Case 2: 2mo, 6mo, 9mo WCC, Neuroblastoma Flashcards
appropriate growth patterns in infants up to 9mo of age using standard growth charts
“1) right after birth - 10% weight los
2) within 1-2w - regain birth weight”
“nutritional requirements for infants at ages 1-2mo
caloric requirements?
Dietary recommendations”
“1) term –> 100-120cal/kg/d. 20-30g daily weight gain
2) preterm –> 115-130 cal/kg/d
3) very low birth weight (VLBW) –> 150cal/kg/d
VitD - 400U / d (or 32oz of formula or milk /d
- supplement for exclusive/mostly breastfed”
“nutritional requirements for infants at age: 9mo
caloric requirements?”
“100cal/kg/d –> 75% from breast mild / formula (24oz/d)
- very small chunks of food (if have teeth)
- self-feed finger foods (toast, crackers, pasta, banana)
- meats
NEVER - popcorn, grapes, hard candies, hot dogs –> d/t risk of choking (b/c infant often swallow w/out chewing)”
“diffdx: abdominal mass in RUQ + pallor in 9mo (with no jaundice, splenomegaly, or lymphadenopathy). otherwise healthy
-plan for evaluation”
1 - Neuroblastoma (peak <2y)–> most common neoplasm in infants; usually with fever, pallor, NO JAUNDICE, wt loss/ retarded growth, lymphadenopathy, painless mass in neck / chest, abd +/- mets to bone marrow
- Hepatic neoplasm –> +/- jaundice; rare in so young
- Hydronephrosis –> usually @ this age; +/- UTI
(1) obstruction at uretero-pelvic junction = hydronephrosis; palpable kidney / flank mass
(2) multicystic kidney
- smooth, rarely cross midline
- 50% abd pain, vomiting, +/- HTN
- Teratoma –> rare malignant tumor; can cause mass effect / compressive sxs in surrounding areas –> abd / back pain; N/V, constipation, UTI
difference between expected developmental milestones (surveillance) and standardized tools
“Developmental surveillance = checking milestones in 4 domains: gross motor, fine motor; communication / social, cognitive/adaptive
==> helps to determine areas of concern - “mental snapshot”
validated developmental screening test (more sensitive/specific v. developmental surveillance) = pick up true developmental / behavioral abnormalities –> done at 9, 18, 24mo”
WCC: maternal / infant factors
“Maternal factors
- complications / infections during pregnancy; meds; drugs / EtOH
- concerns about prenatal labs: HIV, RPR, Hep B, Group B strep
Infant
- delivery date (wrt due date)
- birth weight
- perinatal course (complications in nursery; received newborn meds / vaccines); jaundice; when discharged
- hearing test”
WCC: social hx and diet
“Social hx
- who lives at home; ? Daycare
- IT HELLPS
Income
Transportation
Housing Education Legal Status/immigration Literacy Personal Safety
Diet
- ? Breast / bottle feeding (how formulated)
- how many diapers does she change.”
“what special physical exam tests do you do for a:
2mo”
2mo –> fontanelles; red reflex; ortolani, barlow, moro & babinski reflexes; rashes; back: sacral dimple / hair tuft
immunizations for 2mo
"DTaP (A) Hib (D) IPV (E) PCV13 (F) RotaV (G) and HepB #2 (C) --> +/- 1st HepB if not given in nursery prior to discharge"
immunizations for 6mo
"DTaP #3 Hib #3 HepB #3 RotaV #3 PCV13 #3 \+/- IPV #3"
Does the IPV #3 need to be given in the 6mo visit?
“No
Can give between 6-18mo to reduce # of shots in 6mo visit”
Imaging & pathology of a neuroblatoma
“Abd U/S - retroperitoneal mass arising from the adrenal gland that does not cross the midline. Tumor has heterogeneous consistency with both solid & cystic elemenents (== hemorrhage / necrotic tumor)
AXR - large mass in R/L UQ
Abd CT - same as U/S + diffuse stippled calcification with invasion of renal parenchyma. +/- LN enlargement
Bone marrow aspiration / biopsy - ““small round blue cells”” or small, uniform cells containing dense, hyperchromatic nuclei and scant cytoplasm, forming small cell rosettes”
Neuroblastoma genetics
- assoc.with MYC-N gene
FAMILIAL (1%) - AD, low penetrance
NON-FAMILIAL- somatic mutations
Neuroblastoma labs / studies
1) CBC - Anemia / other cytopenia (2/2 bone marrow infiltration)”
2) Elevated urinary HVA/VMA
IMAGING
1) Abd US –> identification of mass, organ of origin, determine if mass is solid / cystic / combined
2) AXR - identify presence of mass, ?
