cells?
Astrocytes
Oligodendrocytes
Ependymal
Microglia
What do glial cells do?
Surround neurons and support/insulate them
What kind of cell does an astrocytoma come from
Astrocyte
What is the MAIN glial supporting cell in the CNS
Astrocyte
What are the 2 types of astrocytomas?
Diffuse- can’t be respected completely. Grades I-IV.
Circumscribed
The average survival for a high grade astrocytoma is ______ and for low grade astrocytoma it is ______
1 year for high grade
7 years for low grade
What are the 2 MAIN molecular markers that we use to classify astrocytomas and oligodendromas
IDH mutation
1p/19q codeletion
What’s the deal with tumors that have IDH mutation or 1p/19q codeletion?
They have a favorable prognosis
Regarding the IDH mutation and the 1p/19q codeletion:
Most astrocytomas have:
Oligodendrogliomas have:
Most astrocytomas have IDH mutation
Oligodendrogliomas have both
What are the two types of high grade gliomas?
- Anaplastic astrocytoma (Grade III)
2. Glioblastoma multiforme (Grade IV)
How will a High grade glioma present?
SHORT history of headaches, seizures, and focal neuro symptoms based on location
What will you see on MRI of a high grade malignant glioma?
Irregular mass lesions
Heterogeneous
Ring enhancing
T2W/FLAIR imaging shows signal extending beyond margins of contrast enhancement
Predilection to extend across the corpus callosum
Which type of brain tumor is REALLY associated with crossing the corpus calosum?
Glioblastoma Multoforme
What is a FLAIR MRI?
Its some kind of special MRI sequence used to look for specific abnormalities
What is the most common and most deadly glioma in adults?
Glioblastoma multiforme
What is the peak age of glioblastoma multiforme?
55
Youre looking at an MRI, and you are pretty sure you see a high grade glioma. What is necessary to confirm the diagnosis?
Biopsy or surgical resection
MR spectroscopy if you can’t get to it
If a patient has a glioma on their brainstem and there’s no way you are gonna be able to biopsy it or resect it, how can you confirm the diagnosis?
MR spectroscopy
What is the treatment for high grade gliomas?
Resect as much as you can while still PRESERVING brain function
Then do limited-field radiation with 2-3cm margin around it
Chemo during or after radiation
What are some of the ways we reduce the risk of damaging healthy brain tissue when we resect tumors?
Awake craniotomy
Diffusion tensor imaging or stimulation mapping to identify major pathways
Intraoperative MRI
What is the prognosis for high grade gliomas?
All of them recur no matter what
Median time to tumor progression after diagnosis is 6-8 months
What kind of high grade glioma responds best to chemo and radiation?
Anaplastic oligodendrogliomas with 1p/19q codeletion
How can we provide supportive care to patients with high grade gliomas?
Dexamethasone to reduce edema and increase neurological function
Pain and depression treatment
Treat seizures if they occur
Should we get a patient with a high grade glioma on an anti-epileptic drug prophylactically, even if they’ve never had a seizure?
No
What kind of antiepileptic drug should we put a patient with a high grade glioma on?
Use newer ones that have less drug interactions. Usually Keppra
What is the NUMBER 1 prognostic factor for high grade gliomas?
Age (>65 worse)
With standard therapy, GBM patient have a median survival of __________
12-15 months 😢
Do we distinguish between astrocytomas and oligodendrogliomas when we’re talking about low grade gliomas?
No becasue they share so many Clinical features
What do low grade gliomas tend to do to brain tissue
They tend to infiltrate instead of compress/destroy
(Good thing_
How do patient with LOW grade gliomas present?
Seizures*****
High grade was a short history of headaches, seizures and focal neuro symptoms
True or false:
Most low grade gliomas have IDH mutations
True
Low grade gliomas are (well/poorly) circumscribed lesions
Poorly
Which is more sensitive to chemotherapy:
Oligodendrogliomas or Astrocytomas
Oligodendrogliomas
****
Should we immediately give someon with a low grade glioma surgery and radiation?
No. There is no difference in overall survival in patients who receive early radiation.
Why should we delay radiation therapy as long as possible?
It is neurotoxic
What are the CLASSIC histological features of oligodendrogliomas?
Round nuclei with clear halos (fried egg 🍳)
With a network of branching capillaries (“chicken wire”) 🐓
Fried egg and chicken wire on histology
Oligodendrogliomas
The majority of oligodendrogliomas have which molecular marker?
1p/19q codeletion
May also have TP53
What will low grade astrocytomas look like on MRI?
