Brain Tumours Flashcards
Symptoms of a Brain Tumour
Non-Localising: 1- Apathy 2- Personality change 3- Dementia 4- Drowsiness
Localising
1- Cranial Nerve palsy
2- Seizures : generalized/focal ( usually initial presentation )
- have to differentiate between is seizure to TIA/vasovagal
3- Lobar : ex: if frontal then changes in sensation , temporal for memory/concentration
4- differentiate between new onset neurological symptoms form stress
2/3 of patients with space occupying lesions have which classical symptoms
Due to Raised ICP
1- Headache
2- Papilloedema
3- Vomiting
Maybe mental disturbance : drowsiness, coma , dementia , mild personality change
Presentation of Raised ICP headache due to space occupying lesion
- Headache presented on waking up.
Time: disperses within 1-2 hours , can disappear for days or weeks
Characteristics: not of great intensity, throbbing or bursted - usually dull ache
Exacerbating : aggravated by coughing , sneezing , stooping down or exertion
Relieving: relieved by aspirin , codeine , rest
Occipital headache radiating down the neck can indicate what
Post fossa / CP angle tumour
Explain Vomiting presentation in space occupying lesions with raised ICP and where is vomiting most common
Vomiting :
- projectile with no nausea or warning
- before breakfast , with headache
Common in
- children more than adults
- post fossa tumours than supratentorial tumours
Explain the Papilloedema presentation in space occupying lesions with raised ICP
- Usually asymptomatic
- vision could be affected
- enlargement of blind spot and late peripheral constriction of fields
- Usually intermittent loss of vision rather than steady deterioration : amaurosis
- Attacks could be triggered by getting up from sitting/lying down : in the morning
- sleeping may trigger episodes of vision loss
What is Amaurosis and how does it present with space occupying lesions
Vision loss without apparent lesion affecting eye.
Presentation : Fugal bilaterally and lasting less than 1 minute
What are the 2 main types of Intracranial tumours
1- Primary : arise within the brain , categorized via where they arise from
2- Secondary : metastases from cancer elsewhere in body. Usually lung and breast
What is the most common cancers to metastases to the brain
Lung and breast cancer
What percentage of brain tumours are Primary , and what percent of malignant Brian tumours are Primary
30% of all Brian tumours
80% of malignant brain tumours
Where do Primary Brain tumours originate from and what Is each type of tumour called
3 main glial cell types
1- Astrocytomas : astrocytes
2- Oligodendrogliomas : oligodendrocytes
3- Ependymomas : ependymal cells
What are Diffusely Infiltrating Astrocytomas , Explain different Grades and if surgical excision is possible
Tumours developing from a mass but also diffusely infiltrate normal brain = Precludes complete surgical excision
Grade 2 : slow growing , eventually will progress to malignant. 5-7 years survival
( common in younger people , present with seizures )
Grade 3 : Anaplastic Astrocytoma , higher proliferation rate, mitotically active. 2-3 years survival
Grade 4: Glioblastoma, elevated tumour cell proliferation, endothelial proliferation, vascular supply and necrosis. 12-18 months survival
Explain the treatment of Gliomas ( surgical )
1- Histological tissue is obtained for diagnosis via closed biopsy or open craniotomy
2- Tumour debulking of focal tumours to relieve mass or pressure effect if it is safe to do so
Most brain tumours are Primary or Secondary
Secondary
Most common type of Primary tumours is which ?
Gliomas ( glial cells )
List categories of Primary tumours
1- Gliomas : glial cells
2- Meningiomas : arachnoid cap cells
3- Pituitary adenoma : pituitary cells
4- Schwannomas : arise form intracranial nerves
Imaging modalities to diagnose brain tumours
1- MRI + contrast: shows area of disease in brain ( infiltration )
2-
3-
Imaging modalities to diagnose brain tumours
1- MRI + contrast: shows area of disease in brain ( infiltration ) and leaky vessels in tumour
2- PET scan : sensitive guide to indicate malignancy
Surgery for Brain tumours Complication and risks
1- Post -operative complication may render patient disabled or unfit for subsequent oncological treatment
2- Risk of death <15 , risk of haemorrhage <5% , infection 5 , seizures
Limitations of brain tumours surgery ( 3 )
1- If cortical and subcortical low density presenting with seizures and progressive headache = surgical treatment limited to diagnostic biopsy
2- Low grade thalamic astrocytoma presenting with progressive hemiparesis = surgical treatment limited
3- deep tumour = high risk of defect post operatively
Surgical techniques used to facilitate maximal safe resection of brain tumours
1- Image guidance ( pre-op scans )
2- Real time intra-operative imagine ex: Ultrasound , CT, MRI
3- Tumour fluorescence, patient drinks to helps to visualize malignant gliomas
4- Awake surgery with direct electrical stimulation and speech/physiotherapist monitoring
Post surgical adjacent therapy for malignant gliomas
1- Course of fractionated radiotherapy over 2-6 weeks
2- Temozolomide for Glioblastomas that cause DNA damage in tumour cells
3- Radiotherapy + PCV ( Procarbazine, lomustine, vincristine ) chemotherapy for anapaestic oligodenregliomas
Which type of Astrocytoma doesn’t infiltrate the brain
Type 1 pilocytic astrocytoma
Do Astrocytomas or Oligodenrogliomas have a better life expectancy
Oligodenrogliomas
What are Meningiomas, different grades & their treatment
Arise from arachnoid cap cells of meninges Grade 1 ( bening ) , Grade 2 ( atypical ) , Grade 3 ( malignant ).
