Brain tumours Flashcards
1
Q
Most common extra-axial tumour?
A
Meningioma.
2
Q
Describe meningiomas.
A
- Usually benign.
- Arise from residual mesenchymal cells in the meninges.
- Neurologic symptoms arise from brain compression.
3
Q
Give an example of an extra-axial tumour.
A
- Meningioma.
- Pituitary adenoma.
- Craniopharyngioma.
- Choroid plexus papilloma.
- Acoustic neuroma (Vestibular Schwannoma).
4
Q
How do brain tumours typically present?
A
- Progressive neurological deficit (68%) of which motor weakness accounts for 45%.
- Headache.
- Seizures.
5
Q
Why does increased intracranial pressure arise as a result of brain tumours?
A
- Tumour mass.
- Oedema mass effect.
- CSF blockage - hydrocephalus.
- Haemorrhage.
6
Q
Increased intracranial pressure results in?
A
- Headaches.
- Vomiting.
- Mental changes.
- Seizures.
7
Q
What features of a headache are suggestive of brain tumours?
A
- Worse in morning.
- Wakes patient up.
- Worse on coughing/leaning forward.
- Ass./made worse with vomiting.
- Symptoms similar to tension HA/migraine.
8
Q
The mnemonic DANISH is used to remember pathology of what?
A
Cerebellum.
9
Q
When should urgent referral for suspected brain and CNS cancers be made?
A
- Focal neurological deficit.
- Change in behaviour.
- Seizure.
- Headache + vomiting and or papilloedema.
10
Q
Examples of neuroepithelial tissue/cells?
A
- Astrocytes (60%).
- Oligoodendroglial cells.
- Ependymal cells/choroid plexus.
- Neuronal cells.
- Pineal cells.
- Embryonic.
11
Q
Glial tumours arise from?
A
Astrocytes or oligodendrocytes.
12
Q
Astrocytic tumours are graded into a three-tier system of?
A
- Astrocytoma.
- Anaplastic astrocytoma.
- Glioblastoma multiforme.
13
Q
Which astrocytic tumours have a WHO Grading I?
A
- Pilocytic.
- Pleomorphic xanthoastrocytoma.
- Subependymal giant cell.
14
Q
Which astrocytic tumours have a WHO Grading II?
A
- Low grade astrocytoma.
15
Q
Which astrocytic tumours have a WHO Grading III?
A
- Anaplastic astrocytoma.
16
Q
Which astrocytic tumours have a WHO Grading IV?
A
- Glioblastoma multiforme.
17
Q
Describe Grade I astrocytomas?
A
- Slow growing benign tumours of children/young adults.
- e.g. pilocytic astrocytomas.
18
Q
Treatment of Grade I astrocytomas?
A
Surgery - curative.
19
Q
Where do pilocytic astrocytomas typically arise?
A
- Optic nerve, hypothalamic gliomas, cerebellum, brainstem.
20
Q
Low grade astrocytomas have a predilection for which lobe areas?
A
- Temporal.
- Posterior frontal.
- Anterior parietal.
21
Q
How do low grade astrocytomas typically present?
A
Seizures.
22
Q
Poor prognostic features of low grade astrocytomas?
A
- Age >50.
- Focal deficit e.g. seizures.
- Short symptom duration.
- Raised ICP.
- Altered consciousness.
- Enhancement on contrast studies.
23
Q
Treatment of Grade II astrocytomas?
A
SURGERY +/-:
- Radiation, chemotherapy, radio+chemo.
Depends on molecular profile.
24
Q
Grade II astrocytomas become what?
A
Glioblastoma.
25
Management of Grade II astrocytomas that have become glioblastoma?
- Biopsy: stereotactic vs open.
| - Seizure control, prevent herniation and CSF obstruction by cytoreduction.
26
What are the poor prognostic features of those with Grade II astrocytomas that have become glioblastoma?
- age >45.
- Low performance score.
- Large tumours (diameter > 6cm)/ crossing midline.
- Incomplete resection.
27
What grades are considered malignant astrocytomas?
Grades III-IV.
28
Median survival of anaplastic astrocytoma?
2 years.
