Brain Tumours II Flashcards
What is important to note about the general presentation of meningiomas? [2]
How do they cause presentation of sx? [1]
Where do they occur in the brain? [3]
General presentation:
* Often incidental findings - slow growing and usually benign. Common in older people and women
* arise from the dura mater of the meninges and cause symptoms by compression rather than invasion.
BUT - because they can occur anywhere in cranium, then
- Extra axial tumours (outside brain tissue), they can cause direct pressures on other brain structures or invasion of cells
Location:
- falx cerebri, superior sagittal sinus, convexity or skull base.
Describe what is meant by Foster kennedy syndrome [1]
unilateral optic atrophy (vision loss in one eye) and contralateral papilledema (swelling of the optic disc in the other eye), often caused by a space-occupying lesion in the brain compressing the optic nerve
Describe the different forms of pituitary tumours [3]
Secreting tumours vs non-secreting tumours
- Non-secreting adenomas can squash pit. gland (and drop in hormone levels)
- Important to note that not always visual field defects or secreting hormones.
Pituitary adenomas:
- Macro > 1cm vs micro < 1cm
acromeg.
Which cancer are acromegaly patients at risk of? [1]
Bowel cancer
Face House Brackman score relates to what? [1]
Facial paralyiss
tumour blosh??
A 12-year-old child developed headaches, vomiting and a staggering gait. A cerebellar neoplasm was diagnosed.
Which is the most common cerebellar neoplasm of childhood?
Ependymoma
Glioblastoma multiforme
Neuroblastoma
Astrocytoma
Oligodendroglioma
Astrocytoma
Which type of astrocytoma has an intrinsic tendency for malignant transformation to GBM?
Pilocytic astrocytoma
Diffuse astrocytoma
Anaplastic Astrocytoma
What is the histology like of a meningioma? [1]
- Histology: Spindle cells in concentric whorls and calcified psammoma bodies
How would you investigate for prolactinoma?
Basal prolactin raised
Pregnancy test
TFT
U&E
MRI pituitary - choice
Drug class used to manage prolactinoma? [1]
Name two drugs that are used to manage prolactinoma [2]
Dopamine agonists (dopamine causes tonic inhibition of prolactin release):
- bromocriptine
- cabergoline
What are the classic triad signs of acromegaly? [3]
Name some other symptoms [4]
Headaches, arthralgia, sweating
Increased ring/shoe size, weakness, diabetes, carpal tunnel, atherosclerosis
TOM TIP: When preparing for the PACES exam, the link between bilateral carpal tunnel syndrome and acromegaly came up several times. Cases would present a patient with symptoms of bilateral carpal tunnel syndrome. The challenge was not only to diagnose carpal tunnel syndrome but also to identify the features of the underlying cause. Whenever you see a patient in an OSCE station, and you make a diagnosis, ask yourself whether that diagnosis might have an underlying cause and look for features of that cause.
Name and explain which cancer ptx with acromegaly are at a higher risk of [2]
Increased risk of colo-rectal cancer due to high levels of IGF-1
State and explain the standard investigation for acromegaly? [1]
Name two others [2]
OGTT:
- Make patient fast
- At time 0, check glucose and GH
- Give 75g dose of glucose and wait 2hrs
- Normal response: suppression of GH when glucose given
- Acromegaly response: GH increases despite glucose given
Insulin-like growth factor-1 (IGF-1):
can be tested on a blood sample. It indicates the growth hormone level and is raised in acromegaly.
MRI pituitary
Testing growth hormone directly is unreliable: fluctuates in the day.
Describe levels of Ca2+, PO4- and glucose in acromegaly [3]
All raised
Describe vascular and cardiac complicatons of acromegaly [4]
Increased blood pressure:
- Left ventricular hypertrophy
- cardiomyopathy
- arrhythmias
- ischaemic heart disease
[] is one of the most frequent complications in acromegaly, with a median frequency of 33.6%
Hypertension is one of the most frequent complications in acromegaly, with a median frequency of 33.6%
Name three drug therapies for acromegaly? [3]
Octreotide - somatostatin analogue: lowers GH levels / blocks GH release
Pegvisomont – GH receptor antagonist; subcutaneous injection
Bromocriptine (Dopamine agonists): block growth hormone release
What is the first line treatment for acromegaly? [1]
Trans–sphenoidal surgery
Name a cancer that can cause Cushing’s syndrome [1]
small cell cancers of lung
Name and explain the diagnostic test of choice for Cushing’s syndrome
Normal: dexamethasone suppresses cortisol release from adrenal glands
Cushings: cortisol levels are high despite dexamethasone suppressing cortisol release
Management of Cushing’s syndrome:
- Surgery? [1]
- Drugs? [2]
Trans-sphenoidal surgery
Adrenolytics:
Ketoconazole: causes steroidogenesis inhibition.
Metyrapone: reduces the production of cortisol in the adrenals and is occasionally used in treating of Cushing’s
There are three types of dexamethason suppression test.
Describe them [3]
Low-dose overnight test (used as a screening test to exclude Cushing’s syndrome)
- A normal result is that the cortisol level is suppressed.
- Failure of the dexamethasone to suppress the morning cortisol could indicate Cushing’s syndrome, and further assessment is required. THINK CAPE
Low-dose 48-hour test (used in suspected Cushing’s syndrome)
- 0.5mg is taken every 6 hours for 8 doses, starting at 9 am on the first day.
- Cortisol is checked at 9 am on day 1 (before the first dose) and 9 am on day 3 (after the last dose)
- A normal result is that the cortisol level on day 3 is suppressed
- Failure of the dexamethasone to suppress the day 3 cortisol could indicate Cushing’s syndrome, and further assessment is required.
High-dose 48-hour test (used to determine the cause in patients with confirmed Cushing’s syndrome)
- carried out the same way as the low-dose test, other than using 2mg per dose (rather than 0.5mg).
- This higher dose is enough to suppress the cortisol in Cushing’s disease, but not when it is caused by an adrenal adenoma or ectopic ACTH.
What is the order of treatment for:
- Acromegaly [2]
- Prolactinoma [2]
Acromegaly:
- Surgery 1st line
- Drugs 2nd line (octreotide)
Prolactinoma:
- Drugs 1st line (Dopamine agonists: Cabergoline; bromocriptine)
- Surgery 2nd line