calcifications, ? bowel obstruction from mass
3) CXR - assessment for mets to lung
4) Skeletal survey - mets to bone
5) Abd CT - reveals calcifications; surrounding anatomy for surgery; consistence of tumor (homo/heterogeneous); evaluate lungs
6) MRI if near spine
7) bone scan
8) BM aspirates
Neuroblastoma metastases and imaging
CXR
regional LN liver bone marrrow skeleton posterior mediastinum
diffdx infant rashes
“Benign; resolve over time:
- neonatal acne = papules & pustules over the face; d/t hormonal stimulation of sebaceous glands
- seborrheic dermatitis = ““cradle cap””; yellowish, oily scales over the scalp”
parental evaluation of developmental status
“Child between 0-8yo –> to help identify children who may have developmental delay
- parental concerns (10 q on perspective on child for each developmental domain)
- direct toward one of 5 decisions: refer, screen further, watch carefully, counsel parents, reassurence”
“nutritional requirements for infants at age: 4mo
caloric requirements?”
Start on solid foods - rice cereal with a spoon
car seat recommendations: <2yo,
rear-facing car seat; restained in rear seat
car seat recommendations: 2-4yo,
forward-facing car seat; restained in rear seat
car seat recommendations: 4-8yo,
belt-positioning booster seat, restained in rear seat
car seat recommendations: >8yo
nml; restarined in rear seat
car seat recommendations: >13yo
nml; restarined in rear/front seat
Imaging and pathology of a Wilm’s tumor
- U/S renal vein - intrarenal mass
- CT chest and abd - heteroeneous with areas of low density (== necrosis). Pseudocapsule (== d/t sharp demarcation b/w tumor and normal renal parenchyma) = “claw sign” as tumor grows
- pathology == tubules (as though it’s trying to grow into a kidney itself)
Wilm’s tumor labs
Hematuria
Wilm’s tumor metastases
“Imaging: CXR, CT chest (areas of lung below level of diaphragm dome)
- Pulmonary”
Imaging & pathology of a hepatic tumor
“AXR - hepatic enlargement + hepatic tuomors
CT scan - hepatic tumor”
hepatic tumor labs
”.- nml LFTs (in 20%, elevated LFTs, bilirubin)
- increased AFP”
hepatic tumor metastases
“chest CT
- pulmonary”
Imaging & pathology of a teratoma
“CT - identification of teratomas / germ cell tumors. Well-defined mass with both solid & ystic components
X-ray - ONLY if have calcified components (teeth, bony fragments)”
what is the best imaging modality for identifying teratomas & germ-cell tumors?
CT - Well-defined mass with both solid & ystic components
Imaging & pathology of a benign renal mass
“U/S - hydronephrosis
voiding cystourethrogram - for ureteral obstruction; vesicoureteral reflux”
“staging of neuroblastoma
Stage 1, 2A, 2B, 3, 4, 4s
- identify and define treatment and prognosis”
“Stage 1 - tumor localized to area of origin
- tx = surgical resection (chemotherapy if recurrence)
- 90% disease free survival
Stage 2A - extends beyond area of origin; does not cross midline
- tx = surgical resection + low dose chemotherapy if recurrence (radiation for failure to respond)
- 85% disease free 2y survival
Stage 2B - extends beyond area of origin; does not cross midline + ipsilateral LN
- tx:
== [INFANT] surgical resection + low dose chemotherapy if recurrence (radiation for failure to respond)
- 85% disease free 2y survival
== [CHILD] chemo and/or radiation
- 60-70% survival
Stage 3 - extends beyond midline / regional LN involvement
- tx & survival same as 2B
Stage 4 - disseminated to distant LN, bone, bone marrow, liver or other origins (lungs) - tx: == [INFANT] chemo and/or radiation - 60-70% survival == [CHILD] chemo + radiation + BMT - <15% survival
Stage 4S - localized primary tumor + dissemination limited to liver, skin, or bone marrow
- tx:
== [INFANT <6w (-) skin involvement] - 38% survival
== [INFANT > 6w] = observation; chemo / local radiation for enlarging abd mass causing respiratory compromise
- 86% survival”
favorable prognostic factors for neuroblastoma
”.- non-amplification fo n-myc oncogene
- DNA index > 1
- well-differentiated histology (Shimada classification)
- age < 1y”
Components of WCC
“1) interval hx (any illnesses, problems; detailed birth hx for first visit)
2) development - PEDS / ASQ”
developmental screening - when is it mandated to be done by AAP
9mo, 18mo, 30mo
when is specific autism screening recommended
18mo, 2y
infant sleeping recommendations
“sleep through the night by 4-6mo
Sleep in supine (on back)”
Safety concerns for a baby
“NO SMOKING around the baby
NO small objects / plastic bags
NO hot liquids aroud baby
NO leaving baby alone on high places”
car safety: at what age can a child sit in the front seat
“>13yo
the back seat is the safest place in a vehicle for children”
for how long should a child sit in car seat rear-facing
2y
where in a car is the most protected part of a vehicle?