Poorly demarcated hypointesne mass lesion on T1 weighted
Hyperintense lesion on T2/FLAIR
Infiltration of tumor extends beyond margins
20-40% will enhance with Gadolinium
We have like a billion super fancy kinds of MRIs and other imaging these days that we can use to guide treatment for brain tumors. NONE of them are a substitute for good old fashioned______________
Histological tumor diagnosis
How will a low grade oligodendrogliomas present on MRI?
Ill defined
NON ENHANCING
Calcifications more common in oligo than astro
Can we distinguish oligodendrogliomas from astrocytomas just from doing imaging?
NO. Need biopsy
What is the best thing to do for an asymptomatic young patient with a low grade glioma?
Delay surgery and radiation
Just watch them
What kind of patients SHOULD get early radiation for a low grade glioma?
Neurological signs/symptoms OTHER than seizures
Significant mass effect on imaging
Growth of lesion on serial scans
Not candidates for aggressive tumor resection
Have large postoperative tumor burden
> 50 yrs old at diagnosis
What is the prognosis for low grade astrogliomas?
Medan survival is 5-9 yrs
Long history of seizures with no other deficits have favorable prognosis
Age >50 /significant neuro impairment at diagnosis has a negative impact on survival
At time of tumor recurrence, the majority will have undergone a malignant transformation
What is the prgnosis for low grade oligodendrogliomas?
8-12 year survival
May take 8-12 months to see maximum response to therapy on imaging
If a low grade oligodendroglioma has the 1p/19q codeletion, what does that mean for the prognosis’/
Less aggressive
Better response to chemo
Better survival
Which has a longer survival:
Low grade oligodendrogliomas
Low grade astrocytomas
Oligodendrogliomas
What is the most common benign primary brain tumor
Meningioma
Meningiomas arise from ______ cells
Arachnoid 🕷
How do most meningiomas present?
Asymptomatically. Usually found incidentally on imaging
What the fuck is a psammoma body
Clusters of meningiomas that form calcified whorls
➰
What is the CLASSIC sign of meningioma
PSAMOMMA BODIES
What is this:
Meningiomas circling each other, forming calcified whorls
Psammoma bodies
It is super uncommon to get symptoms from a meningioma, but the people that do are usually (male/female)
Female
Where would you look on a picture of a head MRI to find a meningioma/
You’d look at the DURA since they arise from the MENINGES.
Meningiomas have (slow/fast) growth with a (slow/fast) progression of symptoms
Slow
Slow
True or false:
Best treatment for meningiomas is chemotherapy
False.
They do not respond to chemo just cut them out
What is hyperostosis?
Thickening of the bone
What does it mean if there is hyperostosis in the skull adjacent to a meningioma?
Bone is invaded by tumor cells
What is the treatment for meningioma?
Watch and wait, doing serial scans over the years
Dont treat until symptoms or tumor enlarges
Best treatment is total surgical resection
Radiation if they cant get it all or its recurrent
What is the prognosis for meningioma?
Pretty freakin great
90% recurrence free survival at 5 years
65% at 15 years
What kind of patients get primary CNS lymphoma?
Immunocompromised
Old
What is primary CNS Lymphoma?
An aggressive extra-nodal non-Hodgkin lymphoma
HIV patients who gets Primary CNS Lymphoma usually also have this disease:
EBV
How will a patient with primary CNS Lymphoma present?
Altered mental status
Focal neurological deficits that profess rapidly
What will you see on MRI of primary CNS lymphoma?
Multifocal lesions that are bright with homogeneous contrast enhancement in 1/2 of patients
How would your ophthalmologist be the one to find your Primary CNS lymphoma?
20% of the time they infiltrate your eye and retina
In the brain, Primary CNS Lymphoma has a predilection for which structures?
Deep or midline brain structures
What is the MAIN TREATMENT for primary CNS Lymphoma?
CORTICOSTEROIDS
***
METHOTREXATE
STEM CELL TRANSPLANT
Why are corticosteroids one of the BEST treatments for Primary CNS Lymphoma?
Reduce peritumoral edema
DIRECT oncolytic effect
When should you NOT give steroids for Primary CNS Lymphoma?
Prior to biopsy since it will make the biopsy nondiagnostic
****
Should we do surgery for Primary CNS Lymphoma
No
Is whole-brain radiation effective for Primary CNS Lymphona?
Should you use it?
Very effective
Should not use due to neurotoxicity
If you have to do whole brain radiation AND methotrexate for Primary CNS Lymphoma, what order should you do it in to reduce the risk for neurotoxicity?
Methotrexate first
Then do radiation
What is the prognosis for Primary CNS Lymphoma?
