Tumors of the CNS Flashcards
Primary Brain Tumors can arise from what intracranial structures
Primary Brain Tumors: coming from the brain itself (ans its strucutres) as opposed to malignancies spreading to the brain
Arising from
- meninges
- neuroepitheliail tissue
- pituitary/related strucutres (endocrine!)
- crainial nerve tumors (like the sheath: schawannoma)
- germ cell tumors
not all brain tumors are malignant!
& braintumors in general are rare
Genetic and Environmental Predispositions for increased risk of Brain Tumors
Environmental
- proven: high dose radiation exposure: radiation as a child increases the risk fo head and neck cancer!!!!
Genetic
- Li-Fraumeni Syndrome (multiple CA types inc. risk)
- Neurofibromatosis 1 72 (multiple CA types inc. risk)
- Von Hippel-Lindau disease (multiple CA types inc. risk)
- tuberous sclerosis complex
- cowden
- corlin
most common brain tumor in…
- kids
- adults
Kids
- most common = medulloblastoma
- ependymomas
- glioma of BS or optic nerve
- germinoma
- congenital tumor
- astryocytomas
Adults
- meningiomas
- schwannomas (acustic neruoma)
- CNS lymphoma (think immunocomp.)
- Gliomas
how are brain tumors classified
Brain tumors will be classified by histopathology and immunohistology
- Morphologic features: distored tissue? disrupting others? crossing to other lobes?
- growth pattern: rapid? slow?
- Molecular profile: identify the type, the response to treatment & the prognosis
what are Gliomas
- originate where
- types
Gliomas
- primary brain tumors that originate from brain parenchyma directly: glial cells are those helper cells of the brains!
Symptoms: will vary dramatically depedning on the location
Types of Gliomas
- Astrocytes (most common)
- Oligodendromas
- Glioblastoma multiforme (worst prognosis)
- Ependyoma
What are Medulloblastomas
- what are some key features/symptoms
Medullablastomas
- a primary neuroectodermal tumor
- think of these in teh posterior fossa of the brain: squishing
- obstructive hydrocephalus: because its in posterior fossa so its blocking CSF exit!!
Meningiomas
what are they
where
what do they do
Meningiomas: tumr of the meningnes
these are BENIGN tumors of the menignes: can form anywhere there is dura
- symptoms again, will depend on the tumor location
- these will Compress but will NOT invade the brain parynchyma
key: these are less likely to have seizures as a presenting symptom, more likley to have HA and sensory issues as a result
Clinical Presentation of Pts. with Brain tumors
general v focal symptoms
Presentation
General symptoms of all brain tumors = increased intracranial pressure
- HA: severe HA which is WORSE in the morning right when waking up, occasionally related to N/V
Focal Symptoms: due to tissue compression or destruction
- unilateral weakness (since its one side)
- personality changes: especailly if frontal lobe
- cognitive dysfunction: any location can produce this
as tumor increases in size, the focal symptoms progress to more general symptoms
Symptoms: Based on Location
Frontal Lobe = dementia, personality changes, seizures, expressive aphagia (cant get words out) & gait disturbances
Parietal Lobe = Receptive aphasia (word salad, cant speak), sensory loss, hemianopia, spatial disorientation
Temporal Lobe = seizures: complex partial or generalized , quadrantonpia, behavior alterations
Occpital Lobe = contralateral hemianopsia
Thalamus = Contralateral sensory loss, behavior changes, langugae disorders
Cerebellum = ataxia, dysmetria(improper coordination), nystagmus
Brainstem = CN dysfunction, ataxia, pupillary abnormalities, nystagmus, hemipareisis, autonomic dysfunction
Patient Presentation
how and when to get imaging? what kind
Presentation is not great, a HA with red flag symptoms will clue you in & warrent emergent brain imaging
HA + these symptoms? = get a gadolinum MRI a CT is okay if contrast is contratindicated in MRI (once tumor has been identified, then further imaging will be done)
- acute, new severe and CHANGING HA from prior
- fever + HA and other systemic symptoms
- new HA in adult > 50 (never had it like this before)
- HA on exertion, onset at night or early AM
- signs of meningsmus
- new neurlogic signs
- pain with valsava (think increase ICP)
- pregressive HA
- severe and persisent with other worrisome freatures
Flow chart of how to go about brain tumor
- sus for tumor? = do a MRI with contrast
- if it is a tumor: malignant or primary
- malignant? find the source (CT chest, abd, plevis etc.) & biopsy that lesion
- primary brain? consider brain biopsy to see if CA
how are brain tumors “staged”
staging is NOT like other tumors: with T N M grading
these tumors are satge based on histopathological findings and immunohisotolig findigs & imaging
Treatment of Primary Brain Tumors
Mainstay of Treatment = surgery: maximal safe resection
- surgery resection dependson location, pt. & age
- postives = histoligca evaluation, relieve mass effect and better survival
- used with adjuct radiation adn chemo
Radiation
- primary or add-on
- standard external beam
- others include: brachytherapy,stereo. etc.