middle fo the back
what is the most effective car seat restraint?
5-point harness = 2 shoulder straps, a lab belt, and crotch strap
“how many doses are in a DTaP?
When are they given?”
5
“how many doses are in a IPV
When are they given?
“
4
“how many doses are in a Hib
When are they given?
“
3 or 4
“how many doses are in a PCV13
When are they given?
“
4
“how many doses are in a Varicella
When are they given?
“
2
“how many doses are in a Rotavirus
When are they given?
“
2 or 3
“how many doses are in a HepA
When are they given?
“
2
“how many doses are in a HepB
When are they given?
“
3
“how many doses are in a MMR
When are they given?
“
2
STRONG recommendation for flu vaccine for ages?
And who else?
age 6-59mo (6mo-5yo)
household contacts & out-of-home caregivers of those children
anticipatory guidance: 2mo
1) solid foods - rice cereal
2) vitD - 400U/d (supplementation or 32oz), if exclusively breastfed
3) sleep - will sleep through the night by 4-6mo
4) safety - NO smoking around, NO small objects, NO hot liquids, NO leaving infant alone in high places
5) Car seat - rearward, in rear seat
Vaccine adverse events?
what are the severe ones that should be immediately evaluated?
- 24h: fussiness, fever
- for a few weeks: “knots” in the skin at the injection site
severe adverse rxns
- seizures
- inconsolability
“By what ages should an infant double and triple his or her birth weight?
Double his/her birth length
for which patients would this not be the case?”
“DOUBLE weight by 4-5mo
TRIPLE weight by 1yo
DOUBLE length by 4y
NOT applicable to former preemies, SGA, chronic health issues”
define: red reflex
when is it a “normal variant”?
red reflex (can be seen from birth)= red/orange color reflected from fundus thru pupil when viewed thru ophthalmoscope ~10cm away --> direct info about clarity of eye structures (most useful in children ~6mo)
NORMAL VARIANT = symmetric, no leukocoria (white spots)
- Caucasian = bright red
- darker = more skin pigmentation (darker red)
diffdx of “abnormal” red reflex
ABNORMAL - absent red reflex
- cataracts
- glaucoma
- retinoblastoma
- chorioretinitis
when to refer to a pediatric ophthalologist
significant need for fundoscopy
- evaluation of shaken baby
- suspected retinal tear = retinopathy of prematurity @ advanced stage
anticipatory guidance: 6mo
1) dietary - new foods may be added q5-7d
2) walking - NO walkers. Toddler-proof the home (install outlet covers, cabinet locks, stair barriers, stored away cleaning supplies / meds). Poison control # nearby
3) sleep - 2naps/d; sleep through the night
4) safety - NO smoking around, NO small objects, NO hot liquids, NO leaving infant alone in high places
5) Car seat - rearward, in rear seat (<2yo)
for what reason is it that acetaminophen given at the same time as vaccines is a concern?
acetaminophen can cause a lower Ab response to some immunizations (decreased inflammation).
only given if absolutely necessary
For an suspected abdominal mass (ex. neuroblastoma), what is the first best test?
Abdominal ultrasound
For an suspected abdominal mass (ex. neuroblastoma), would an abdominal xray be a good first test?
