01 CNS Tumors 2 - Copy

8/2/2019 01 CNS Tumors 2 - Copy

1/56

Astrocytoma

Most common primary intra-axial brain tumor

12,000 cases/year Classification:

1.fibrillary

2.gemistocytic3.protoplasmic

4.pilocytic

5.microcystic cerebellar

CNS tumors


2/56

SPREAD

-tracking through the white matter(corpus

callosum,cerebral peduncles,centrum

semiovale,internal capsule)

-CSF pathways

-rarely spread systematically


3/56

Neuropathological Grading (WHO)

Characteristic Astrocyto.

(Gr.I)

Anaplastic

Astrocyto.

(Gr.II)

GBM

(Gr.III)

hypercellularity slight

moderate mod.-

marked

pleomorphism slight moderate mod.-marked

Vascularproliferation

none permitted common(not req.)

necrosis none none required


4/56

Neuroradiological Grading

Grade CT features MR findings

I Low density,no mass

effect

Abnormal signal,no

mass effect

II Low density + masseffect

Abnornal signal +mass effect

III Complex enhancement

IV Necrosis(ring enhancement)


5/56

Approximate survival (Astrocytoma)

Grade Median survival

I 8-10 yrs

II 7-8 yrs

III 2 yrs

IV


6/56

Low grade astrocytoma

tend to occur in children and young adults

demonstrate low deg.of cellularity

calcifications are rare, mitosis are absent

0.7-16% among astrocytoma

young agegood prognosticator

increased ICP,altered conciousness,personality

change,significant neurologic deficit=poorprognosis


7/56


8/56


9/56

treatment

Gross total excision if feasible

surgery is not curative for most infiltratinghemispheric gliomasdue to its characteristic whichextend at least 2 cm into the normal brain

Seizure control 15-75% will undergo malignant degeneration in 5

years

Relieve pressure from large tumors threateningwith hernation

Relieve obstruction of csf pathway

Post op Radiation for grade II astrocytomas


10/56

High grade astrocytoma (grade III and IV)

Anaplastic astrocytoma:

mean age:46 yrsmean duration of symp:15.7mos.

Glioblastoma multiforme:

mean age:56 yrs

mean duration of symp:5.4mos

GBM most common primary brain tumor

most malignant(kernohan IV) histological feature:

neovascularization with endothelial proliferation

areas of necrosis

pseudopallisading around area of necrosis


11/56

GBM


12/56

AA GBM


13/56

Treatment

Functional surgery Tumor debaulking/ cytoreduction

Prolong survival

External beam radiation Chemotherapy

Stereotactic biopsy:

1.eloquent/inaccessible2.small tumors

3.dx.


14/56

Cerebellar Astrocytoma

often cystic,half have mural nodule

better prognosis than supratentorial mean age of occurrence is lower

27% of pediatric p-fossa tumors

postop.survival longer

Presentation:

usually those of any p-fossa mass (ataxia, hydrocephalus,

cerebellar signs)

Pathology:

-solid/cystic(proteinaceous fluid)

-50% have mural nodule,cyst lining of reactive,non-neoplastic tissue

Prognosis:

10yr survival=94%


15/56


16/56

Treatment

Excision

Surveillance for recurrence


17/56

Oligodendroglioma-frequently presents with seizure

-often calcified

-predilection in the frontal lobes- fried egg appearance on microscopy

- 4% of primary brain tumors

- Average age =40yrs

- Male:female(60:40)

Presentation:

-50-80% -seizure

-often related to mass effect and less commonly to inc.ICP

Pathology:

-cells with monotonous round nuclei often in cellular sheets

-fried egg-lucent perinuclear halo

-16% of hemispheric ODG are cystic


18/56


19/56

Treatment

Gross total resection if possible

Chemotherapy

Radiation therapy

Prognosis:

10 yr=10-30%

-frontal lobe ODG survived longer


20/56

Meningiomas slow growing,extra-axial,usually benign

arise from arachnoid falx,convexity,sphenoid bone

cause hyperostosis of adjacent bone

freq.calcified

classic pathological finding:psammoma bodies multiple in 8% of cases

Meningioma en plaque=diffuse type

-14.3-19% of primary intracranial neoplasm

-peak incidence=45 years-F:M(1.8:1)

-1.5%=childhood

-19-24%=adolescent

-60-70%=falx,convexity,sphenoid bone


21/56

Parasagittal and falx meningiomas


22/56

Parasagittal and falx meningiomas:

half invade the superior sagittal sinus

manifest.=motor difficulty with the contralateral foot

Olfactory groove meningioma: foster-kennedy syndrome

mental status changes

urinay incontinence

visual impairment Seizure

Pathological Classification:

