CNS neoplasms Flashcards
Risk factors for CNS neoplasms?
3
- Genetic mutation
- Neurofibromatosis
- Exposure to high dose ionizing radiation (radiation therapy, atomic bomb survivors, CT scans etc)
Studies show slight increase in incidence of brain tumors in the following groups
3
- White collar professionals
- –Laboratory researchers, healthcare professionals - Electrical workers
- Prior head trauma
Classification of CNS neoplasms
are based on what?
Describe Grade I-IV?
- Based on cellular origin and histologic appearance
Grade I-IV
Grade I: benign
Grade II: malignant
Grade III: malignant tissue that has cells that are actively growing
Grade IV: malignant tissue has cells that look most abnormal and tend to grow quickly
Tumor Classification
3
- Neuroglial (Glioma)
- Meningioma
- Schwannoma
What are the three types of Neuroglial subtypes of neoplasms?
Subtype of schwannoma?
- Astrocytoma
- Oligodendroglioma
- Ependymoma
- Acoustic neuroma
- Glial tissue is what?
- Derived from? 3
- These are what percent of all malignant brain tumors?
- the supportive tissue of the brain
- Derived from astrocytes, oligodendrocytes or ependymal cells
- Encompasses 80% of all malignant brain tumors
Astrocytic tumors
1. what are the two subtypes?
- Glioblastomas
2. Astrocytomas
What are the 4 stages of tumors that arise from the astrocyte?
Give the grades and describe each
- Grade I - is benign (excision is curative) almost always diagnosed in childhood
- Grade II – slow growing and invade surrounding tissue
- Grade III – Rare and require aggressive treatment due to tentacle like growth are hard to resect
- Grade IV – also called Glioblastoma. Aggressive fast growing cancer
Grade IV astrocytoma AKA Glioblastoma
- generally located where?
- benign or malignant?
- Why are they very difficult to remove?
- Survival range?
- Treatment? 3
- Generally located within the cerebral hemispheres of the brain
- Usually highly malignant
- Most common malignant brain tumor
- Very difficult to remove due to finger like tentacles
- Survival average is about 2 years
- Treatment:
- surgery
- radiation
- chemotherapy
Glioblastomas
- Can be what grades?
- are most common where? 2
- Can have areas of what?
- Growth rate and progression?
- What are the little holes on the MRI?
- Can be grade II-III
- Most common in the frontal or temporal lobes
- Can have areas of hemorrhage
- Generally slow growing and present for years before diagnosis
- necrosis
Oligodendroglioma
- Whats the most common presenting symptom?
- Frontal lobe tumors may cause what? 4
- Treatment? 3
- Most common presenting symptom is seizure
- Weakness on one side of the body
- Personality changes
- Behavior changes
- Difficulty with short term memory
- Treatment
- Surgery
- Radiation
- chemotherapy
- Prognosis of oligodendroglioma?
2. Median time of survival?
- Better prognosis than compared to astrocytic tumors
2. From time of diagnosis the median time of survival is 4-10 years
Ependymoma
- Where are ependymal cells found? 2
- More common in what population?
- Describe the age distribution?
- Ependymal cells line the ventricles of the brain and the center of the spinal cord
- More common in children
- Bimodal distribution peaks at age 5-6 and 20-30 years
Compare and contrast Intracranial Ependymoma (3 fetaures) and Spinal cord ependymona (4 features)?
Intracranial
- Most common in kids
- Poor prognosis
- Symptoms are from increased ICP
Spinal cord
- Most common in adults
- Better prognosis
- May cause cord compression symptoms
- Most common spinal cord tumor
What symptoms are from ICP?
7
- Hydrocephalus
- Headache
- Nausea, vomiting
- Ataxia
- Strabismus
- Irritability
- Altered mental status
What are the most common primary brain tumor?
Meningioma
Meningioma neoplasms are derived from what?
Derived from the meningothelial cells that arise from the coverings of the brain and spinal cord
Meningioma
- often benign or malignant?
- Describe their growth pattern? 2
- Treatment?
- Often benign
- Usually grow inward putting pressure on the brain and spinal cord
- Can grow outward and cause thickening of the skull
- Treatment:
- surgery
- radiation
Meningioma prognosis
- 5 year survival rate?
- Treatment? 2
- Estimated 5 year survival rate is 73-94%
Difficult to estimate due to many people found to have meningiomas die from other causes - Treatment:
- Surgery
- radiation
Meningioma symptoms for the following pathophysiology?
- Irritation? 1
- Compression? 5
- Sterotypic? 6
- Vascular? 1
- Misc? 2
- Irritation:
- seizures - Compression:
- HA;
- focal weakness;
- dysphagia;
- apathy;
- somnolence - Stereotypic:
- CN deficits;
- change in mentation;
- visual changes;
- anosmia,
- exopthalmos;
- tongue atrophy - Vascular:
- compression of cerebral arteries - Misc:
- hydrocephalus;
- panhypopituitarism
Tumors of the cranial and paraspinal nerves
4
- Schwannoma
- Neurofibroma
- Perineurioma
- Malignant peripheral nerve sheath tumor
- What are schwannomas?
- Describe their growth?
- Benign or malignant?
- Where do the tumor cells always stay?
