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CNS CLERKSHIP > Brain tumours > Flashcards

Brain tumours Flashcards

1
Q

Most common extra-axial tumour?

A

Meningioma.

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2
Q

Describe meningiomas.

A
  • Usually benign.
  • Arise from residual mesenchymal cells in the meninges.
  • Neurologic symptoms arise from brain compression.
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3
Q

Give an example of an extra-axial tumour.

A
  • Meningioma.
  • Pituitary adenoma.
  • Craniopharyngioma.
  • Choroid plexus papilloma.
  • Acoustic neuroma (Vestibular Schwannoma).
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4
Q

How do brain tumours typically present?

A
  • Progressive neurological deficit (68%) of which motor weakness accounts for 45%.
  • Headache.
  • Seizures.
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5
Q

Why does increased intracranial pressure arise as a result of brain tumours?

A
  • Tumour mass.
  • Oedema mass effect.
  • CSF blockage - hydrocephalus.
  • Haemorrhage.
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6
Q

Increased intracranial pressure results in?

A
  • Headaches.
  • Vomiting.
  • Mental changes.
  • Seizures.
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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.
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8
Q

The mnemonic DANISH is used to remember pathology of what?

A

Cerebellum.

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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.
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10
Q

Examples of neuroepithelial tissue/cells?

A
  • Astrocytes (60%).
  • Oligoodendroglial cells.
  • Ependymal cells/choroid plexus.
  • Neuronal cells.
  • Pineal cells.
  • Embryonic.
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11
Q

Glial tumours arise from?

A

Astrocytes or oligodendrocytes.

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12
Q

Astrocytic tumours are graded into a three-tier system of?

A
  • Astrocytoma.
  • Anaplastic astrocytoma.
  • Glioblastoma multiforme.
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13
Q

Which astrocytic tumours have a WHO Grading I?

A
  • Pilocytic.
  • Pleomorphic xanthoastrocytoma.
  • Subependymal giant cell.
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14
Q

Which astrocytic tumours have a WHO Grading II?

A
  • Low grade astrocytoma.
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15
Q

Which astrocytic tumours have a WHO Grading III?

A
  • Anaplastic astrocytoma.
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16
Q

Which astrocytic tumours have a WHO Grading IV?

A
  • Glioblastoma multiforme.
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17
Q

Describe Grade I astrocytomas?

A
  • Slow growing benign tumours of children/young adults.

- e.g. pilocytic astrocytomas.

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18
Q

Treatment of Grade I astrocytomas?

A

Surgery - curative.

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19
Q

Where do pilocytic astrocytomas typically arise?

A
  • Optic nerve, hypothalamic gliomas, cerebellum, brainstem.
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20
Q

Low grade astrocytomas have a predilection for which lobe areas?

A
  • Temporal.
  • Posterior frontal.
  • Anterior parietal.
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21
Q

How do low grade astrocytomas typically present?

A

Seizures.

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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.
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23
Q

Treatment of Grade II astrocytomas?

A

SURGERY +/-:
- Radiation, chemotherapy, radio+chemo.
Depends on molecular profile.

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24
Q

Grade II astrocytomas become what?

A

Glioblastoma.

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25
Q

Management of Grade II astrocytomas that have become glioblastoma?

A
  • Biopsy: stereotactic vs open.

- Seizure control, prevent herniation and CSF obstruction by cytoreduction.

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26
Q

What are the poor prognostic features of those with Grade II astrocytomas that have become glioblastoma?

A
  • age >45.
  • Low performance score.
  • Large tumours (diameter > 6cm)/ crossing midline.
  • Incomplete resection.
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27
Q

What grades are considered malignant astrocytomas?

A

Grades III-IV.

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28
Q

Median survival of anaplastic astrocytoma?

A

2 years.

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29
Q

Most common primary brain tumour?

A

Glioblastoma multiforme.

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30
Q

Median survival of Glioblastoma multiforme?

A

<1 year.

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31
Q

How does glioblastoma multiforme spread?

A

White matter tracking/CSF pathways.

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32
Q

Treatment of malignant astrocytomas?

A

Non-curative, to improve survival quality.

  • Surgery: cytoreduction + reduce mass effect.
  • Supramarginal resection if of non-eloquent cortex.
  • Post-op radiotherapy, external beam.
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33
Q

Stupp protocol (NEJM 2005) improves median survival of malignant astrocytomas to?

