Brain Tumours (Clinical) Flashcards
What are common primary brain tumours?
neuroepitheal tissue - glioma (glioblastoma multiforme)
meninges - meningioma
pituitary - adenoma
What are common secondary brain tumours?
Commonest tumours that spread to the brain are:
- renal cell carcinoma
- lung carcinoma
- breast carcinoma
- malignant melanoma
- GI tract
How many lesions is there in primary and secondary brain tumours?
in primary there is usually 1 but in secondary there can be many
What is the most common brain tumour seen clinically?
Metastases
US >100 000 new cases year (17 000 primary tumours)
15-30% patients with cancer will get cerebral metastasis
15% cerebral metastasis is presenting symptom
9% cerebral met is only detectible site of spread
increasing incidence of cerebral metastases
What are gliomas?
Gliomas are derived from astrocytes - structural and nutritional support to nerve cells
WHO grade gliomas I-IV, what is the most common grade and what are the features of it?
Grade IV:
- most common
- most aggressive
- Glioblastoma multiforme (GBM)
- spread by tracking through white mater and CSF pathway
- very rarely spread systemically
Are gliomas malignant?
yes but do not metastasise
What is a meningioma?
A meningioma is a tumor that forms on membranes that cover the brain and spinal cord just inside the skull
What are the characteristics of a meningioma?
slow growing
extra-axial
usually benign
arise from arachnoid
frequently occur along falx, convexity, or sphenoid bone
usually cured if completely removed
WHat is the most common pituitary tumour?
adenoma most common
Are pituitary tumours malignant?
no only 1% are
What is the presentation of pituitary tumours?
visual disturbance due to compression of optic chiasm, bitemporal vision defect
hormone imbalance
WHat is the clinical presentation of brain tumours?
raised intracranial pressure (mass effect)
focal neurological deficit
epileptic fits
CSF obstruction
What are the symptoms of having raised ICP?
headache (typically morning headache)
nausea/vomiting
visual disturbance (diplopia, blurred vision)
somnolence
cognitive impairment
altered consciousness
What are the signs of raised ICP?
- papilloedema
- 6th nerve palsy - long cause so can be effected in many areas
- cognitive impairment
- altered consciousness
- 3rd nerve palsy
How does a brain tumour cause hydrocephalus?
CSF production is 400 - 450 cc/day and we only have around 150 so produce 3 times the volume and therefore we circulate the CSF 3 times a day
Caused by tumours in or close to csf pathways (especially posterior fossa tumours)
especially in children
How do you diagnose a brain tumour?
history and examination
think of sources of secondary tumours (eg CXR)
CT scan
MRI scan
biopsy
What are some examples of focal neurologicl deificts?
- hemiparesis - weakness of one entire side of the body
- dysphasia - language disorder marked by deficiency in the generation of speech, and sometimes also in its comprehension, due to brain disease or damage
- hemianopia - blindness over half the field of vision
- cognitive impairment (memory, sense of direction)
- cranial nerve palsy
- endocrine disorders
A 66 year old, left handed, woman presents with ataxia and in-coordination. Where would you suspect her lesion to be?
- Left frontal lobe
- Right frontal lobe
- Brain stem
- Cerebellum
4
A 44 year old, right handed, woman presents with acalculia, agraphia, finger agnosia and right/left confusion. Where would you suspect her lesion to be?
- Left parietal lobe
- Right parietal lobe
- Left occipital lobe
- Cerebellum
1
A 30 year old, right handed, man presents with a bi temporal hemianopia. Where would you suspect his lesion to be?
- Right frontal lobe
- Pituitary
- Left optic nerve
- Right occipital lobe
2
50 year old right handed man
Presented to medical team with cognitive language dysfunction:
- difficulty reading e mails
- difficulty expressing what he wished to say
- short-term memory impairment
6 week history of posterior rib pain
PMHx included a left nephrectomy for renal cell carcinoma 5 years previously
- Left temporo-parietal area
- Right fronto-temporal area
- Left occipital lobe
- Right parietal lobe
1
dominant hemisphere is the left as right handed
Transferred to neurosurgery ward
Underwent a craniotomy and excision lesion
Histology confirmed this to be clear cell carcinoma consistent with renal primary
WHat ar ethe 2 kinds of epilepsy?
focal or generalised
Epilepsy only occurs in lesions above the _________
tentorium
WHat can epilepsy indicta ein relation to a tumour?
first fit - 20% chance of tumour
draws attention to possibility of tumour
indicates location of tumour
What happens if someone has multiple mestastses?
no surgery
Cana . tumour be removed by surgery?
yes
What investigations can be done for brian tumours?
