Neurooncologi BS Flashcards
Primary brain tumors
Intraaxial/intrinsic/parenchymal
VS
Extraaxial/extrinsic
explain
Intra:
-Always malignant except hemangioblastoma
-Infiltrative
-All type of glioma, most in adult: Glioblastoma multiforme
Extra:
-Benign, capsulated
-Compresses surrounding brain
-Meningioma, neurinoma
Klasifikasi tumor otak (5)
-Neuroepithelial
-Meningioma
-Acoustic neuroma
-Pituitary adenoma
-Metastatic tumor
Tumor otak persentase tertinggi
Neuroepitelial
Tumor neuroepitelial persentase tertinggi
Glioma/astrocytoma
Most brain tumor location (which lobe)
Frontal lobe
Malignant tumors more likely in … (men/women), meanwhile non malignant tumors more likely in …
men , women
Clinical manifestations of brain tumor (2)
-Increased ICP
-Focal sign and symptoms
Glioma/astrocytoma explain:
intrinsic/extrinsic?
border?
low-high grade benign or malignant?
continuum with what tumor?
low grade characteristis?
anaplastic astrocytoma characteristics?
Glioblastoma multiforme characteristics?
May invade whole hemisphere, and it is called?
Intrinsic
no clear border
low-> benign, high-> malignant
Glioblastoma multiforme
Avascular, fibrous
Nuclear pleomorphism, mitosis
Endothelial prolif, central necrosis
Gliomatosis cerebri
Glioma/astrocytoma grading
Pilocytic astrocytoma (grade I)
1: Astrocytoma (grade II)
2: Anaplastic astrocytoma (Grade III)
3-4: Glioblastoma multiforme (Grade IV)
Astrocytoma histologic diagnosis parameters (4)
Nuclear atypia
Mitoses
Endothelial proliferation
Necrosis
Anaplastic astrocytoma:
Prone to?
Morphology?
Prone to hemorrhage
Grossly, friable, granular, gray
Glioblastoma Multiforme, key features
endothelial proliferation and necrosis
Gliomas, aims of surgery (3)
provides pathological dx
decrease ICP
cytoreductive
Gliomas, type of surgery
-lobectomy (cerebral poles)
-resection/biopsy (involves eloquent area)
-stereotactic biopsy (small, deep tumor)
High grade glioma management
high grade: 100gr with 10^11 cells
Radical excision -> RDT -> Chemotx
Glioma nomenclature
diagnosis final: histo - grade - molecular characteristics
Anaplastic astrocytoma - WHO Grade III - IDH-wild type
glioma prognosis parameter (3)
-isocitrate dehydrogenase mutation
-O-6-methylguanine-DNA methyltransferase promoter methylation
-1p19q co-deletion
Meningioma peak incidence age
45, decade 4-6
Meningioma f:m ratio and spinal meningioma f:m ratio
3:2
spinal-> 5:1
Meningioma mostly located … , where specifically ..
supratentorial, falk-parasagittal (25%)
Meningioma classification based on
site of attachment and location
Meningioma grading WHO 2000
Grade I -> benign
Grade II -> atypical
Grade III -> malignant/anaplastic
Simpson classification of extent of resection
I. Gross total resection of tumor, dural attachment, abnormal bone
II. Gross total resection of tumor, coagulation of dural attachments
III. Gross total resection of tumor, w/o resection/coagulation of dural attachments or extradural extension
IV. Partial
V. Biopsy (simple decompression)
Meningioma angiography purpose: (3)
-see tumor blood supply
-see intra tumoral vascular network
-see shift/encasement of intracranial large vessel
meningioma blood supply
Falcine/convexity tumor?
Frontobasal tumor?
Ventricular tumor?
MMA
Ethmoidal artery
Choroidal artery
Management of meningioma, best choice
total removal tumor, dural attachment, involved bone
base of brain, dural removal is not possible
Meningioma goals of surgery (3)
-total removal tumor, dural, bone
-relieving neurological symptoms
-avoid CSF leakage after surgery
Preop management?
and in perifocal edema?
