Neoplasms Flashcards
Non-localizing neoplasm sx’s
Speed
- slow (neurilemma, meningioma) - few sx’s until late - seizures
- rapid (glioblastoma, mets) - weeks -> months
- hemorrhage, infarction (outgrows), edema -> more rapid (?CVA)
Pressure, mass effect - growth, edema, hydrocephalus (obstruc)
- h/a - worse in mornings (pressure), n/v, location non-specific
- herniation falx, tentorium, lobular -> rostro-caudal, CN palsies, etc
- papilledema, lose retinal venous pulsations, widening blind spot
- infant widening sutures, no papilledema
- high BP, high or low HR
Overview of mass lesions
Often non-specific, non-localizing sx’s
Ddx:
- hemorrhage - parenchymal, extra-axial
- tumor - usu intra-axial - benign or malignant
- infectious - abcess, granuloma, hemorrhagic encephalitis
- usu systemic sx’s
- demyelinating plaque (MS)
- usu hx of resolving neuro deficits
Localizing neoplasm sx’s
Pressure, edema, ischemia (steals blood supply)
Astrocytomas - often fewer sx than size dt infiltration
Frontal - often few specific sx’s vs motor, sensory, brain stem, spinal
Seizures - aura or onset = cerebral locus
False-localizing - most dt tentorial herniation
- CN3 (compression), CN6 (stretch) - uni or bilateral
- contralateral cerebral peduncle -> ipsilateral hemiparesis
- PCA compression vs tentorium -> contralateral hemianopsia
- hydrocephalus (compress of Monroe, 3rd, 4th, aqueduct) -> diffuse cerebral (?dementia)
- personality, gait
Neoplasm epidemiology
Peds - posterior fossa, spinal
- ex medulloblastoma near cerebellum - rapidly fatal
Adult - anterior or middle fossa
- rare cerebellar hemangioma -> polycythemia (secretes epo)
- mets (see separate slide)
- astrocytomas (esp GBM) most common -> meningiomas
Predisposition -
- hereditary - neurofibromatosis, tuberous sclerosis
- radiation - ex tinea capitus
Meningioma
Dural -> dural tail on MRI, hard, calcified
- path - psammoma bodies (calcified whorls), nuclear pseudo-inclusions (clearing), cellular whorls
Slow, usually benign, often asymptomatic, seizures
Sx’s - local pressure - most frequent falx, cortical convexity
- olfactory groove -> personality and smell
- sphenoid wing -> optic, extraocular nerves
- foramen magnum -> very high cervical myelopathy
May monitor, shrink with radiation, most resectable
Women > men
Overview of gliomas
Most common intra-axial primary neoplasm
Astrocyte (including glioblastoma) > oligodendro
- can have mixed types
Invasion - few local symptoms until late, seizures
- larger than seen on imaging
- difficult to resect completely -> lots of deficits
Prognosis poor - radiation shrinks, newer chemo
- ganglioglioma very favorable - long-standing seizures, bizzare binucleate neurons
Astrocytoma
Most common glioma
Diffuse, infiltrative border
Path - endothelial proliferation, necrosis (pathogn for GBM)
- pseudopalisade around necrotic core
- intermediate filament = glial fibrillary acidic protein (GFAP)
Grade I - pilocytic - threadlike, (also on side of cyst vs mass)
- juvenile in cerebellum, pons, hypothal
Grade 2 - astrocytoma, Grade 3 - anaplastic astrocytoma
Higher grades - naked nuclei” (no cytoplasm)
Glioblastoma multiforme = grade 4 (highly anaplastic)
- rapid -> necrosis -> ring enhancement on MRI
- degeneration (p53, younger - 20-40’s) or primary (EGFR, older)
Oligodendroglioma
Type of glioma but less common than astrocytoma
Less aggressive -> seizures, calcification
- pathology = fried egg (blue yolk), delicate capillaries (chicken wire)
- small uniform nuclei
Slightly better prognosis with radiation, chemo
- deletion of 1p and/or 19q -> better prognosis
Schwannoma
aka neurolemoma (covering of nerve)
Peripheral - cranial or spinal nerves - prox or distal
- often small, temporal, well-circumscribed, seizures common
Path - spindle cell (long) + cigar nuclei, thick-walled vessels
- Verocay bodies - nuclear-free zone with membrane between
2 Schwannomas = neurofibrimatosis type 2 until proven otherwise
Ex acoustic neuroma - really from vestibular nerve
- > compresses acoustic -> gradual hearing loss
- facial -> weakness
- vertigo - but usually not dt slow growth
- generally resectable
Ependyoma
Ependymal (choroid plexus) cells
- usu aqueduct, 4th ventricle, spinal - “drop” metastases
- enhance on MRI (not ring)
- path - pseudorosette (no neuclei around vascular vs neuropil), may form cilia, basal bodies, ependymal canals
Common young
Most resectable -> adjuvant -> often recur
Primitive neuroectodermal tumors
Common children, young adult -> post fossa, cerebellum, 4th, tectum
- lots of nuclei - “small blue tumors”, little cytoplasm, NOT anaplastic
- “rosettes” - small clearings within small nuclei
- Homer-Wright if around pink fibrillar processes
- Flexner-Wintersteiner if around lumen
- chemo, radiation -> not completely curable -> spread through CSF
Retino, pineal - “blastoma” + location
- Medulloblastoma - commn in post fossa
Primary neural - ganglion cell, bizarre binucleate
- pure gangliocytoma or mixed ganglioglioma
Spinal tumors
Radicular pain, myelopathy
Most are mets
extradural - ex multiple myeloma vs vertebra - compress roots
- epidural -> cord compression -> back pain -> rapid steroids, surgery
- suspicion if hx CA, new type, not positional/movement, awakens
intradural but extramedullary - Schwann, neurofibroma, meningioma
intramedullary - glioma, ependyoma -> can metastasize
Pituitary tumors
Usually lose regulatory functions
- posterior -> diabetes insipidus
- anterior -> hypogonad, hypoadren, hypothyr, poor growth
- hypothal - eating, placcid, rage + Horner’s, temperature
Optic chiasm compression -> bitemporal hemianopsia
- sim from craniopharyngioma - benign, cystic, from Rathke’s pouch
Can have positive secretion
- ant pit adenoma -> prolactin -> galactorrhea, amenorrhea, infertile
- eosinophilic adenoma -> growth hormone -> gigantism or acromeg
- basophilic adenoma -> hyperadren (Cushings)
Brain mass diagnostics
MRI +/- contrast is best - tumors enhance dt abnormal BBB
- CT may miss intracranial with similar density
MR spectroscopy - chemical constituents - ie tumor vs abcess
Angiography - AV malformations, aneurysms, may aid surgery planning
PET - may be useful esp if multiple, mets
Spine - MRI if progressive para or quadriparesis
LP - risk of herniation -> only if CT negative, suspect infection
- neoplasm - very high protein, may see malignant cells (1 or 2ndary)
- rare inflammatory - usu mononuclear, sometimes PMNs/meningitis
- ex chronic meningitis from metastases
CNS metastasis
Sharp edge vs primary glioma
- good news: easy to resect unless multiple
- bad news: already Grade 4
Path - cells different…
Most common - breast, lung, colon, renal,
- most likely - ovary, melanoma
- unlikely - prostate, endometrial
Lymphoma if immune suppressed (HIV) -> nerve roots, meninges
Can have primary lymph, melanoma, seminoma, teratoma