- can improve survival with high risk gliomas
- but watch radiaion SE
Chemo (pediatric tumors more chemo than rad. to reduce risk of expsoure)
- usually given in combo with radiaion
- can have implantable chemo wafer
- deplays progression, doesnt help survival
- can use a combo of radiation, surgery and chemo
- management of the sequelae (increase ICP, seizures, etc.)
some just need routine monitoring!
Treating sequaleae of Brain tumor
Increased Intracranial Pressure
increased intracrainial pressure = big deal = can lead to airway compromise
- always protect the airway
- dextamethasone for increased ICP
- mannitol for herniation
- hyperventilation: can temporarilty reduce ICP but less used today
Post-Operative Management
- after surgery or radiation etc.
Glucocorticoids: help reduce vasogenic edema and radiation-assocaited edema byt dec. inflammation
- taper after 1 week
VTE prophylaxis: the risk is HIGH for a DVT!!!
- give coumadin or DOACS
Seizure Meds: 30% will have seizure after excision
- prophylatic seizure meds for 1 week after surgery with anticonvulsants (levetiracitam = Keppra)
follow-up MRI 2-3 weeks
Primary CNS Lymphoma
- what is it
- who gets it
- presentation
- diagnosis
- treatment
Primary CNS Lymphoma
- commonly B-cell lymphoma
who? = commonly immunocompromised or suppressed like HIV pts.
Presentations
- multiple masses = immunocomp.
- single lesion (immunocompetent)
- meningeal involvement (that spreads into the CSF)
Diagnosis
- MRI and sterotacti biopsy
Treatment
- chemotherapy
- add on rituximab
- whole brain irridation if chemo not able to tolerate
Metastatic Intracranial Lesions
- how common
- how do they present
10x more common than a primary brain tumor
- these pts. will present with the same as primary tumors: increased ICP, HA and focal/diffused cerebral function
- often multiple lesions
- can be the reason to diagnosis the unknown cancer
Types of Metastatic Cancers that commonly go to brain
- adults
- kids
Adults (lung and breast and melanoma!!!)
- bronchogenic (lung) CA
- adenocarcinomas of breast, thyroid and kidney
- melanoma
- lymphoma
Kids
- neuroblastoma (sympatheitc ganglion tumor)
- ALL: acute lymphoblastic leukemia
Management of Malignant CA to brain
Management varies based on the Primary Tumor
- a single lesion + healthy pt (realative) = surgery
- radiation (+/- surgery)
- sstemic immunotherapy
- palliative care (melanoma and prostate commonly)
Spinal Tumors
Three Locations & tumors that exisit there
Locations for Tumor Formation
Intrameduallary (within the SC itself)
- ependymoma
- astrocytoma
- metastisis
Intradural Extrameduallary (in the lining but not int he cord itself)
- meningiomas
- nerve sheath
Extradural: outside the SC
- metatsis
- chodomas
- sarcmoas
- lymphoma
- MM
- benign lesions
- langerhans cell histercytosis
Spinal Tumors
Presention
Diangosis
Presentation
- Pain: backpain that is gnawing, unremitting and often waking them up at night
- sensory dysthesias
- muscle weakness
- symptoms can begin unilateral & progress to bilateral
PE
- sensory and motor testing to help define location
- can hep show brown sequard syndrome
Diagnosis
- MRI: test of choice
- if cant - CT myelogram
Spinal Tumors
Treament of Primary and mets
Treatment of Primary
- decompression and surgery
- radiation
Treatment of Mets
- decompression
- radiation
Spinal Cord Compression
what is it
symptoms
Etiology
- AN ONCOLOGIC EMERGENCY!!!
- commonly a result of a met in the vertebrae eroding into the SC
Symptoms
- pain is first: usually 7 weeks before neuro symptoms
- pain is local to the lesion, worse at night and can be siatic type
- sensory symptoms follow: hyperesthesia that becomes anesthertic below the level
- motor finding follow:leading to proximal muscle weakness that cen become paralysis
- Later findings: bladder and bowel dysfunction and impotence
Spinal Cord Compression
Diagnosis
Treatment
Diagnosis
- MRI with CONTRAST
- if cant CT myleogram
Management
- opiodids for pain
- steroids!!!
- radiation (good response)
- surgery