NO - can only identify the mass and see if there are calcifications. no other info.
abdominal US
An abdominal mass is evaluated on abdominal US and found to be purely cystic. is this a good thing?
YES! less likely to be malignant
For an suspected abdominal mass (ex. neuroblastoma), why is a CT better than abdominal US in some ways? if this is the case, why don’t we do an abd CT first?
CT –> reveals calcifications; surrounding anatomy for surgery; consistence of tumor (homo/heterogeneous); evaluate lungs
If a lesion is purely cystic, a CT scan is not needed (b/c very unlikely to be malignant). Do US first to see if solid, cystic, combined.
what are the components of a good WCC?
1) interval hx
2) development
3) growth
4) diet hx
5) social hx
6) physical exam
7) anticipatory guidance
8) immunizations and labwork
You are seeing a 36-month-old boy for his well-child visit. His parents are anxious about ensuring that his development is appropriate. He passed a hearing screen at birth and, other than a few colds, has been generally healthy. He has never been hospitalized or had any serious illness. He is able to run well, walk up stairs, and walk slowly down stairs. He uses more words than the parents are able to count, but can use them only in short, two or three-word sentences. His speech is understandable. He can draw a circle, but not a cross. Neurologic examination shows normal cranial nerves, normal sensitivity, normal motor reflexes, and no Babinski sign. Which of the following is the most appropriate next step in the management of this patient?
A Perform a brain-stem auditory evoked potential hearing screen
B Perform a screening exam for autism
C Reassure the parents that the boy’s development appears normal
D Refer the child to a developmental specialist for comprehensive evaluation
E Refer the child to a specialist for evaluation of his delayed motor development
C
A brain-stem auditory evoked potential hearing test (BAER) –> language milestones
Autism –> lack of symbolic play, repetitive movements, or poor sociability
Sammy is a healthy male child brought into your office by his mother for a well-child examination. As part of your evaluation you assess his developmental milestones. He is able to run, make a tower of 2 cubes, has 6 words in his vocabulary, and can remove his own garments. What would you estimate Sammy’s age to be based upon his developmental milestones?
A 12 months B 15 months C 18 months D 30 months E 36 months
C. walk backward, and 50–90% of children can run at this stage. Scribble, build a tower of 2 cubes, have 3-6 words in her or his vocabulary, and be able to help in the house and remove garments
“Rapunzel” - can run, throw things, stack a tower
15 months –> stoop and recover and walk well, put a block in a cup, have a vocabulary of a few words, wave bye-bye, and drink from a cup. Running, building towers of blocks, removing clothing, and a 6-word vocabulary are more advanced skills than a 15-month-old would be expected to have.
Mark is a 5-month-old male who is brought to the urgent care clinic with a three-day history of rhinorrhea and non-productive cough. When he was born he was large for gestational age, and his exam then was notable for macrocephaly, macroglossia, and hypospadias. On physical exam now his vitals signs are stable. He has copious nasal discharge, but his lungs are clear to auscultation. On abdominal exam, you palpate an abdominal mass on the right side just below the subcostal margin. It is 7 cm in diameter and does not cross the midline. The abdomen is soft and non-tender with active bowel sounds. What is the most likely cause of his mass?
A Wilms’ tumor
B Teratoma
C Renal cell carcinoma
D Hepatoblastoma
LGA
Wilms’ tumor is commonly associated with Beckwith-Wiedemann syndrome, a genetic overgrowth syndrome. Other features that may be seen in children with this syndrome include omphalocele, hemihypertrophy, hypoglycemia, large for gestational age, and other dysmorphic features.
RCC more common in adulthood
While children with Beckwith-Wiedemann syndrome can have hepatoblastoma (in addition to other types of tumors), this is not the most common tumor in this genetic condition. Note that hepatoblastoma may also be associated with familial adenomatous polyposis.
An asymptomatic, healthy 9-month-old female is found to have a palpable RUQ mass on exam. After further imaging and lab studies, the mass is diagnosed as a neuroblastoma that has involvement in the bone marrow as well. The mother is worried about the prognosis. Which of the following is true about the prognosis of neuroblastoma in this child?
A Lymph node involvement is a poor prognostic factor
B Prognosis of neuroblastoma is predictable
C Children who are older than 12 months have a better prognosis than younger children
D Favorable histology does not play a role in prognosis
E Non-amplification of the n-myc gene is a favorable prognostic factor.