29
Most common primary brain tumour?
Glioblastoma multiforme.
30
Median survival of Glioblastoma multiforme?
<1 year.
31
How does glioblastoma multiforme spread?
White matter tracking/CSF pathways.
32
Treatment of malignant astrocytomas?
Non-curative, to improve survival quality.
- Surgery: cytoreduction + reduce mass effect.
- Supramarginal resection if of non-eloquent cortex.
- Post-op radiotherapy, external beam.
33
Stupp protocol (NEJM 2005) improves median survival of malignant astrocytomas to?
14 months.
34
What is the Stupp protocol?
Surgery + radiotherapy + Temozolomide.
35
Following surgery for brain tumour removal, when is it not safe to drive post-op?
- If at risk of seizures.
| - Significant &/or homonymous visual field defect.
36
Patients deemed unsafe to drive following brain surgery must do what?
Inform the DVLA.
| - If they do not then you must as your duty of care.
37
When should radiotherapy be used in intracranial tumour treatment?
- Malignant tumours post surgery.
- Low grade astrocytomas: incomplete removal or malignant degeneration.
- Benign astrocytomas: recurrence/progression not amenable to surgery.
- S/E of tumour: IQ drop by 10 points, skin, hair, tired.
38
Oligodendroglial tumours account for what percent of glial tumours?
20%.
39
Oligodendroglial tumours have a predilection for which areas?
Frontal lobes.
40
Oligodendroglial tumours typically occur in which age groups?
25-45 y/o.
41
How do oligodendroglial tumours typically present?
As seizures.
42
Why are oligodendroglial tumours referred to as collision tumours?
Oligodendroglial cells coexist with astrocytic cells in a neoplastic collision type of tumour.
43
What features might suggest an oligodendroglial tumour rather than an astrocytoma?
- Calcification (usually peripheral).
- Cysts.
- Peritumoral haemorrhage.
44
Oligodendroglial tumours are chemosensitive to which drugs?
- Procarbazine, Lomustine, Vincristine.
45
Treatment of oligodendroglial tumours?
Chemotherapy + surgery.
- Surgery less convincing for high grade.
- Radiotherapy reduces seizures.
46
Median survival for low grade oligodendroglial tumours?
10 years.
47
Meningiomas arise from which cell type?
Arachnoid.
48
Are meningiomas intra- or extra- axial?
Extra-axial.
49
Meningiomas account for what percentage of intracranial neoplasms?
20%.
50
Ratio of meningiomas male:female?
2:3
51
Meningioma symptoms?
- Mostly asymptomatic.
| - Headaches, skull base: CN neuropathies, regional anatomical disturbance.
52
Classify meningiomas.
- Classic.
- Angioblastic.
- Atypical (2%).
- Malignant (5%).
53
What are the "classic" types of meningiomas?
Meningotheliomatous, fibrous, transitional.
54
Radiation induced meningiomas are common in who and where?
Those who had childhood leukaemia, typically occurring in the midline.
55
What CT features may suggest a meningioma?
- Homogenous densely enhancing mass.
- Oedema.
- Hyperostosis/skull "blistering".
56
What MRI features must be evaluate pre-op for meningiomas?
- Dural tail.
| - Patency of dural sinuses.
57
Why might angiography +/- embolisation be carried out for pre-op meningiomas?
- Generally vascular tumours, procedures may ease complete tumour resection by diminishing op time and blood loss.
58
Angiography of meningiomas is not generally indicated unless what?
Embolisation is planned.
59
Treatment of small meningiomas?
surgery is expected.
60
Treatment of meningiomas?
- Preop embolisation.
| - Surgery, radiotherapy.
61
5 year survival rate of meningiomas?
90%.
62
Describe Simpson's Grade I (for extent of resection).
Complete removal inc. underlying bone and ass. dura.
63
Symptomatic recurrence of Simpson's Grade I at 10 years?
9%.
64
Describe Simpson's Grade II (for extent of resection).
Complete removal and coagulation of dural attachment.
65
Describe Simpson's Grade III (for extent of resection).
Complete removal w/o resection of dura or coagulation.