Adequate cerebral imaging: CT, MRI, PET, (Angiography)
If suspecting metastasis:
- CT chest/abdo/pelvis
- mammography
- biopsy skin lesions/lymph nodes
What are the management goals?
accurate tissue diagnosis
improve quality of life - decreasing mass effect/improve neurological deficit
aid effect of adjuvant therapy (if required)
prolong life expectancy
What are the different management principles?
corticosteroids (Dexamethasone)
treat epilepsy (anticonvulsant drugs)
analgesics/antiemetics
counselling
surgery
radiotherapy
chemotherapy
endocrine replacement
What are the management options for glioblastoma multiforme?
complete surgical excision impossible - biopsy or debulk only
medical: Steroids, anticonvulsants
radiotherapy
chemotherapy
What are the management options for metastasis (most important to confirm diagnosis)?
•11% with abnormal cerebral imaging and a history of cancer, do not have cerebral mets
medical - steroids, anticonvulsants
radiotherapy - whole brain, steriotatic -techniques for surgical treatment or scientific investigation that permit the accurate positioning of probes inside the brain or other parts of the body
surgery
What is the prognosis of a meningioma?
commonly cured by surgery may require anticonvulsants (drug used for treatment of epileptic seizures)
What is the prognosis of astrocytomas?
low grade - long life expectancy
high grade/GBM - average 1-1.5/2 yr survival
What is the prognosis of mestastases?
frequently good medium term remission
46 year old women
Head injury 2004 when fell off bike
Unable to work since as suffered post concussion syndrome
Cerebral MRI performed as part of thorough neurological assessment
Where is the lesion?
- Brainstem
- Occipital lobe
- Cerebellum
- Parietal lobe
3
What is the lesion likely to be?
- Glioblastoma multiforme
- Meningioma
- Pituitary adenoma
- Metastasis
2
What advice would you give?
- Radiotherapy
- Chemotherapy
- Surgical excision
- Nothing and get back to mountain biking
3 - cant always operate on all meningiomas though
MRI demonstrated a lesion most likely to be meningioma
Not thought that this was causing her symptomatology
Patient wanted lesion removed
50 year old women
4th October presented to ED with decreased level of consciousness
1/12 of “slowing down”
making uncharacteristic mistakes at work
4 day history of drowsiness
headache and nauseated
PMH - Nil
No allergies, no medications
Smokes pkt cigarettes/day, minimal alcohol
Worked as a dog catcher
Estranged from husband and lived with 19 year old daughter
Examination findings:
GSC 11 - e3v3m5
Pupils equal and reactive to light
No apparent focal neurological signs
Mild pyrexia (37.5°C)
Examination of chest/abdomen/breast normal
No palpable lymphadenopathy or skin lesions
What investigation would you do next?
- Lumbar puncture (LP)
- CT/MRI brain
- CXR
- Full blood count
2
multiple lesions seen on CT
T1 (contrast) axial MRI
Definitely do NOT perform a lumbar puncture when there are signs and symptoms to suggest an intracranial mass lesion
Why not do a LP?
- You might cause meningitis
- You might cause a herniation syndrome and the patient could die
- You might cause an air embolism
- You might make the patient’s headache worse
2
coning
REVISION SLIDE
Common types of brain tumours are:
metastasis (secondary) - renal, lung, malignant melanoma, breast, GI tract
primary malignant - glioma (GBM)
primary benign - meningioma and pituitary adenoma
Brain tumours present with:
signs of raised intracranial pressure (headache, nausea/vomiting/papilloedema)
seizures
neurological deficit
Management: appropriate investigations, ease symptoms, aid effect of adjuvant radiotherapy/chemotherapy, prolong life expectancy
