Brain Tumours & Metastases Flashcards
Primary Brain Tumours (e.g., Glioblastoma) Brain metastases Metastatic disease Acoustic neuroma
Primary Brain Tumours
Primary brain tumours originate within the brain or surrounding structures, as opposed to metastatic tumours which spread from other sites.
Classification of Primary Brain Tumours is completed by ___
Histology
Name some examples of Gliomas
Gliomas (tumours of glial cells):
Astrocytomas (including glioblastoma multiforme).
Oligodendrogliomas.
Ependymomas.
Meningiomas (arise from meninges).
Medulloblastomas (common in children, cerebellum).
Pituitary tumours (e.g., prolactinomas).
Schwannomas (e.g., vestibular schwannomas).
Craniopharyngiomas (near the pituitary).
Meningiomas arise from __
Meninges
Epidemiology of Glioblastoma multiforme
Most common primary malignant brain tumour in adults.
Epidemiology of Meningiomas
Most common primary benign tumour in adults.
Epidemiology of Medulloblastomas
Most common malignant brain tumour in children.
Causes and risk factors of Primary Brain Tumours
Genetic syndromes: Neurofibromatosis type 1 and 2, Li-Fraumeni syndrome, tuberous sclerosis, and von Hippel-Lindau disease.
Ionising radiation.
Family history of brain tumours.
General Symptoms of Primary Brain Tumours
(due to raised intracranial pressure):
Headache (worse in the morning or with straining).
Nausea and vomiting.
Papilloedema (optic disc swelling).
Seizures.
Focal Neurological Symptoms of Primary Brain Tumours depend on what?
Depend on tumour location
Focal Neurological Symptoms: Frontal Lobe
Personality changes, poor decision-making, hemiparesis.
Focal Neurological Symptoms: Temporal Lobe
Seizures, memory impairment, language disturbances.
Focal Neurological Symptoms: Parietal Lobe
Sensory loss, visuospatial issues
Focal Neurological Symptoms: Occipital Lobe
Visual field defects.
Focal Neurological Symptoms: Cerebellum
Ataxia, balance issues.
Focal Neurological Symptoms: Brainstem
Cranial nerve palsies, ataxia.
Dx/ Ix for Primary Brain Tumours
Neuroimaging:
MRI (with contrast): Gold standard for characterising brain tumours.
CT scan: Quicker but less detailed.
Biopsy:
Essential for definitive diagnosis and histopathological classification.
Other Tests:
Blood tests: Check endocrine function if a pituitary tumour is suspected.
Lumbar puncture: Rarely used but may assist in medulloblastoma or other paediatric cases.
Name some examples of Primary Brain Tumours
Glioblastoma Multiforme (GBM), Meningiomas, Vestibular Schwannomas (Acoustic Neuromas), Medulloblastomas, Pituitary Tumours
Prognosis of Glioblastoma Multiforme (GBM)
Poor prognosis because it is highly aggressive
Characteristic feature found on Imaging of Glioblastoma Multiforme (GBM)
“Ring-enhancing lesion” on contrast MRI.
Tx for Glioblastoma Multiforme (GBM)
Surgery, radiotherapy, temozolomide (chemotherapy).
Growth pattern of Meningiomas
Typically slow-growing and benign.
Sx for Meningiomas
Often incidental findings; may cause focal deficits.
Tx for Meningiomas
Surgical resection if symptomatic.
Features of Vestibular Schwannomas (Acoustic Neuromas)
Affects CN VIII, leading to hearing loss and tinnitus.
Symptoms of Vestibular Schwannomas (Acoustic Neuromas)
Balance problems, facial numbness (compression of CN VII).
Tx for Vestibular Schwannomas (Acoustic Neuromas)
Surgery or stereotactic radiosurgery.
Features of Medulloblastomas
Common in children; arises in the posterior fossa.
Sx for Medullablastomas
Ataxia, hydrocephalus.
Tx for Medulloblastomas
Surgery, craniospinal radiotherapy, and chemotherapy.
Features of Pituitary Tumours
Hormonal dysfunction (e.g., prolactinoma causing amenorrhoea, galactorrhoea).
Tx for Pituitary Tumours
Medical therapy (e.g., dopamine agonists for prolactinomas) or surgery.
Management for Primary Brain Tumours
Surgical Resection, Radiotherapy:
Post-surgery or for non-operable tumours.
Chemotherapy:
Typically adjunctive (e.g., temozolomide for GBM).
Symptom Control
Surgical Resection is the primary tx for ____
Primary treatment for accessible tumours.
What is used for symptom control in Primary Brain Tumours
Corticosteroids: To reduce cerebral oedema.
Antiepileptics: For seizure control.
Rehabilitation: Occupational and physiotherapy for functional impairments.