A

14 months.

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34
Q

What is the Stupp protocol?

A

Surgery + radiotherapy + Temozolomide.

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35
Q

Following surgery for brain tumour removal, when is it not safe to drive post-op?

A
  • If at risk of seizures.

- Significant &/or homonymous visual field defect.

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36
Q

Patients deemed unsafe to drive following brain surgery must do what?

A

Inform the DVLA.

- If they do not then you must as your duty of care.

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37
Q

When should radiotherapy be used in intracranial tumour treatment?

A
  • 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.
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38
Q

Oligodendroglial tumours account for what percent of glial tumours?

A

20%.

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39
Q

Oligodendroglial tumours have a predilection for which areas?

A

Frontal lobes.

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40
Q

Oligodendroglial tumours typically occur in which age groups?

A

25-45 y/o.

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41
Q

How do oligodendroglial tumours typically present?

A

As seizures.

42
Q

Why are oligodendroglial tumours referred to as collision tumours?

A

Oligodendroglial cells coexist with astrocytic cells in a neoplastic collision type of tumour.

43
Q

What features might suggest an oligodendroglial tumour rather than an astrocytoma?

A
  • Calcification (usually peripheral).
  • Cysts.
  • Peritumoral haemorrhage.
44
Q

Oligodendroglial tumours are chemosensitive to which drugs?

A
  • Procarbazine, Lomustine, Vincristine.
45
Q

Treatment of oligodendroglial tumours?

A

Chemotherapy + surgery.

  • Surgery less convincing for high grade.
  • Radiotherapy reduces seizures.
46
Q

Median survival for low grade oligodendroglial tumours?

A

10 years.

47
Q

Meningiomas arise from which cell type?

A

Arachnoid.

48
Q

Are meningiomas intra- or extra- axial?

A

Extra-axial.

49
Q

Meningiomas account for what percentage of intracranial neoplasms?

A

20%.

50
Q

Ratio of meningiomas male:female?

A

2:3

51
Q

Meningioma symptoms?

A
  • Mostly asymptomatic.

- Headaches, skull base: CN neuropathies, regional anatomical disturbance.

52
Q

Classify meningiomas.

A
  • Classic.
  • Angioblastic.
  • Atypical (2%).
  • Malignant (5%).
53
Q

What are the “classic” types of meningiomas?

A

Meningotheliomatous, fibrous, transitional.

54
Q

Radiation induced meningiomas are common in who and where?

A

Those who had childhood leukaemia, typically occurring in the midline.

55
Q

What CT features may suggest a meningioma?

A
  • Homogenous densely enhancing mass.
  • Oedema.
  • Hyperostosis/skull “blistering”.
56
Q

What MRI features must be evaluate pre-op for meningiomas?

A
  • Dural tail.

- Patency of dural sinuses.

57
Q

Why might angiography +/- embolisation be carried out for pre-op meningiomas?

A
  • Generally vascular tumours, procedures may ease complete tumour resection by diminishing op time and blood loss.
58
Q

Angiography of meningiomas is not generally indicated unless what?

A

Embolisation is planned.

59
Q

Treatment of small meningiomas?

A

surgery is expected.

60
Q

Treatment of meningiomas?

A
  • Preop embolisation.

- Surgery, radiotherapy.

61
Q

5 year survival rate of meningiomas?

A

90%.

62
Q

Describe Simpson’s Grade I (for extent of resection).

A

Complete removal inc. underlying bone and ass. dura.

63
Q

Symptomatic recurrence of Simpson’s Grade I at 10 years?

A

9%.

64
Q

Describe Simpson’s Grade II (for extent of resection).

A

Complete removal and coagulation of dural attachment.

65
Q

Describe Simpson’s Grade III (for extent of resection).

A

Complete removal w/o resection of dura or coagulation.

66
Q

Describe Simpson’s Grade IV (for extent of resection).

A

Subtotal resection.

67
Q

Describe Simpson’s Grade V (for extent of resection).

A

Simple decompression +/- biopsy.

68
Q

Symptomatic recurrence of Simpson’s Grade II at 10 years?

A

19%

69
Q

Symptomatic recurrence of Simpson’s Grade III at 10 years?