Median survival 3-4 years
More than half will relapse even with a high response to methotrexate treatment
What is the most common solid tumor in children
Brain tumor
What is the most common embryonal brain tumor of childhood
Medulloblastoma
Where do medulloblastomas usually arise?
Cerebellum vermis
4th ventricle
What is the first line treatment for medulloblastoma
Surgery
Most adult brain tumors are (above/below) the tentorium
Above
Most pediatric brain tumors are (above/below) the tentorium
Below
Ex: Medulloblastoma is in the cerebellar vermis and 4th ventricle
What are the symptoms of medulloblastoma?
Headaches
Vomiting in the morning
Gait ataxia
Lethargy
Possible signs of increased ICP
Invasion into brainstem causes cranial nerve palsies and long-tract findings (spasticity, hyperreflexia)
What kind of tumor is most likely to metastasize outside the CNS
Medulloblastoma
Why do most children with medulloblastoma need a CSF shunt?
Because the tumor blocks the 4th ventricle
Why do we defer radiation as long as possible for children with medulloblastoma?
Becasue theyre still developing and its really bad for kids
Where is a medulloblastoma most likely to recur?
Posterior fossa
What is the prognosis for medulloblastoma?
If they have resection, chemo and radiation, they have a 5 yr survival over 65%
Large cell and anaplastic tumors have worse outcome
Due to the treatment, the child will have cognitive deficits, behavioral disorders, growth failure, hormone problems, and will need to be in special education 👩🏻🏫
Where do ependymomas come from?
Ependymal cells which line the ventricles and central canal.
Usually in the 4th ventricle
How do most patients with ependymoma present?
Hydrocephalus and increased ICP
It is usually in the 4th ventricle
Ependymomas are most common in (adults/children)
Children
What is the most common type of brain tumor overall?
Metastatic tumors that have spread from another kind of cancer in the body
What is the HALLMARK of a metastasis to the brain?
Tumor is in the gray-white matter junction in the middle cerebral artery territory
What are the 5 most common type of tumors to metastasaize to the brain?
- Lung **
- Breast ***
- Melanoma
- Renal
- GI tumors
If you think a patient might have a metastatic tumor in their brain, what else should you look for on exam?
Cachexia
Lymphedema
Asymmetric breath sounds (lung cancer)
Breast mass (breast cancer)
Skin lesions (melanoma)
What are the symptoms or raised ICP?
Headache that is nocturnal or worse in the morning. Aggravated by coughing, Valsalva, or postural change
Nausea
Papilledema
Altered mental status
False localizing signs (CN VI palsy)
What can cause pain from a brain tumor?
Local invasion of dura, vasculature and periosteum
Brain itself has no pain receptors
New or old tumor:
Swelling and expansion
New
New or old tumor:
Atrophy
Old/chronic disease
What kind of imaging is a “virtual biopsy” that looks at metabolites to see what a tumor is all about
MR Spectroscopy
Which is better to see bone involvement of a tumor: CT or MRI
CT
If a patient has a tumor in the cerebral hemisphere, what is the most common presenting symptom
Seizure
If a patient has a tumor in the posterior fossa, what kind of symptoms will you see
Ataxia
Cranial nerve signs
If a patient has a tumor within a ventricle or near a cerebral aqueduct, what kind of symptoms will you see?
Signs on increased ICP
If a patient has a tumor on their spinal cord, what kind of symptoms will you see
Paraparesis
Sensory loss
Urinary incontinence
What is the first drug you can start to decrease mass effect and edema of a brain tumor
Dexamethasone
Why is dexamethasone the best steroid for brain tumors
Low mineralocorticoid activity
Long half life
What do you need to do to establish a tumor diagnosis and grade it?
Biopsy (stereotactic or an open surgery)
Cancer is a hypercoagulable state, so what should your patient be on
LMWH
Can you give someone tPA if they have a brain tumor
Relatively contraindicated (not absolute)
Butterfly sign on imaging
Glioblastoma multiforme
What are common sites of origin for meningiomas?
Sites of dural reflectoin: falx cerebri, cerebral convexity, parasagittal area etc
90% of Prumary CNS Lymphomas are classified as ________
Large-cell-B-lymphoma
Adults or children:
Medulloblastoma
Children
Adults or children:
Ependymoma
Children
Tumor associated with HIV+ patients and EBV
Primary CNS Lymphoma
Psamomma bodies and whorl pattern
Meningioma
Most deadly brain tumor
GBM
1 prognostic factor for GBM
Age >65
Arises from arachnoid cells
Meningioma
Most found incidentally on imaging
Meningioma
most common type of cancer to metastasize to brain
Lung
40% of non small cell lung cancer patients have brain Mets
