Brain Tumours II

Question 2

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]

Answer 2

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.

Question 3

Describe what is meant by Foster kennedy syndrome [1]

Answer 3

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

Question 4

Describe the different forms of pituitary tumours [3]

Answer 4

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

Question 5

acromeg.

Question 6

Which cancer are acromegaly patients at risk of? [1]

Answer 6

Bowel cancer

Question 7

Face House Brackman score relates to what? [1]

Answer 7

Facial paralyiss

Answer 8

tumour blosh??

Question 9

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

Answer 9

Astrocytoma

Question 10

Which type of astrocytoma has an intrinsic tendency for malignant transformation to GBM?

Answer 10

Pilocytic astrocytoma
Diffuse astrocytoma
Anaplastic Astrocytoma

Question 11

What is the histology like of a meningioma? [1]

Answer 11

• Histology: Spindle cells in concentric whorls and calcified psammoma bodies

Question 12

How would you investigate for prolactinoma?

Answer 12

Basal prolactin raised
Pregnancy test
TFT
U&E

MRI pituitary - choice

Question 13

Drug class used to manage prolactinoma? [1]

Name two drugs that are used to manage prolactinoma [2]

Answer 13

Dopamine agonists (dopamine causes tonic inhibition of prolactin release):

• bromocriptine
• cabergoline

Question 14

What are the classic triad signs of acromegaly? [3]

Name some other symptoms [4]

Answer 14

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.

Question 15

Name and explain which cancer ptx with acromegaly are at a higher risk of [2]

Answer 15

Increased risk of colo-rectal cancer due to high levels of IGF-1

Question 16

State and explain the standard investigation for acromegaly? [1]

Name two others [2]

Answer 16

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.

Question 17

Describe levels of Ca2+, PO4- and glucose in acromegaly [3]

Answer 17

All raised

Question 18

Describe vascular and cardiac complicatons of acromegaly [4]

Answer 18

Increased blood pressure:
- Left ventricular hypertrophy
- cardiomyopathy
- arrhythmias
- ischaemic heart disease

Question 19

[] is one of the most frequent complications in acromegaly, with a median frequency of 33.6%

Answer 19

Hypertension is one of the most frequent complications in acromegaly, with a median frequency of 33.6%

Question 20

Name three drug therapies for acromegaly? [3]

Answer 20

Octreotide - somatostatin analogue: lowers GH levels / blocks GH release

Pegvisomont – GH receptor antagonist; subcutaneous injection

Bromocriptine (Dopamine agonists): block growth hormone release

Question 21

What is the first line treatment for acromegaly? [1]

Answer 21

Trans–sphenoidal surgery

Question 22

Name a cancer that can cause Cushing’s syndrome [1]

Answer 22

small cell cancers of lung

Question 23

Name and explain the diagnostic test of choice for Cushing’s syndrome

Answer 23

Normal: dexamethasone suppresses cortisol release from adrenal glands

Cushings: cortisol levels are high despite dexamethasone suppressing cortisol release

Question 24

Management of Cushing’s syndrome:

• Surgery? [1]
• Drugs? [2]

Answer 24

 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

Question 25

There are three types of dexamethason suppression test. Describe them [3]

Answer 25

**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.**

Question 26

Answer 26

Question 27

Answer 27

Question 28

Answer 28

Question 29

Answer 29

Question 30

What is the order of treatment for: - Acromegaly [2] - Prolactinoma [2]

Answer 30

Acromegaly: - **Surgery 1st line** - **Drugs 2nd line** (octreotide) Prolactinoma: - **Drugs 1st line** (Dopamine agonists: Cabergoline; bromocriptine) - **Surgery 2nd line**