- Nerve sheath tumor composed of Schwann cells
- Relatively slow growing
- Mostly benign and less than 1% become malignant
- The tumor cells always stay on the outside of the nerve
So what is damaging about schwannomas because they dont go inside the nerve?
tumor itself may either push the nerve aside and/or up against a bony structure thereby possibly causing damage
What is the most common schwannoma?
Acoustic neuromas are the most common schwannoma
Acoustic neuroma
- Arises from where?
- Benign or malignant?
- Describe its growth?
- How can they cause serious complications?
- What are other locations that this could be affecting?
- Arises from the eighth cranial nerve
- Benign
- Usually slow growing
- Can cause serious complications and even death if they grow and exert pressure on nerves and eventually on the brain
- Other locations include the spine and, more rarely, along nerves that go to the limbs.
Acoustic neuroma symptoms
7
- Unilateral hearing loss
- Tinnitus
- Occasional dizziness
- Difficulty swallowing
- Impaired eye movement
- Taste disturbance
- Unsteadiness
Treatment of acoustic neuromas?
3
- Surgical excision
- Stereotactic radiation surgery to arrest growth
- In some cases they are followed by observation for growth
acoustic neuromas: When would we observe the tumor without treatment?
5
- Small tumor size,
- not significantly symptomatic, 3. elderly,
- poor surgical candidates or if the
- patient declines other treatment
Primary CNS lymphoma
- Typically occurs in pts with what?
- Derived from where?
- Most often occurs where?
- What structures may it involve? 3
- Typically occurs in patients with immunodeficiency syndromes
- –Organ transplant, HIV, autoimmune disease - Derived from the B lymphocytes
- Most often occurs in the cerebral hemispheres
- May involve the
- eyes,
- CSF or
- spinal cord
Treatment of CNS lymphoma
2
What do we usually not do in these patients?
- Steroids to decrease brain edema
- –May cause tumor regression - Chemotherapy and/or radiation
Usually inoperable due to location deep in the brain
- Why can’t you give steriods before the diagnosis of CNS lymphoma?
- What is the most common brain tumor?
- because the steriods will degreade and change the tumor enough so that you will get an incorrect diagnosis
- metastatic tumors
Metastatic tumors
1. What are the most common cancers to metastasize to the brain?
5
- Lung 16-20%
- Renal cell cancer 7-10%
- Malignant melanoma 7%
- Breast 5%
- Colon 1-2%
Treatment of metastatic tumors?
radiation or chemotherapy
Clinical presentation is variable depending on what?
2
In general symptoms start with 3.____________ and move to more generalized symptoms as the 4.__________?
- tumor size
- origin
- focal neurologic signs
- tumor size increases
What are the generalized symptoms of brain tumors? 5
What are the focal symptoms of brain tumors? 5
- Headaches
- Seizures
- N/V
- Depressed level of consciousness
- Neurocohnitive dysfunction
- Seizures
- Weakness
- Sensory loss
- Ahpasia
- Visual spatial dysfunction
Symptoms of brain tumors
7
- Headache
- Seizures
3 Syncope - Nausea and vomiting
5.Numbness, tingling, weakness - Balance issues
- Cognitive dysfunction
Congnitive dysfunction caused by brain tumors?
5
- Personality changes
- Changes in memory, attention
- Altered language ability
- Problems with executive functioning
- Change in daily patterns of eating and sleeping
Describe tumor headaches
8
(which one is a big indicator)
- Dull, constant
- Usually bilateral and not throbbing
- Occipital or frontal lobes
- Increased with coughing or straining
- Worse with change in body position or after lying down to rest
- Tend to be worse at night and may awaken the patient from sleep**
- Nausea and vomiting
- Change in pattern from usual headache
48% of patients with brain tumors have headaches
According to American Family Physician
“Any patient with chronic, persistent headache in association with what 5 things should be evaluated for a brain tumor”?
- protracted nausea, vomiting,
- seizures,
- change in headache pattern,
- neurologic symptoms, or
- positional worsening
Seizures are the most common symtpoms of what tumors?
2
- gliomas
2. cerebral metastases
Medical management of symptoms:
- Headaches/Brain edema?
- Seizures?
- Headache/Brain edema
- -Steroids
* **Decadron - Seizures
Anti-seizure medications
- What is a tumor hemorrhage?
- They can bleed a lot when given what?
- In patients with WHAT? always be on the lookout for signs and symptoms of cerebral metastasis or hemorrhage.
- Brain tumors bleed
- They can bleed a lot when given anticoagulation
- -They are a contraindication to thrombolytics - known cancer (example lung or renal cell)
Primary care work up for brain tumors
- History
- PE includes?
- Imaging? 1
- Physical exam to include
- complete neurologic evaluation
- Include complete visual exam - Imaging
- MRI with gadolinium
- CT is not as detailed and difficult to see posterior fossa structures
Complete neurologic exam to include what?
3
- stereognosis,
- graphesthesia and
- testing of CN I
If you are going to do a CT scan looking for brain tumors what must you do?
give contrast!
Neurosurgical workup: Whats involved?
3
- +/- Lumbar puncture to examine cells in certain cases
- +/- cerebral angiogram
- Biopsy
Treatment?
3
Surgical resection
Chemotherapy
Radiation
Primary brain tumors stay where?
Primary brain tumors stay within the CNS