1.meningotheliomatous/syncitial

-sheets of polygonal cells

2.fibrous or fibroblastic

-cells separated by connective tissue stroma

3 t iti l


23/56

3.transitional

-contains whorls,some of which are calcified(psammoma bodies)

4.angiomatous-meningotheliomatous variety with closely packedblood vessels

5.angioblastic-meningeal hemangiopericytoma

6.malignant

-characterized by frequent mitoses,cortical

invasion,metastases

Most common site of mets:

Lung,liver,lymph nodes and heart


24/56


25/56


26/56

treatment

Surgery

Total excision

Recurrence:

Gross total excision=11-15% in 10 years

Incomplete= 59% in 5 years

Recurrence:Gross total excision=11-15%

Incomplete=29%


27/56

SIMPSON GRADING

I=macroscopically complete

II=macroscopically complete+coagulationIII=macroscopically complete without coag.or dural

excision

IV=partial removal

V=simple decompression

Value of XRT

Recurrence rate

total resection:4%

partial resection without XRT:60%

partial resection with XRT:32%

ACOUSTIC NEUROMA


28/56

ACOUSTIC NEUROMA

are really schwannomas

superior vestibular division of the 8th nerve

3 common early symptoms: hearing loss(98%)

tinnitus(70%)

dysequilibrium(67%)

8-10%

Antoni A fibers

-narrow and bipolar cells

Antoni B fibers

-loose reticulated

arise from loss of a tumor suppressor gene on the long arm ofchrom.22

Neurofibromatosis type 2


29/56

Neurofibromatosis type 2

inc.incidence

bilateral AN

Symptoms:

Unilateral sensorineural hearing loss,tinnitus,dysequilibrium(VIII)

Otalgia,facial numbness and weakness,taste changes (V,VII)

Brain stem compressionSigns:

VII-earliest cranial invloved

Rinne test-positive

Weber test-lateralized to side of better hearing

other signs:abnormal corneal reflex,nystagmus,facialhypoesthesia,facial weakness,abnormal eye movement,papilledema,babinski sign

Radiographic evaluation:


30/56


MRI

-diagnostic procedure of choice

-sensitivity:98%-0% false positive rate

-char.=round or oval enhancing tumor centered on IAC

CT scan

-second choice

-normal in 6%

-advantage over MRI:shows bony anatomy- trumpeting-enlarge IAC ostium


31/56


32/56

Treatment

Excision

Radiation

Gamma knife surgery

ACOUSTIC NEUROMA


33/56

ACOUSTIC NEUROMA

Cranial nerve preservation in suboccipital removal

Size of tumor Preserved function

VII nerve VIII nerve

2 cm 50-76% 6%

Complications(morbidity/mortality)


34/56

Complications(morbidity/mortality)

meningits-5.7%

CSF leaks-7.2%

CVA-0.7%

shunt req.-0.7%

Cranial nerve dysfx.=VII, VIII,IX,X,XIIbrainstem dysfx.

Follow-up

-CT-scan,MRI


35/56

PITUITARY ADENOMA

-arise primarily from the adenohypophysis

-10% of the intracranial tumors

-most common in the 3rd and 4th decades of life

-affect both sexes equally

-incidence inc.in MEN/MEA

Microadenoma=< 1cm


36/56

Presentation:


37/56

Presentation:

-endocrine disturbance

-mass effect

-pituitary apoplexy-CSF rhinorrhea

*Pituitary apoplexy=abrupt onset of neurologicdeterioration(HA,visualdist.,opthalmoplegia,reduced mental status)

-Hge. and/necrosis(3% of macroade.)

Classified:

1.Functional

2.Non-functional

Functional Pituitary Tumors:


38/56

Functional Pituitary Tumors:

Hormone secreted

1.ACTH/corticotropin

a.endogeneous hypercoticolism(cushings dse)

b.Nelsons syndrome

2.Prolactin

-amenorrhea-galactorrhea

-impotence

-infertility

3.Growth hormone

-acromegaly in adults

-gigantism in prepubertal children

Non-Functional Pituitary Tumors:


39/56

Non Functional Pituitary Tumors:

Manifestation:

1.visual disturbance-bitemporal hemianopsia(opticchiasm)

2.hypopituitarism

3.cavernous sinus

4.prolactin levels(ng/ml)

150=prolactinoma

5.posterior pituitary

check adequacy of ADH

*Dexamethasone suppression test

Endocrine evaluation


40/56

Endocrine evaluation

-may give indication of tumor type

-needs hormone to be replaced

-comparison following treatment1.Adrenal axis

-cortisol

2.thyroid axis

-T4,TSH

3.gonadal axis

-FSH,LH,sex steroids(estradiol,testoterone)

