Brain tumours Flashcards
Symptoms of a brain tumour
Focal (related to area of lesion) vs generalised
Non-localising e.g apathy, personality change, dementia, drowsiness
Localising
Lobar (FPTO)
Cranial nerve palsy, I,II, (III,IV,VI),V VII,VIII, (IX,X,XI) XII
Seizures- focal, generalised
Recognition of seizure vs TIA/ VV etc
Recognition of new onset- subtle neuro symptoms vs stress etc
Raised intracranial pressure
2/3rds patients with space occupying lesions have classical triad of
1. Headache
2. Papilledema
3. Vomiting (most remainder have at least 2 of these)
Many mental disturbances- drowsiness, coma, mild personality change or even profound dementia
Raised ICP- headache
On waking ( due to raised ICP after hours of lying supine)- can disappear for days or even weeks Not greatly intense, throbbing or bursting- aggravated by coughing, sneezing, stooping down or exertion Relieved by aspirin (bleeding) , codeine or going to bed? Site may not give guide to tumour location- occ. headache radiating down neck can indicate post. fossa/ CP angle tumour
Raised ICP- vomiting
Before breakfast frequently as accompaniment of headache
Projectile- more occurs without nausea and without warning
Children more likely to vomit than adults- post. fossa tumour more likely to vomit than supratentorial tumours
Raised ICP- Visual symptoms (papillodema)
Often asymptomatic- vision eventually affected and number of tumours first detected by opticians
Enlargement of blind spot, late peripheral constriction of fields
Intermittent loss more common than steady deterioration- sitting up and lying down e.g morning
Sleeping may precipitate episodes of loss of vision
Types of IC tumour
Primary- arise within brain/ IC constituents e.g glioma( glial cells), meningiomas (arachnoid cap cellls), pituitary adenoma (pituitary cells), schwannomas (IC nerves)
Secondary- metastates from cancer elsewhere in body- typically lung and breast, but melanoma, renal cell, sarcoma and thyroid increased propensity to MS in brain
Gliomas
30% all brain tumours, 80% of all malignant Originate from Astrocytomas- astrocytes Oligodendrogliomas- oligodendrocytes Ependymomas- ependymal cells
Diffusely infiltrating astrocytomas
Develop to form mass but also diffusely infiltrate normal brain precluding complete surgical excision
II- low grade- slow growing, likely to eventually progress to malignant ( 5-7 yrs survival)
III- anaplastic astrocytoma- higher proliferation rate, more mitotically active (mean survival 2-3 years)
IV- glioblastoma- characterised histologically by elevated tumour cell proliferation, endothelial prolif, necrosis- mean survival 12-18 m
Treatment of gliomas- surgery
Obtain “tissue” (histological) diagnosis- closed biopsy, open via craniotomy
More definitve procedure when possible is tumour debulking of focal tumours to relieve mass/ pressure effect
Surgery- complications
May render patient disabled and unfit for subsequent oncological treatment
death, stroke like risks (speech, sensorimotor deficits, dyspraxia, hemianopia), haemhorrage, wound infection, seizures (eventually happen in majority of glioma patients)
Surgical techniques
Image guidance (detailed preop scans)
Real time- intra-operative imaging, e.g ultrasound, CT/MRI
Tumour fluorescence ie gliolan helps visualise malignant gliomas
Awake surgery with direct electrical stimulation and speech/physiotherapist monitoring
Radiotherapy- adjuvant for malignant gliomas
fractionated RT over 2-6 weeks
in assc. with temozolomide for glioblastomas- extended survival if methylation of MGMT promoter site (downregulate DNA damage repair gene, higher likelihood of tumour cell death)
Radiotherapy + PCV (procarbazine, lomustine, vincristine) chemotherapy for anaplastic oligodendrogliomas (deletion of 1p and 19q) may extend survival
Low grade gliomas
15% of new adult brain tumours, more likely in young adults- typically present with seizures, >90% resection delays time to malignant transformation and significantly extends overall survival
Meningiomas
Arachnoid cap cells of meninges- I (benign), II (atypical), III (malignant)
Majority benign and if resectable patient may be disease free- risk of local reccurence (follow ups)
Any small vol post surgery can be treated with highly precise radiation therapy
Tumours in deep seated locations, adherent to important BV’s, nerves (brainstem) may not be completely resectable mandating adjuvant SRS/ other radiotherapy
II- higher propensity to recur locally
III- frankly malignant
Brain metastases
primary sites lung, breast, melanoma, renal, thyroid- treatment depends on extent of primary/extracranial disease, expected prognosis, age and number/vol brain mets
surgical resection for solitary large tumours (pressure effects)
Stereotactic RadioSurgery
Whole brain radiotherapy (palliative)
Chemotherapy/ systemic anti-cancer treatment (biologics)