Majority are benign and resected if possible. Small risk of local recurrence but there’s still follow up imaging.
If tumour indeed-seated locations or adherent to important blood vessels or nerved there will be SRS or other forms of radiotherapy
Grade 2 have higher propensity to recur locally
Grade 3 are malignant and likely to recur in shorter period and have a risk of extra-cranial metastasis
Primary sites of Brain metastases
1- Lung 2- Breast 3- melanoma 4- Renal 5- Thyroid
Treatment options for brain metastases are dependent on ?
Patient performance status , tumour burden and primary cancer type , age , number and volume of brain mets , expected prognosis
Surgical resection of brain metastases are usually for which kind of tumours
Large tumours causing pressure effects
What is SRS
Stereotactic Radiosurgery that focuses beams of radiation to small or medium sized tumours
What is used for widespread brain metastases palliative care
Whole brain radiotherapy
If BBB is permeable and patient has Brain metastases what treatment option is used
chemotherapy / systemic anti-cancer treatement
What is a Spinal ependyomoma and what is done during surgery
Spinal tumour and during surgery there is monitoring of signals to legs to limit any spinal cord trauma.
What are the 3 types of radiation techniques for Brian tumours
1- Conventional fractionated radiotherapy ( whole brain )
2- advanced ERBT techniques ( IMRT )
3- Sterotactic radio surgery/therapy
Explain childhood brain tumours
Location: usually in infratentorial compartment ( cerebellum , fourth ventricle )
Surgery : complete surgical resection is optimal primary treatment
Types :
1- Pilocytic astrocytoma : complete resection can lead to normal life expectancy
2- Medulloblastoma: can metastasize through CSF pathways ( spine ). Require post surgical radio&chemotherapy
3- Ependymoma : tendency to recur and metastasize. Anaplastic ependymoma requires post-operative radio
Wen is radiotherapy avoided and why
In ages under 4 due to CNS toxicity on developing Brian and spinal cord
What is proton therapy
A form of targeted radiation used for Brain tumours. Only affects tumour cells
Explain Cranial Nerve tumour ; vestibular schwannomas ( presentation and association conditions )
Location : Slow growing benign nerve sheath tumours arising on vestibular nerve
Presentation: Hearing loss, Tinnitus , balance problems
Associated with Neurofibromatosis
What treatment is indicated for small volume lesions <3cm in diameter and Bria metastases
Stereotactic Radiosurgery
Explain Presentation of Pituitary tumours
Large ( marcroadenomas )
- Compression of adjacent structures
- compression of optic nerves = bitemporal hemianopia
Small( micro adenomas )
- prolactinoma
- GH-secreting ( acromegaly)
- ACTH ( Cushing’s disease )
General Principles of Brain Tumours
- Early detection = better prognosis
- symptoms referable to tumour site
- Surgery Biopsy for diagnosis / resection to alleviate mass
- Post-operative Radiotherapy for malignant tumours
- Post-operative chemotherapy , usually for malignant gliomas
SRS for brain metastases & brain tumours of small volume
What is the Palliative Care for Brain tumours
1- Medication to manage symptoms
2- Anti-seizure medication in tumour delayed epilepsy
3- Anti-emetics , analgesics
4- Dexamethasone for peri-tumoral oedema
5- end of life car/hospice
How do brain tumours develop
1- Deregulated cell division and loss of normal checkpoint controls
2- Angiogenesis : recruitment of blood supply to feed tumour
3- invasion/infiltration into surrounding brain
4- Metastases
5- Tumours can adapt
What is Angiogenesis
recruitment of blood supply to feed tumour