Prognosis of a Primary Brain Tumours depends on ___
Dependent on tumour type, grade, and location.
Prognosis of Glioblastomas
Poor prognosis (median survival ~12-18 months).
Prognosis of Meningiomas
Excellent prognosis if benign and resectable.
What are Brain Metastases?
Brain metastases refer to secondary tumours that have spread to the brain from a primary cancer elsewhere in the body. These are the most common type of brain tumour in adults.
Name some common primary cancers (Brain Metastases)
Lung cancer (most common cause).
Breast cancer.
Melanoma (high propensity to metastasize to the brain).
Kidney cancer.
Colorectal cancer.
Epidemiology of Brain Metastases
Occurs in approximately 10-30% of adult cancer patients.
Most common in patients with advanced or late-stage cancer.
Pathophysiology of Brain Metastases
Tumour cells spread via the bloodstream or lymphatic system to the brain
Common locations of Brain Metastases include:
Cerebral hemispheres (~80%).
Cerebellum (~15%).
Brainstem (~5%).
Symptoms of Brain Metastases
Raised Intracranial Pressure:
Headaches (worse in the morning).
Nausea and vomiting.
Blurred vision due to papilloedema Memory impairment, confusion, or personality changes.
Are seizures common in Brain Metastases
Common presentation in metastases involving the cerebral cortex.
Dx/ Ix for Brain Metastases
Imaging:
MRI with contrast: Gold standard for identifying and characterizing brain metastases.
CT scan with contrast: Quicker, used in emergency settings.
2. Biopsy:
Rarely required but may be necessary if there is diagnostic uncertainty.
Ix to identify a primary tumour
Chest X-ray or CT thorax, abdomen, and pelvis.
Mammography or breast MRI.
Colonoscopy if colorectal cancer is suspected.
PET-CT scan for metastatic workup.
Differential Dx for Brain Metastases
Primary brain tumours (e.g., glioblastoma).
Abscesses or infections (e.g., toxoplasmosis in immunocompromised patients).
Stroke or haemorrhage.
Autoimmune conditions (e.g., multiple sclerosis).
Symptomatic Tx for Brain Metastases
Corticosteroids (e.g., dexamethasone): Reduce cerebral oedema and pressure.
Antiepileptic drugs: For seizure control (e.g., levetiracetam).
Analgesics: For headache and pain relief.
Definitive Tx for Brain Metastases
Surgical resection: For accessible and symptomatic metastases in selected patients.
Radiotherapy:
Whole brain radiotherapy (WBRT): For multiple metastases.
Stereotactic radiosurgery (SRS): For small, isolated lesions.
Systemic Therapy:
Chemotherapy, immunotherapy, or targeted therapy depending on the primary cancer type.
Prognosis of Brain Metastases
Poor overall prognosis, dependent on factors such as:
Number and size of metastases.
Control of primary tumour.
Performance status of the patient.
Median survival for Brain Metastases without tx
~1 month.
Median survival for Brain Metastases with tx
(e.g., surgery + radiotherapy): 3-12 months.
What is Metastatic Disease ?
Metastatic disease refers to the spread of cancer cells from a primary tumour to distant sites in the body, forming secondary tumours.
Common sites of Metastatic disease
Bone: Common in breast, prostate, and lung cancers.
Liver: Frequently seen in colorectal and pancreatic cancers.
Lung: Commonly affected in metastatic breast, colorectal, and kidney cancers.
Brain: Seen in melanoma, lung, and breast cancers.
Peritoneum: Often involved in ovarian and gastric cancers.
Mechanism of Spread in Metastatic Disease
Hematogenous Spread: Via the bloodstream; common in sarcomas and carcinomas.
Lymphatic Spread: Via the lymphatic system; common in carcinomas.
Direct Invasion: Into surrounding tissues.
Transcoelomic Spread: Across body cavities (e.g., pleural or peritoneal).
Symptoms of Bone Metastases
Bone pain (worse at night).
Pathological fractures.
Hypercalcaemia (confusion, constipation, polyuria).
Symptoms of Liver Metastases
Jaundice.
Hepatomegaly.
Right upper quadrant pain.
Elevated liver enzymes.
Symptoms of Lung Metastases
Cough, haemoptysis.
Dyspnoea.
Chest pain.
Symptoms of Brain Metastases
Headaches, seizures.
Focal neurological deficits.
Cognitive and personality changes.
Symptoms of Peritoneal Metastases
Ascites (fluid accumulation in the abdomen).
Abdominal pain and bloating.
Ix for Metastatic Disease
General Workup:
Full blood count.
Liver function tests.
Tumour markers (e.g., CA-125 for ovarian cancer, PSA for prostate cancer).
Imaging:
CT scan of the chest, abdomen, and pelvis: Commonly used for staging.