E.
Even stage 4s is favorable b/c it can resolve in babies.
younger children have better prognoses
BROAD spectrum of clinical courses
Favorable
- young age (esp. <1yo)
- well differentiated tumor
A 9-month old baby boy comes to the clinic for a well child visit. The child is at the 50th percentile for weight, length, and head circumference. He is reaching all developmental milestones appropriately. The mother has no concerns at this visit. The child has previously received the following vaccines: 3 doses of DTaP, 3 doses of Hib, 2 doses of HepB, 3 doses of RotaV, 2 doses of IPV and 3 doses of PCV13, and no influenza vaccines. Which vaccines should the child receive at today’s visit?
A Influenza, Hep B, IPV, DTaP B Influenza, IPV C Influenza, Hep B, IPV D Hep B, DTaP, IPV E Hep B, IPV, and MMR
C
Yearly flu shot >6mo
All DTaP have been given
Still needs 3rd
HepB shot
MMR is > 12mo
A 10-month-old asymptomatic infant presents with a RUQ mass. Work-up reveals a normocytic anemia, elevated urinary HVA/VMA, and a large heterogeneous mass with scant calcifications on CT. A bone marrow biopsy is performed. Which of the following histologic findings on bone marrow biopsy is most consistent with your suspected diagnosis?
Multiple Choice Answer:
A Sheets of lymphocytes with interspersed macrophages
B Small round blue cells with dense nuclei forming small rosettes
C Hypersegmented neutrophils
D Stacks of RBCs
E Enlarged cells with intranuclear inclusion bodies
B
Neuroblastoma
In addition to neuroblastoma, other tumors associated with small blue cells include Ewing’s sarcoma and medulloblastoma, both of which tumors are seen in children.
Diffdx for childhood RUQ mass, where bone marrow biopsy shows Small round blue cells with dense nuclei forming small rosettes
Neuroblastoma
Ewing’s sarcoma
Medulloblastoma
All tumors from children
Vaccine-preventable diseases
- Pneumococcus
- Measles
- Mumps
- Rubella
- Diphtheria
- Tetanus
- Pertussis
- Haemophillus influenza B
- Polio
- Cervical cancer (HPV)
- Hep A and B
- Rotavirus
List of live vacicnes
==> depends on replication of live agent ==> borad immune response
- requiring 1-2 doses for complete / long-term immunity
= herd immunity and shed it.
- Oral polio virus vaccine (OPV)
- Rotavirus vaccine (PRV, HRV)
- Measles, mumps, rubella vaccine (MMR)
- Varicella-zoster virus vaccines (VZV,ZV)
- Live, attenuated influenza vaccine (LAIV)
- Yellow fever vaccine (YFV): for travel
- Typhoid fever vaccine (Ty21a strain): for travel
List of inactivated vaccines
==> immune response: serum Ab production
- require 2-3+ doses for full protection (+/- preservatives, adjuvants)
CANNOT REPLICATE CAUSE DISEASE
- Diphtheria Tetanus Pertussis (DTP)
- Inactivated poliovirus vaccine (IPV, Salk)
- Influenza vaccine (TIV)
- Hepatitis B vaccine (HBV)
- Hemophilus influenza, type B conjugate vaccine
- Pneumococcal conjugate (PCV7)
- Meningococcal conjugate (MCV4)
- Human Papillomavirus vaccine (HPV)
- Typhoid vaccine (Vi polysaccharide)
contraindications to ALL vaccines
- anaphylaxis
- encephalopathy
- pregnancy (for live vaccines)
- immunosuppression = disease, chemo,
steroids (for live vaccines
contraindications to live vaccine
- pregnancy (for live vaccines)
- immunosuppression = disease, chemo,
steroids (for live vaccines
If a child comes in with a runny nose but no fever, should we still give her her shots?
NO
b/c it’s mild
What are some commonly thought (but INCORRECT) contraindications to vaccines
-Mild illness Antimicrobial -therapy -Disease exposure or convalescence -Pregnant or immunosuppressed person in household -Breastfeeding -Preterm birth -Allergy to products not present in vaccine or allergy that is not anaphylactic -Family history of adverse events -Tuberculin skin test -Multiple vaccines
define: thimerosal
used in multi-dose vials of flu vaccine
Mumps
Sxs = orchitis, parotiditis + fever, HA, sore throat
VIRAL
tx = symptomatic pain mgmt
tetanus
Cause: Clostridium tetani (soil)
Sx: mild jaw spasms (lockjaw) –> back spasms, fever, tetany (–> torn muscles & broken jws)
Tx: penicillin, clinda, metronidazole (most effective), tetanus Ig, surgical debridement.