66
Describe Simpson's Grade IV (for extent of resection).
Subtotal resection.
67
Describe Simpson's Grade V (for extent of resection).
Simple decompression +/- biopsy.
68
Symptomatic recurrence of Simpson's Grade II at 10 years?
19%
69
Symptomatic recurrence of Simpson's Grade III at 10 years?
29%
70
Symptomatic recurrence of Simpson's Grade IV at 10 years?
44%
71
Symptomatic recurrence of Simpson's Grade V at 10 years?
100%
72
Nerve sheath tumours?
- Schwannomas (neuromas).
- Neurofibromas.
- Malignant peripheral nerve sheath tumours.
73
What are acoustic neuromas?
Vestibular schwannomas (CN VIII - vestibulocochlear).
74
Acoustic neuromas/ vestibular schwannomas are commonly associated with which condition?
Neurofibromatosis type II.
75
Symptoms of acoustic neuromas?
- Hearing loss.
- Tinnitus.
- Dysequilibrium.
76
Acoustic neuromas may have impact on which structures?
- CN V, VII, VIII.
- Brainstem function.
- Hydrocephalus.
77
Management of acoustic neuromas?
- Audiology/audiometry.
- Radiographic evaluation.
Expectant: hydrocephalus management, radiation, surgery.
78
When is gamma knife offered in the management of acoustic neuromas?
If high risk or refusal of surgery - low dose.
79
What are the downsides of gamma knife treatment in the management of acoustic neuromas?
- Vestibular function substantially worsens in first 6 months and remains stable thereafter.
- Hearing tends to gradually decline over time in the treated ear.
80
What are the post-op risks of acoustic neuroma removal?
- Facial nerve palsy.
- Corneal reflex.
- Nystagmus.
- Abnormal eye movement.
81
Radiotherapy is not given to those under 3 y/o why?
Hypothalamic and cognitive dysfunction result.
82
90% of germ cell tumours occur in?
Those under 20 y/o.
83
Peak incidence of germ cell tumours?
10-12 years old.
84
Germ cell tumours more common in which sex?
Male.
85
Germ cell tumours may metastasise via?
CSF.
86
Most common CNS germ cell tumour?
Germinomas.
87
Management of germinomas?
Radiotherapy (65-95% 5 year survival rate).
88
Example of non-germinomatous germ cell tumours?
- Teratoma.
- Yolk sac tumour.
- Choriocarcinoma.
- Embryonal carcinoma.
LESS RADIOSENSITIVE THAN GERMINOMAS AND THUS POORER 5 YEAR SURVIVAL RATE 17-38%.
89
Describe general appearance of germ cell tumours on CT.
- Iso- or hyper- dense.
| - Enhance.
90
Describe general histology of germ cell tumours.
often of mixed histology.
91
What tests should be performed for any midline brain tumour in a child?
- ALP.
- HCG.
- LDH.
92
If ALP, HCG and LDH are negative in a child with a midline brain tumour, what must then be performed?
Biopsy +/- CSF sample.
93
Alpha fetoprotein is present in which tumours?
Yolk sac tumours and teratomas.
94
Human choriogonadotrophin (beta-HCG) is present in which tumours?
Choriocarcinoma and germinoma.
95
Placental alkaline phosphatase (PLAP) is present in which tumours?
Germinoma, choriocarcinoma, yolk sac.
96
How do you treat hydrocephalus?
Ventriculoperitoneal shunt.
- 50% revision rate in 10 years.
97
Presenting complaint of pituitary tumours?
- Bitemporal hemianopia.
- Headache.
- Endocrine abnormalities.
98
Management of prolactin secreting pituitary tumours?
Cabergoline.
| - Rarely requires surgery.
99
GH or IGF-1 secreting pituitary tumour management?
- Surgery and somatostatin analogues.
Acromegaly can kill by hypertrophic cardiomyopathy.
100
Symptoms of panhypopituitarism?
- Pallor, yellow tinge to skin.
- Fine wrinkling of skin.
- Absent axillary hair.
- Puffy, expressionless face.
101
What condition is common post-op of panhypopituitarism treatment?
Diabetes insipidus.
