Brain tumours Flashcards
How can brain tumours present? 4
Progressive motor deficit (68%)
Motor weakness (45%)
Headache 54%
Seizures 26%
Describe what symptoms are caused by a raised ICP?
headaches:
- worse in morning/awakening
- worse on coughing/leaning forward
- may be assoc. and get better with vomiting
Why can tumours cause raised ICP?
- tumour mass or oedema effect
- blockage of CSF flow
- haemorrhage
What would be the clinical features of a parietal lobe lesion?
sensory inattention
apraxias
astereognosis (tactile agnosia)
inferior homonymous quadrantanopia
Gerstmann's syndrome (lesion of dominant parietal): alexia, acalculia, finger agnosia and right-left disorientationWhat would be the clinical features of a temporal lobe lesion?
Wernicke’s aphasia: unable to understand language
superior homonymous quadrantanopia
auditory agnosia
prosopagnosia (difficulty recognising faces)
What would be the clinical features of an occipital lobe lesion?
homonymous hemianopia (with macula sparing)
cortical blindness
visual agnosia
What would be the clinical features of a frontal lobe lesion?
expressive (Broca's) aphasia: located on the posterior aspect of the frontal lobe, in the inferior frontal gyrus. Speech is non-fluent, laboured, and halting
disinhibition
perseveration
anosmia
inability to generate a listWhat would be the features of a cerebellar lesion?
midline lesions: gait and truncal ataxia
hemisphere lesions: intention tremor, past pointing, dysdiadokinesis, nystagmus
What is the most common type of brain tumour?
Astrocytic tumours
What is the WHO grading of astrocytic tumours?
I - pilocytic/pleomorphic xanthoastrocytoma/supependymal giant cell
II - low grade astrocytoma
III - anaplastic astrocytoma
IV - glioblastoma multiforme
(III and IV are malignant)
WHO I astrocytoma:
- benign or malignant?
- fast or slow growing?
- who is affected?
- where are these found?
- what is the treatment of choice?
Truly benign
Slow growing
Children, young adults
Pilocytic astrocytomas:
- optic nerve, hypothalamic gliomas
- cerebellum, brainstem
Treatment of choice: surgery - curative
WHO II astrocytoma:
- where do these tend to occur?
- what is the presentation?
- what are poor prognostic factors?
Occur in the temporal/posterior frontal/anterior parietal
- presentation: siezures
- grow slowly but can transform into malignant neoplasms
what are poor prognostic factors for WHO II astrocytoma?
- age >50
- focal deficit
- short duration of symptoms
- raised ICP
- altered consciousness
- enhancement of contrast studies
What is the treatment of WHO II astrocytomas?
Surgery +/- one of below
- no treatment
- radiation
- chemo
- combined radio and chemo
What is the median survival of WHO III astrocytoma?
can arise de novo
- Median survival: 2 yrs
WHO IV
- is this common?
- what is the median survival?
- what is the spread?
- most common primary tumor
- Median survival: < 1yr
- spread: white matter tracking/ CSF pathways
What is the first line approach of brain tumours?
surgical
What are the three goals of surgery for brain tumour?
(i)to obtain a histological diagnosis
(ii) reduce the mass of the
tumour whilst preventing iatrogenic neurological deficit as effectively as possible and
(iii) to treat hydrocephalus if present.
-Surgery can be curative for most benign
tumours whilst debulking improves prognosis for malignant tumours provided the tumour is not infiltrating essential areas of the brain such as language areas
What chemotherapy is used for brain tumours?
- Temozolomide
- PCV
- Carmustine wafer
What is the role for radiotherapy in brain tumours? what are the skin effects?
Clear role in Malignant tumours post surgery
Low grade astrocytomas:
- incomplete removal
- malignant degeneration ( +/- surgery)
Benign astrocytomas:
-only if recurrence/ progression not amenable to surgery
Side effects:
–drops IQ by 10, skin, hair, tired
what novel therapies can be used for brain tumours?
immunotherapy
What is the second most common brain tumour?
oligodendroglial tumours
-20% of glial tumours
Oligodendroglial tumours:
- where do these occur?
