brain tumours

Question 1

commonest brain tumour? where are they usually found in the brain?

Answer 1

metastases
seen at boundaries between grey + white matter

Question 2

difference between location of brain tumours in kids vs adults

Answer 2

kids = 70% BELOW tentorium cerebelli
adults = 70% ABOVE

(2nd most common cancer in kids)

Question 3

commonest primary cancers of metastatic brain tumours?

Answer 3

lung
breast
renal cell carcinoma
melanoma

Question 4

how do infratentorial and supratentorial present differently?

Answer 4

infra = cerebellum/posterior fossa -> ipsilateral symptoms

supra -> contralateral

infra more common in kids

Question 5

inherited syndromes that increase risk of brian tumours

Answer 5

neurofibromatosis
von hippel-lindau
tuberous scelrosis
Li-fraumeni syndrome

ionising radiation
immunosuppression

Question 6

brain tumour presentation

Answer 6

progressive neurological deficit - correlate to tumour location
headache
- with or without raised ICP
- worse in morning, wakes them uo
- worse on coughing/leaning forward
- assoc with vomiting

motor weakness
papilloedema
sizures
endocrine disturbances
visual disturbances

Question 7

management of metastatic tumours

Answer 7

cerebral oedema surrounding the tumours responds to steroid therapy
resection via surgery, stereotatic radiotherapy + whole brain radio therapy

NB: many systemic therapies for primary tumours do not cross blood brain barrier + therfore do not control brain metastases

Question 8

urgent cancer referral criteria

Answer 8

progressive neurological deficit (in absence of alternative disorder)
change in behaviour - psycholocial, cognitive
seizure
headache with vomiting and/or papilloedema

Question 9

types of primary brain tumour - glioma + non-glioma

Answer 9

glioma (intrinsic)
- astrocytic = commonest
- oligodendroglioma

non-glioma
- craniopharyngioma
- meningioma
- schwannoma
- lymphoma (high grade)

Question 10

astrocytoma

Answer 10

from astrocytes
- star shaped with multipolar cytoplasmic processes
maintain BB barrier
envelope synaptic plates, wrap around vessels + capillaries within the brain

4 grades

Question 11

astrocytoma grading

Answer 11

I = pilocytic -> children
o Pleomorphic xanthoastrocytoma – babies
o Subependymal giant cell – tuberous sclerosis

II – low grade astrocytoma -> all become malignant at some point, atypia

III – anaplastic astrocytoma, atypia + mitosis
IV – glioblastoma multiforme, atypia + mitosis with vascular proliferation or necrosis

Question 12

grade I astrocytoma

Answer 12

truly benign, slow growing
children, young adults

imaging - sometimes enhance but well demarcated
- often secrete fluid causing hydrocephalus -> signet ring shape

pilocytic astrocytoma
- tend to be in posterior fossa - cerebellum brain stem
- NF1 - optic nerve
- hypothalamic gliomas - uncontrollable laughin but actually a seizure

mx - surgery =curative

Question 13

presentation of kids with cerebellum tumours

Answer 13

walk on tip toes
hypotonia
see changes on ipsilateral side to tumour

Question 14

general management of brain tumours

Answer 14

must tell DVLA
chemo - temoxolomide
radio
- post surgery
- use in low grade if incomplete removal, malignant degeneration
- not in benign
- drops iq by 10(don’t give to <3yrs)

novel therapies - immunotherapies, focused ultrasound

Question 15

grade II low grade astrocytoma

Answer 15

atypia
not truly cancerous - pre-cancer
common loction - temporal lobe, pos. frontal, ant. parietal
seizures common

Question 16

poor prognostic factors for grade II astrocytoma

Answer 16

age >50
short duration of symptoms
raised ICP (papilloedema)
altered consciousness
enhancement on contrast studies
diameter >6cm
tumours crossing midline

Question 17

treatment of grade II astrocytoma

Answer 17

serial imagin - monitor
radio/chemo
gold = surgery +/- above

seizure control, herniation, CSF obstruction

Question 18

malignant astrocytomas

Answer 18

grade III-IV
contrast enhancement on imagin is a key sign

Question 19

anaplastic astrocytoma

Answer 19

can arise de novo
median survival -> 5yrs

Question 20

glioblastoma multiforme (IV astrocytoma)

Answer 20

commonest primary tumour
median survival <1yr - 15months
conditions with multiple gliomas - neurofibromatosis, tuberous sclerosis

spread - white matter tracking/csf pathways -> EVERYWHERE

Question 21

glioblastoma multiforme of histology + imaging

Answer 21

imaging = solid tumour with central necrosis + a rim that enhances with contrast

histology = pleomorphic tumour cells border necrotic areas

Question 22

management of glioblastoma multiforme

Answer 22

Stupp protocol = surgery + radio + temozolomide -> improves survival to 14 months

very difficult to get all
cytoreduction/non-curative surgery
tell DVLA

Question 23

oligodendroglia tumours

Answer 23

20% of glial tumours
produce myelin
frontal lobes
benign, slow growing
adult 24-45yrs
seizure presentation

calcifications with FRIED EGG appearance

Question 24

management of oligodendroglia tumours

Answer 24

chemo sensitive - PCV

! radio + PCV -> double survival !

median survival - 10yrs low grade

Question 25

medulloblastoma

Answer 25

2nd most common tumour in kids after pilocytic astrocytoma
poorly differentiated
occurs midline of cerebellum

treatment = super RADIOSENSITIVE

(75% 5yr survival with resection + radiotherapy)

Question 26

important bits about intrinsic tumours

Answer 26

headaches that wake you +/- vomitng - check pupils
new neurological deficit - incl seizures

kids (posterior fossa) - tiptoeing, ataxia
-> vomiting with headache in kids

Question 27

meningiomas

Answer 27

2nd commonest primary in adults (to glioblastoma)
typically benign

arise from arachnoid cap cells of meninges + typically located next to the dura
-> causes symptoms of compression rather than invasion

Question 28

types of meningioma

Answer 28

CCRAP
clear cell
chordoif
rhabdoid
anaplastic
papillary

after childhood leukaemai - radiotherapy indiced mid line menignioma

Question 29

meningioma presentation + management

Answer 29

majority asymptomatic
headaches
cranial nerve neuropathies

if small - just treat seizures
if vascular supply - embolise them
surgery = curative

Question 30

acoustic neuroma presentation

Answer 30

often seen at cerebellopontine angle
“cone shape”
bilateral assoc with NF2

hearing loss unilateral
tinitus
facial nerve palsy
dizziness/imblance
sensation of fullness in ear

Question 31

pineal tumours

Answer 31

midline tumours of kids
important in diurnal rhythm + sleep

*any midline tumour in kid -> do tumour markers, test serum + CSF
- alpha-fetoprotein
- beta HCG
- LDH
(if neg - biopsy, test CSF)