MRI: Particularly for brain and spinal metastases.
Bone scan: For suspected bone metastases.
PET-CT: Highly sensitive for detecting metastases across the body.
Biopsy:
Required to confirm the metastatic nature of the disease and often to identify the primary tumour if unknown.
Differential Dx for Metastatic Disease
Primary tumours at the site of metastasis.
Benign conditions (e.g., cysts, abscesses).
Inflammatory or autoimmune diseases (e.g., sarcoidosis).
Management of Metastatic Disease
Systemic Therapy:
Chemotherapy: Targets rapidly dividing cells across the body.
Hormonal Therapy: For hormone-sensitive cancers (e.g., tamoxifen for breast cancer).
Targeted Therapy: Focuses on specific molecular pathways (e.g., trastuzumab for HER2-positive breast cancer).
Immunotherapy: Enhances the immune response to cancer cells (e.g., checkpoint inhibitors like pembrolizumab).
2. Local Treatments:
Surgery: For resectable metastases (e.g., liver metastases in colorectal cancer).
Radiotherapy: To control symptoms like pain or prevent complications (e.g., spinal cord compression).
3. Supportive and Palliative Care:
Symptom Management: Pain relief, antiemetics, bisphosphonates for bone metastases.
Psychological Support: Counselling and therapy for patients and families.
End-of-Life Care: Ensuring comfort and dignity in advanced stages.
Prognosis of Metastatic Disease
Heavily dependent on:
Type and aggressiveness of the primary tumour.
Extent of metastatic spread.
Patient’s overall health and response to treatment.
Median Survival for Metastatic Disease
Varies widely; for example:
Brain metastases: ~6-12 months with treatment.
Bone metastases: Prognosis depends on cancer type (e.g., prostate cancer metastases can be indolent).
What is an Acoustic Neuroma?
(Vestibular Schwannoma):
A benign, slow-growing tumour arising from the Schwann cells of the vestibulocochlear nerve (cranial nerve VIII).
Epidemiology of Acoustic Neuroma
Typically occurs in adults aged 40-60 years.
Accounts for 8% of all intracranial tumours and 90% of cerebellopontine angle tumours
Neurofibromatosis Type 2 (NF2) is associated with ___
bilateral acoustic neuromas.
Acoustic Neuroma originates from ___
the vestibular division of cranial nerve VIII
What does an Acoustic Neuroma compress?
Compresses adjacent structures:
Cochlear nerve: Hearing impairment.
Facial nerve: Facial weakness or paresthesia.
Trigeminal nerve: Sensory loss in the face.
Brainstem and cerebellum: Ataxia and other neurological symptoms in advanced cases.
Early symptoms of Acoustic Neuroma
Unilateral hearing loss: The most common presenting feature, typically sensorineural.
Tinnitus: Persistent ringing in one ear.
Vertigo or imbalance.
Later symptoms of Acoustic Neuroma
from nerve/brainstem compression):
Facial numbness or weakness (trigeminal or facial nerve involvement).
Ataxia: Due to cerebellar involvement.
Headaches and papilledema: From raised intracranial pressure in large tumours.
Bilateral tumours are indicative of ___
NF2.
Dx for Acoustic Neuroma
Audiometry:
Shows sensorineural hearing loss.
2. Imaging:
MRI with contrast: Gold standard for detecting tumours in the cerebellopontine angle.
CT scan: May be used if MRI is unavailable.
3. Vestibular Testing:
May show impaired vestibular function.
4. Genetic Testing:
For NF2 if bilateral tumours or family history are present.
Differential Dx for Acoustic Neuroma
Ménière’s disease.
Presbycusis (age-related hearing loss).
Chronic otitis media.
Brainstem tumours.
Multiple sclerosis (if presenting with vertigo or sensory symptoms).
Conservative managment for Acoustic Neuroma
Observation and serial MRIs: For small, asymptomatic tumours or elderly patients.
Surgical resection of Acoustic Neuroma
Recommended for large tumours or significant symptoms.
Risks include damage to the facial nerve, resulting in permanent weakness.
Stereotactic Radiosurgery for Acoustic Neuroma
(e.g., Gamma Knife):
Used for small to medium-sized tumours.
Aims to halt growth while preserving function.
Complications of Acoustic Neuroma
Facial nerve damage:
Can occur during surgery, leading to weakness or paralysis.
Hearing loss:
Permanent hearing loss may result from tumour or treatment.
Hydrocephalus:
From compression of the brainstem or blockage of cerebrospinal fluid flow.
Cerebellar dysfunction:
Imbalance and ataxia.
Prognosis for Acoustic Neuroma
Excellent prognosis with early detection and treatment.
Growth rate is usually slow, allowing for careful monitoring in many cases.