ACROMEGALY


41/56

ACROMEGALY

1.growth hormone

>10ng/ml

2.borderline cases

somatomedine-C (IGF-I)

glucose suppression test

growth hormone releasing hormone stimulation test

3.PRL

PITUITARY TUMORS


42/56

U U O S


MRI-imaging of choice

-information about invasion of cav. sinus-location/inv.of parasellar carotids

CT

Contrast enhancement:(time dependent)

1.normal pituitary

2.macroadenomas enhance more

3.microadenomas enhance less

Angiography-localize the parasellar carotids

Treatment


43/56

Treatment1.Acromegaly

surgery

medical tx:bromocriptine,octreotideradiation

Medical

1.bromocriptine2.Octreotide

Radiation

-not routinely useSurgery

PITUITARY TUMORS


44/56

PITUITARY TUMORS

Indications for surgery

1.prolactinomas

2.primary cushings dse.

3.acromegaly

4.macroadenomas5.pituitary apoplexy

6.histopathologic dx

*Diabetic Insipidus

PITUITARY TUMORS


45/56

Post-op. comlications:

1.hypopituitarism

2.secondary empty-sella syndrome3.infection-pituitary abscess,meningitis

4.CSF rhinorrhea

5.Carotid artery rupture

6.nasal septum perforation

Outcome(transphenoidal surgery)

endocrinologic cureprolactinoma=25%

growth hormone=20%

Gross total unusual in tumors>2cm

recurrence=12%

CRANIOPHARYNGIOMA


46/56

CRANIOPHARYNGIOMA-arise from anterior superior margin of the pituitary

-lined with with stratified squamous epithelium-solid and cystic component

-cholesterol crystal

-calcification (50%)

-2.5%-4%

-50%occur in childhood(5-10yrs)


47/56

CRANIOPHARYNGIOMA


48/56

CRANIOPHARYNGIOMA

Treatment:

surgery

outcome=5-10% mortality

5 year survival=55-85%

Radiationcontroversial

Recurrence

most occur in


49/56

CRANIOPHARYNGIOMA

Comparison of Craniopharyioma:Rathkes cleft cyst

Feature Craniopharyngio. Rathkes cleft cyst

Site of origin Anterior superior

margin of pit.

Pars intermedia of

pit.Cell lining Stratified

squamous epith.Single layer

cuboidal epith.

Cysts contents Cholesterolcrystals

Resembles motoroil

Surgical

treatment

Total removal Partial excision

And drainage

CEREBRAL METASTASIS


50/56

CEREBRAL METASTASIS-most common brain tumor seen clinically

-15-20% of patient with Ca

-15% as initial presenting symptom in pt.with no CA hx.

-43-60% will have an abnormal CXR

CEREBRAL METASTASIS


51/56

CEREBRAL METASTASIS

Incidence inc.:

1.increasing length of survival

2.enhanced ability to diagnose CNS tumors

3.many chemotherapeutic agents cant cross the BBB

4.some chemotx.agent weakens the BBB

CEREBRAL METASTASIS


52/56

CEREBRAL METASTASIS

Sources of Cerebral mets.in adults

Primary %

Lung CA 44%

breast 10%

kidney 7%

GI 6%

melanoma 3%

undetermined 10%

CEREBRAL METASTASIS


53/56

Specific Types of Cerebral mets:

1.melanoma

-classically inv.the pia and arachnoid

-primary site cannot be identified in 14% of cases

2.Lung CA

-commonest source-radiosensitive

3.Renal Cell CA

Signs and symp.

-slowly progrssive

Evaluation:


54/56

CT

-solitary in 50-65%

-arise in the gray-white matter junction

-profound white matter edema

-enhance

MRI

-more sensitive

Lumbar puncture

-useful in carcinomatous meningitis

Met.workup:

1.CXR

2.CT of the chest/abdomen

3.stool exam

4.mammogram

Management:


55/56

-median survival=32 wks

-mostly palliative

Medical:

anticonvulsant

corticosteroid

H2 antagonist

Surgical mngt:

Solitary lesion

1.primary dse. Is quiescent

2.lesion accesible

3.symptomatic or life-threatening

4.dx.unknown

Multiple lesion

-irradiation

CEREBRAL METASTASIS


56/56

Outcome:

resection of single mets+postop radiotx=8 months

Radiotx=15 wks

Steroids=2 months

Not tx=1 month

Date post:	06-Apr-2018
Category:	Documents
Upload:	arcdemon-sompra
View:	222 times
Download:	0 times

01 CNS Tumors 2 - Copy

Documents