Brain Tumours Flashcards by Joanna Mitchell

What is a brain tumour?

Overgrowth of tissue 
Can be benign or malignant
Primary or secondary 
Supratentorial or infratentorial 
Extrinsic (meninges, bone, blood vessel) or intrinsic

How well did you know this?

Not at all

Perfectly

How do brain tumours commonly present?

Progressive neurological deficit - usually contralateral motor weakness
Headache
Seizure

How well did you know this?

Not at all

Perfectly

What are the consequences of increased ICP (normal is 5-10 mmHg)?

Headaches
Vomiting
Mental changes
Seizures

How well did you know this?

Not at all

Perfectly

Describe the monroe kelly doctrine?

The head is a "rigid closed box" 
3 components: 
Brain (80%) 
Blood (10%) 
CSF (10%)

How well did you know this?

Not at all

Perfectly

Describe a classical headache assoc with brain tumours

Can occur with/without raised ICP
Worse in morning - wakes them up
Increased with coughing/ learning forward
May be associated with and increase vomiting

How well did you know this?

Not at all

Perfectly

Describe the aetiology of a tumour headache

Raised ICP
Invasion/ compression of dura, BVs, periosteum
Diplopia (CN 6)
Difficulty focussing
Cushing’s triad (tonsillar herniation; extreme hypertension, brady)
Psychogenic (stress of loss of functional capacity)

How well did you know this?

Not at all

Perfectly

What is the imaging of choice for someone with suspected brain tumour?

MRI

How well did you know this?

Not at all

Perfectly

How can tumours of the CNS be classified?

Meninges
Neuroepithelial tissue
Nerve sheath cells
Developmental lesions
Sella lesions
Germ cells
Local extension from adjacent structures
Haemopoietic/ lymphomas 
Mets

How well did you know this?

Not at all

Perfectly

What is the commonest type of brain tumour?

Neuroepithelial tissue: 
Astrocytes - 60% (2/3rd are high grade) 
Oligodendrocytes
Ependymal
Neuronal
Pineal 
Embryonic

How well did you know this?

Not at all

Perfectly

How can astrocytic tumours be graded?

1; purely benign; pilocytic, pleomorphic xanthoastrocytoma, subependymal giant cell
2; low grade
3; anaplastic
4; GBM

How well did you know this?

Not at all

Perfectly

How are tumours graded in terms of pathology?

Microvascular proliferation
Nuclear pleomorphism
Excess mitoses
Angiogenesis

How well did you know this?

Not at all

Perfectly

Describe grade 1 astrocytoma’s

Truly benign 
Slow growing 
Common in children/ young adults 
Commonly cause increased ICP 
Tx; surgery (curative)

T1 MRI scan used - you can tell as the CSF is black, contrast used (only use contrast in T1 weighted MRI images)

How well did you know this?

Not at all

Perfectly

Describe grade 2 astrocytoma’s

Fibrillary, gemistocytic, protoplasmic

Show hyper cellularity, pleomorphism, vascular proliferation, necrosis

Predilection; temporal lobe

Presentation; seizures

How well did you know this?

Not at all

Perfectly

Describe the poor prognostic factors associated with low grade astrocytoma’s

Age >50 
Focal deficit 
Short duration of symptoms
Raised ICP
Altered consciousness
Enhancement on contrast studies

How well did you know this?

Not at all

Perfectly

Describe the tx of grade 2 astrocytoma’s

Surgery +/- radiation, chemo, radio/chemo combo

Surgical biopsy; stereotactic vs open
Seizure control, herniation, CSF obstruction, cytoreduction

How well did you know this?

Not at all

Perfectly

Describe a landmark trial in the treatment of grade 2 astrocytoma’s

N=251 with a follow up of 11.9 years
55% had died
Patients who received radio + chemo (PCV) has an overall longer survival (13.3 vs 7.8 years)
Rate of progression free survival at 10 years was 51% compared to 21% in group that received radio alone

Describe the malignant astrocytoma’s

Grade 3; arise de novo. Median survival 2 yrs

Grade 4; most common primary brain tumour. Median survival 14-15 months
Spread; white matter tracking/ CSF pathways

Multiple gliomas = NF, TS, PML

What is the treatment for malignant astrocytoma’s

Non curative surgery - survival quality

Surgery; cytoreduction without causing a neurological deficit (reduce mass effect)

Post op radio; external beam therapy

Stupp protocol; Sx + Rt + TMZ (temozolomide)

If MGMT methylated tumour - increased life expectancy

When is radiotherapy utilized in brain tumours?

Always after malignant tumours
Low grade; incomplete removal, malignant degeneration
Benign astrocytoma’s; only if recurrence/ progression not amenable to surgery

Are there any novel therapies for treatment of brain tumours currently in phase 3 of clinical trials?

Yes; TTFs (electrical current) which prevents tumour mitoses
Increased survival of 2 months

Describe meningiomas

Originate from arachnoid cap cells
Extra-axial
20% of intracranial neoplasms
Majority are asymptomatic

Assoc with breast cancer and NF 2 (22q)
Associated with bone = meningioma en plaque

90% are benign and slow growing
Classification; classic, angioblastic, atypical, malignant

Symptoms of meningioma

Headache
Skull base; CN neuropathy
Regional anatomical disturbance

Describe grade 3 meningiomas

Clear cell
Choroid
Rhabdoid
Papillary 
Radiation induced meningioma (after childhood leukaemia - typically in midline)

How can meningiomas be assessed preoperatively?

CT; homogenous (lights up like a lightbulb), densely enhancing, oedema, hyperostosis
MRI; dural tail, patency of dural sinuses

Angio +/- embolization; external carotid artery feeders, occlusion of sagittal sinus

What is the treatment for a meningioma?

``` Small; expectant Periop embolization Surgery Radiotherapy Recurrence; depends on grade and extent of resection Outcome; 5 yr survival is 90% ```

Describe nerve sheath tumours

Schwannomas Neurofibromas Malignant peripheral nerve sheath tumours

Describe vestibular schwannomas

``` Sensorineural hearing loss Tinnitus Disequilibrium CN palsies; 5, 7, 8 Brainstem function Hydrocephalus ```

What is the treatment for vestibular schwannomas

Expectant - perform audiometry, radiographic evaluation. 1/3rd won't grow Hydrocephalus management - shunt insertion Radiation - stereotactic radiosurgery Surgery

What needs to be analysed post op after surgery for vestibular schwannoma

Facial nerve palsy (grading system) Corneal reflex (ulcer, sympathetic ophthalmoplegia) Nystagmus Abnormal eye movement

What blood tests should be performed in children with midline tumour on MRI scanning?

AFP b-HCG LDH If neg; needs a biopsy and CSF sample via ETV Germ cells are chemo and radio sensitive

How can hydrocephalus be treated?

VP shunt | 50% revision rate within 10 years

Describe the pituitary gland tumours

Px; bitemporal hemianopia, HA, endocrine abnormalities Ix; prolactinoma (cabergoline CURES) GH/ IGF-1; acromegaly can kill due to HOCM; surgery and somatostatin analogues Cortisol (test in morning); Cushing's disease can be fatal TSH, fT4, fT3 FSH, LH (high only after menopause) VA and visual fields = indication for surgery

Describe the signs of panhypopituitarism

``` Pallor Fine wrinkling of skin Absent axillary hair Face puffy Expressionless ``` Tx; GS first, then LF/FSH, then TSH, then ACTH then prolactin

What is decorin?

Inhibits primary breast cancer growth and distant mets in a mouse model Shrinks tumour in animal models of GBM