- who is affected?
- what is the presentation?
- frontal lobes
- adults 25-45yrs (small peak in 6-12yrs)
- siezure presentation
Oligodenroglial tumours:
are these low or high grade?
low grade but can undergo malignant conversion
What is the treatment for oligodendroglial tumours?
Chemosensitive- Procarbazine, Lomustine, Vincristine
Surgery + Chemotherapy
Surgery for high grade less convincing
Radiotherapy controversial but decreases seizures
Median survival: 10 yrs (low grade)
Meningiomas:
- are these common?
- M:F
- what syndromes can exist with these?
20 % of intracranial neoplasms
Majority asymptomatic
M:F = 2:3
Syndromes:
Breast cancer, NF II (22q)
Multiple meningiomas (8%) Meningioma en plaque
What symptoms can occur from meningiomas?
Headaches
Skull base - cranial nerve neuropathies
Regional anatomical disturbance
What is the pathology of meningiomas?
- benign or malignant?
- slow or fast growing?
- 90% benign
- slow growing
What is involved in the preop evaluation of meningiomas?
CT:
-homogenous, densely enhance, skull blistering (hyperostosis)
MRI:
-dural tail, patency of dural sinuses
If embolisation planned then angiography +/- embolisation:
-external carotid artery feeders, occlusion of sagittal sinus
What is the treatment of meningioma?
Small meningiomas: expectant
Preoperative embolisation
Surgery
Radiotherapy
Recurrence –depends on grade and extent of resection
Outcome: 5 yr survival 90 %
what is an acoustic neuroma?
what can this occur as part of?
Vestibular schwannomas ( of 8th nerve)
Can occur as part of Neurofibromatosis II
What symptoms can occur due to an acoustic neuroma?
Hearing loss
Tinnitus
Dysequilibrium
What is the treatment of an acoustic neuroma?
1st do audiologic/audiometry and radiological evaluation
Expectant - 25% managed medically
Hydrocephalus management
Radiation
Surgery - 50% managed surgically
Describe the medical management of acoustic neuroma?
i. Periodic neuro exam
ii. Hearing aid
iii. Periodic MRI
between 10 and 43% of patients “useful” hearing & 75% increase in size over 2yrs
Describe the surgical management of acoustic neuroma
earing preservation surgery” rarely preserves useful hearing, which tends to deteriorate fairly rapidly with time, with or without a tumour still being there
What is done for acoustic neuroma if <3cm?
gamma knife:
If high risk or refusal of surgery. Give low dose
Single sitting & MRI monitoring after
Hearing tends to gradually decline over several years in the treated ear.
Vestibular function tends to worsen substantially in the first 6 months and remain stable thereafter.
Malignant transformation is rare
What is experienced post-op after acoustic neuroma treatment?
Facial nerve palsy
Corneal reflex
Nystagmus
Abnormal eye movement
Germ cell tumours:
- who is affected?
- what is seen on CT?
- what is the histology often?
- how can these metastise?
- which are the most common?
- which are radiosensitive?
- 10-12 yr (90% <20yrs)
- M>F
CT: iso or hyper dense
may metastasize via CSF
Germinomas most common - these are radiosensitive
Non-germinomatous are not radiosensitive
What tumour marker is present in yolk sac tumours and teratomas?
-alpha fetoprotein
What tumour marker is present in choriocarcinoma and germinomas?
beta-HCG
What tumour marker is present in germinomas and choriocarcinoma and yolk sac?
Placental alkaline phosphatase
What is best management for siezures post neurosurgery?
phenytoin or lorazepam
what is initial treatment for a CNS tumour?
dexamathasone with lansoprazole cover
