surgery - NEURO neurological malignancy Flashcards
what is a glioma?
includes all primary brain tumours that originate from neuroepithelial glial cells (including ependymal cells, astrocytes, oligodendrocytes and astrocytes)
both adults and children affected.
which type of glioma most common in kids?
low grade glioma
main types of gliomas?
ependymomas, astrocytomas, and oligodendrogliomas.
how are gliomas classified?
Gliomas can be classified by histological cell type (as above), location* (infratentorial vs supratentorial) or grade (grade I to IV).
what is low/high grade glioma?
low grade (Grade I and II)
High grade tumours (Grade III and IV) - poorer prognosis
features of gliomas?
same as space-occupying lesion
seizures*, cranial nerve palsies or visual field defects, language dysfunction, or features of raised intracranial pressure
ix for gliomas?
CT head imaging with IV contrast
MRI
angiography
biopsy through stereotactic or open exploration
what dis?
glioma L parietal lobe
mx of low grade gliomas?
watch and wait approach through radiological surveillance
regular MRI scans
surgery = total or partial tumour debulking
radio + chemotherapy
mx of high grade gliomas?
Surgery = total or partial decompressive tumour debulking
radiotherapy and chemotherapy - temozolomide
what is meningioma?
non-glial cell growth arising from the arachnoid meningothelial cells within the meninges
benign and slow growing
who are meningitis more common in?
females
how are meningiomas classified?
RF for meningiomas?
ncreasing age, previous cranial irradiation, or certain genetic disorders (e.g. neurofibromatosis type II)
features of meningiomas?
space-occupying lesion features
seizures, cranial nerve palsies or visual field defects, language dysfunction, or features of raised intracranial pressure
ix for meningiomas
CT head imaging with IV contrast - well-circumscribed (globose) extra-axial masses, dural thickening
MRI
angiography
biopsy
what dis?
A = meningioma with surrounding oedema on CT
B = meningioma on MRI
mx of meningioma
endovascular embolisation, surgical removal, radiotherapy
chemo
classification of pituitary tumours?
Microadenoma = <1cm diameter
Macroadenoma = >1cm diameter
Giant adenomas = prolactinoma with >4cm diameter
features of pituitary tumours?
hormonal effects (hyper- or hypo-secretion) of the tumour.
headaches
visual field defects (classically a bitemporal hemianopia, as growth superiorly leads to compression of the optic chiasm)
cranial nerve palsies (through compression on the cavernous sinus (affecting cranial nerves V1, V2, III, IV, and VI).
CSF rhinorrhoea
pituitary apoplexy
what is pituitary apoplexy?
symptoms
mx
features of hyper+hyposecretion of the following hormone:
prolactin
hyper = Infertility, galactorrhoea, amenorrhoea (women) / impotence (men)
hypo = Failure of lactation (rare)
features of hyper+hyposecretion of the following hormone:
ACTH
hyper = Weight gain, fatigue, purple striae, osteoporosis, hypertension*
hypo = Fatigue, skin pigmentation, vomiting, weight loss; features of an Addisonian crisis (rare)
features of hyper+hyposecretion of the following hormone:
GH
hyper = Acromegaly in adult and gigantism in children
hypo = Fatigue, reduced strength, weight gain. Dwarfism in children.
features of hyper+hyposecretion of the following hormone:
FSH and LH
hyper = Usually asymptomatic
hypo = Amenorrhoea, infertility, loss of libido
features of hyper+hyposecretion of the following hormone:
TSH
hyper = Palpitations, anxiety, weight loss, heat intolerance, shortness of breathØ
hypo = Fatigue, constipation, weight gain, hair loss, swelling of extremitiesØ
ix of pituitary tumours?
general
high-resolution CT scan or a MRI scan
hormones
ix for prolactin
Serum prolactin >2000 mU/l is indicative of a prolactinoma
ix for GH?
Insulin-like growth factor 1 (IGF-1) as the screening test, then confirmed by failure to suppress growth hormone levels in a glucose tolerance test is diagnosti
ix for ACTH?
confirm raised cortisol levels (via 24-hour urine cortisol), then check plasma ACTH levels, then confirm pituitary source via short Synacthen test
ix for gonadotrophin?
Check LH and FSH levels
ix for TSH?
TFTs
mx for pituitary tumours?
Prolactinoma can be managed by via dopamine agonists (e.g. cabergoline), reducing both prolactin levels and the size of the tumour. Somatostatin analogues (e.g. ocreotide) and GH receptor antagonists can also be used to inhibit GH seceretion.
surgical mx for pituitary tumours
trans-sphenoidal removal of the sellar mass
Highly focal radiotherapy
post op complications for trans-sphenoidal surgery?
CSF leak + meningitis
DI
classifications of spinal tumours?
intramedullary, extramedullary, and extradural
benign or malignant.
what are extradural spinal tumours?
arising within the vertebrae themselves
Enneking staging
what are intramedullary spinal tumours?
arise from within the spinal cord itself
slow growing
high risk of iatrogenic injury
what are extra medullary spinal tumours?
arise from a range of tissues, such as nerves, blood vessels, meningeal layers, located within the space between the dura and spinal cord
PAINFUL
surgical resected
features of spinal tumours?
pain, aggravated by supine position
motor symptoms (weakness or paralysis, loss of sphincter function)
sensory symptoms (paraesthesia)
weight loss, fatigue
red flags of back pain?
Age <16 years or >55 years first episode
History of cancer
Night pain
Progressive neurology
Persistent or unrelenting symptoms
History of trauma (especially if known osteoporotic)
Known immunocompromised
RF for spinal tumours?
Neurofibromatosis type 1 and type 2 (schwannomas), Tuberous Sclerosis (astrocytomas), Von Hippel-Lindau disease (hemangioblastomas), and Li-Fraumeni syndrome (gliomas)
radiation exposure
ix for spinal tumours?
FBC, LFTs, CRP and ESR, and bone profile
xray
PET CT
spinal MRI
biopsy of primary tumour
mx of spinal tumour
surgery - decompression + excision, adjuvant chemotherapy, and adjuvant radiotherapy
steroids oral
pain management
what are oligodendrogliomas?
who do they occur in?
primary brain tumours derived from oligodendrocytes
30-50yo
where are oligodendrogliomas found in the brain?
impact on symptoms?
frontal lobes
personality changes, disinhibition, loss of social inhibitions, and executive dysfunction, reflecting frontal lobe involvement
progression of oligodendrogliomas?
6m
MRI findings in oligodendrogliomas?
mass lesion in the frontal lobe, sometimes with areas of calcification or cystic changes
what is glioblastoma multiform?
who does it affect?
highest-grade astrocytic tumour (WHO Grade IV) and is highly aggressive
> 50yo
how do glioblastoma multiform present?
rapid onset of symptoms, including motor deficits, headaches, and seizures. The rapid symptom progression over weeks rather than months is characteristic of GBM.
GBM on imaging?
a ring-enhancing lesion with central necrosis due to its aggressive nature
what signs + symptoms in trigeminal neuralgia raise suspicion of serious underlying cause?
Sensory changes
Deafness or other ear problems
History of skin or oral lesions that could spread perineurally
Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally
Optic neuritis
A family history of multiple sclerosis
Age of onset before 40 years