Perifocal edema-> IV steroid 5-7 days prior to surgery, tapered postop
mannitol->during craniotomy before opening duramater
CSF drainage
Hb concentration brought up to >= 13g/dL
Antibiotic, broad spectrum iv, 1 hour preop
in medial sphenoid wing meningioma/clinoidal meningioma, encasement of ICA, MCA has risk of
Postop arterial spasm causing infarction
If there is mass effect and high ICP, emergency basis?
decompressive craniotomy
Meningioma surgical complication
Hematoma at tumor bed
Pneumocephalus
Infarction
Schwannoma f:m ratio
2:1
Schwannoma morphology?
grossly firm, circumscribed, encapsulated
Schwannoma classification (microscopically) (2)
Antoni type A and B
Curative therapy Schwannoma
Total resection
Schwannoma size
small?
medium?
large?
<1,5cm
1,5-2,5cm
>2,5cm
Acoustic Neuroma caused by loss of function of a gene on chromosome … which has a function of … ?
22, supresses growth of Schwann cells (neurofibromatosis type 2)
Acoustic neuroma clinical mainfestation (early 4, late +1)
-Hearing loss unilateral
-Tinnitus
-Loss of balance
-Fullness in ear
-ICP increase (hydrocephalus)
Acoustic neuroma treatment (3)
Observation:
-<2cm
-old
-minimal symptom
Radiation
-small/medium
-old
-not pressing on brainstem
Microsurgery
-large >2.5cm
-small/possible hearing
-young,healthy
Preservation of CN function during operation is called … consists of (3)
Intraoperative Monitoring (IOM)
-Direct stimulation of facial nerve (NIM Response)
-Transcranial electrical stimulation of facial motor cortex
-Auditory brainstem response (ABR) via Electrocochleagram (ECoG)
Pituitary adenoma arise from which lobe … which develops from …
Anterior lobe (adenohypophysis) , Rathke’s pouch
Pituitary adenoma benign lesion mostly found in … and mostly accompanied by … syndromens of compression of …
Sella turcica; hypersecretory syndrome; compression of optic nerve, optic chiasm, cavernous sinus, occulomotor nerve, etc
Pituitary adenoma aim of therapy
Hormonal balance and preservation of neurological function
Pituitary adenoma classification based on size
Microadenoma <10mm
Macroadenoma >10mm
macroadenoma pituitary hydrocephalus patophysiology
macroadenoma -> grow locally -> erosion and remodelling of sellar floor and posterior clinoid process -> spread superiorly compressing optic chiasm -> may obstruct 3rd ventricel
Classification of pituitary adenoma which has no hormone (2)
Null Cell, acidophil stem cell
Classification of pituitary adenoma largest percentage
Prolactin
Pituitary adenoma Clinical manifestation (mass effect)
-headache (acromegaly)
-Chiasmal syndrome (visual acuity, field)
-Hypothalamic syndrome (thirst, sleep, appetite, temperature regulation, Diabetes Insipidus)
-3rd ventricle obstruction (hydrocephalus)
Pituitary adenoma Clinical manifestation (endocrine disturbance)
PRL: amenorrhea-galactorrhea
GH: gigantism-acromegaly
ACTH: cushing disease
TSH: thyrotoxicosis
Acute panhypopituitarism -> usually after tumor apoplexy
Operative approach for pituitary (5)
- Transcranial/craniotomy
- Sublabial transseptal transsphenoidal
- Endonasal transsphenoidal (this)
- Transsphenoidal with endoscopic assisted
- Fully endoscopic transsphenoidal surgery
Endonasal transsphenoidal approach (step by step)
- Vertical incision of septal mucosa of rt.nostril, at bone-cartilage junction
- Bilateral mucosal dissecion posteriorly, starts from the anterior edge of the bony septum
- Visualization of rostrum sphenoid sinus
- Removal of the bony nasal septum
- Removal of anterior wall of the sinus
- Coagulation of the mucosa of the sinus and removal of the sellar floor
- Coagulation & incision of the sellar dura
- Removal of the Macroadenoma