A

29%

70
Q

Symptomatic recurrence of Simpson’s Grade IV at 10 years?

A

44%

71
Q

Symptomatic recurrence of Simpson’s Grade V at 10 years?

A

100%

72
Q

Nerve sheath tumours?

A
  • Schwannomas (neuromas).
  • Neurofibromas.
  • Malignant peripheral nerve sheath tumours.
73
Q

What are acoustic neuromas?

A

Vestibular schwannomas (CN VIII - vestibulocochlear).

74
Q

Acoustic neuromas/ vestibular schwannomas are commonly associated with which condition?

A

Neurofibromatosis type II.

75
Q

Symptoms of acoustic neuromas?

A
  • Hearing loss.
  • Tinnitus.
  • Dysequilibrium.
76
Q

Acoustic neuromas may have impact on which structures?

A
  • CN V, VII, VIII.
  • Brainstem function.
  • Hydrocephalus.
77
Q

Management of acoustic neuromas?

A
  • Audiology/audiometry.
  • Radiographic evaluation.

Expectant: hydrocephalus management, radiation, surgery.

78
Q

When is gamma knife offered in the management of acoustic neuromas?

A

If high risk or refusal of surgery - low dose.

79
Q

What are the downsides of gamma knife treatment in the management of acoustic neuromas?

A
  • Vestibular function substantially worsens in first 6 months and remains stable thereafter.
  • Hearing tends to gradually decline over time in the treated ear.
80
Q

What are the post-op risks of acoustic neuroma removal?

A
  • Facial nerve palsy.
  • Corneal reflex.
  • Nystagmus.
  • Abnormal eye movement.
81
Q

Radiotherapy is not given to those under 3 y/o why?

A

Hypothalamic and cognitive dysfunction result.

82
Q

90% of germ cell tumours occur in?

A

Those under 20 y/o.

83
Q

Peak incidence of germ cell tumours?

A

10-12 years old.

84
Q

Germ cell tumours more common in which sex?

A

Male.

85
Q

Germ cell tumours may metastasise via?

A

CSF.

86
Q

Most common CNS germ cell tumour?

A

Germinomas.

87
Q

Management of germinomas?

A

Radiotherapy (65-95% 5 year survival rate).

88
Q

Example of non-germinomatous germ cell tumours?

A
  • Teratoma.
  • Yolk sac tumour.
  • Choriocarcinoma.
  • Embryonal carcinoma.

LESS RADIOSENSITIVE THAN GERMINOMAS AND THUS POORER 5 YEAR SURVIVAL RATE 17-38%.

89
Q

Describe general appearance of germ cell tumours on CT.

A
  • Iso- or hyper- dense.

- Enhance.

90
Q

Describe general histology of germ cell tumours.

A

often of mixed histology.

91
Q

What tests should be performed for any midline brain tumour in a child?

A
  • ALP.
  • HCG.
  • LDH.
92
Q

If ALP, HCG and LDH are negative in a child with a midline brain tumour, what must then be performed?

A

Biopsy +/- CSF sample.

93
Q

Alpha fetoprotein is present in which tumours?

A

Yolk sac tumours and teratomas.

94
Q

Human choriogonadotrophin (beta-HCG) is present in which tumours?

A

Choriocarcinoma and germinoma.

95
Q

Placental alkaline phosphatase (PLAP) is present in which tumours?

A

Germinoma, choriocarcinoma, yolk sac.

96
Q

How do you treat hydrocephalus?

A

Ventriculoperitoneal shunt.

  • 50% revision rate in 10 years.
97
Q

Presenting complaint of pituitary tumours?

A
  • Bitemporal hemianopia.
  • Headache.
  • Endocrine abnormalities.
98
Q

Management of prolactin secreting pituitary tumours?

A

Cabergoline.

- Rarely requires surgery.

99
Q

GH or IGF-1 secreting pituitary tumour management?

A
  • Surgery and somatostatin analogues.

Acromegaly can kill by hypertrophic cardiomyopathy.

100
Q

Symptoms of panhypopituitarism?

A
  • Pallor, yellow tinge to skin.
  • Fine wrinkling of skin.
  • Absent axillary hair.
  • Puffy, expressionless face.
101
Q

What condition is common post-op of panhypopituitarism treatment?

A

Diabetes insipidus.

CNS CLERKSHIP (43 decks)

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