Prognosis: 25% mortality without tx. With tx, <10% mortality.
how much time apart do you have to space the live vaccines
6w
b/c they will cancel each other out via antibody response (TNF a & b)
If a child comes in with a fever, should we still give her her shots?
NO
b/c the immune system will kill the vaccine
under what age do we NOT give live vaccines (except for 1)
12mo
But can give rotavirus
Pertussis
Cause: Bordatella pertussis
Sx: whooping cough, chronic cough, apnea with respiratory insufficiency
Tx: Azithromycin
Prognosis: older children =good ; infants = higher mortality rate (more complications - esp. <6mo)
first vaccine that we give newborns
Hep B (dose #1)
A six-year-old, previously healthy boy presents with a 3 by 5 cm mass on the left side of his neck
- fever to 103
- pain to palpation
- decreased PO, but drinking and eating without difficulty. no trouble breathing
What information would you like to know to develop an appropriate differential diagnosis?
what parts of physical exam?
HISTORY
- local v. regional v. generalized
- UL v. b/l
- time course (acute, crhonic, recurrent)
- exposures(infectious)
- fever
- warm, tender to touch
- immunization hx
- PMH
PHYSICAL EXAM
- look for other nidus of infection = ears, throat, neck, location
- palpation of swelling
- regional exam (pharynx, dental, parotid)
- systemic findings
if a node is tender to touch, would we think it’s bacterial v. viral?
bacterial
swelling of a node: warm, tender, fluctuant
diffdx?
staph/strep, cat scratch
swelling of a node: matted and firm
diffdx?
lymphoma, mets
swelling of a node: not warm or tender
diffdx?
mycobacterium
most common cause of supraclavicular lymphadenopathy in teen
hodgkin’s disease
in what age is lymphadenopathy AT ALL not normal/benign?
newborns
where is lymphadenopathy typical and harmless in <1yo kid?
occipital, inguinal (diaper)
where is lymphadenopathy typical and harmless in >1yo kid?
cervical
child v. adult: if have a head/neck mass, diffdx?
CHILD = lymphoma ADULT = oropharynx, neck cancer
cervical pyogenic adenitis
- presentation
- cause
- tx
- complications
children 1-4yo
- firm, tender node
- fever
- area over mass is warm, red, tender
preceding URI
–> strep/staph == NOT thru pharynx – usually secondary to viral infection, with bacteria
tx = PO Augmentin (staph/strep + anaerobic) +/- surgical I and D if insufficient Abx penetration
complications = fluctuance +/- abscess formation
catch-scratch disease
- presentation
- cause
- tx
- complications
presentation
- 3-10d after: papule / pustule at site of innoculation injury
- 10-50d after = regional lymphadenopathy == usually tracking from prior papules (arm/axilla)
- cause = cats, gardens
- dx =clinical, positive serology
- tx = azithromycin / doxycycline; usually self-resolve in 2-8mo
- complications = encephalitis, neuritis, hepatitis, mesenteric lymphadenitis
infectious diffdx of cervical lymphadenopathy
- bacterial cervical lymphadenitis
- catch scratch dz
- Mycobacterium marinum (esp ring-enhancing lesion on CT) == abrupt onset of lymphadenopathy == otherwise normal
diffdx abdominal mass in children
- non-tumor == constipation
- TUMOR = Wilm’s, neuroblastoma (in adrenal), rhabdomyosarcoma,
Wilm’s tumor treatment, prognosis
- total nephrectomy == very hypervascular, usually taken in one piece (b/c lots of inflammatory changes)
- 5-year
Rhabdomyosarcoma
- epidemiology
- location
- workup
- therapy and prognosis
peak 10yo
==> head/neck, GU (pelvic), extremities
- w/up = (1) CT primary + lungs, biopsy. (2) bone scan, BM aspiration/biopsy, CSF (if parameningeal)
- tx = complete resection if localized
- prognosis = low risk (90% survival); intermediate risk (80% risk); high risk (30% risk)
