Brain Tumors

NEURO - ONCOLOGY

• A medical discipline that deals with the diagnosis and treatment of– 1° CNS Neoplasms– Metastatic and non-metastatic complications of

extra neural cancer– Pain associated with cancer

Incidence Rate of Primary Brain Tumors

14 / 100,000 population

Expected Incidence of Primary Brain Tumors in ASEAN Countries

COUNTRY POPULATION 2002 (WHO)

EXPECTED INCIDENCE

Brunei 334,000 46

Cambodia 13,440,000 1,876

Indonesia 214,839,000 30,077

Malaysia 22,632,000 3,168

Myanmar 48,363,000 6,770

Philippines 77,130,000 10,798

Singapore 4,107,000 574

Thailand 63,583,000 8901

Vietnam 79,174,000 11,084

Estimated No. of Cancer Cases 80 / 100,000 populationEstimated Prevalence rate of CNS Metastasis – 12% of

cancer cases

Country Population Incidence of CA CNS Metastasis

Brunei 334,000 267 3

Cambodia 13,440,000 10,672 1,280

Indonesia 214,839,000 171,871 20,624

Malaysia 22,632,000 18,105 2,172

Myanmar 48,363,000 38,690 4,642

Philippines 77,130,000 61,680 7,404

Singapore 4,107,000 3,285 394

Thailand 63,583,000 50,800 6,096

Vietnam 79,174,000 63,280 7,593

Total 523,602,000 418,650 50,208

Frequency of Intracranial Metastases Primary Tumors

New Cases No. of Deaths

% w/Mets & Autopsy

Est. No. of Deaths w/ICT

Lung 172,000 153,000 34 52,020

Breast 183,000 46,300 30 13,890

Melanoma 32,000 690 72 4,968

Colon & Rectum

149,000 56,000 7 3, 920

Urinary 78,800 21,900 23 5,037

Prostate 200,000 38,000 31 11,780

Pancreas 27,000 25,900 7 1,813

Leukemia 28,600 19,100 23 4,393

Lymphoma 45,000 21,200 16 3,392

Causes for the increase in incidence of brain metastasis

1. Availability of diagnostic procedures like imaging has led to more accurate diagnosis

2. Improved care has lead to longer lives allowing more time for wider dissemination of metastasis

3. CNS is a sanctuary for neoplastic cells when the systemic tumor is controlled

Brain Tumors

1. Leading cause of death from childhood cancers among persons up to 19 years old

2. Second leading cause of cancer related deaths in males ages 20 – 39 years of age

3. 5th leading cause of cancer related deaths in women 20 – 39 years of age

Some Changing Trends in CNS Cancer1. Primary CNS lymphomas are increasing

(MSKCC – 1 % - 15%)2. Leptomeningeal carcinomatosis from leukemia is

decreasing from a high 50% to much lesser due to the development of systemic chemotherapeutic agents that cross the blood brain barrier

3. Testicular and breast cancer patients who received systemic chemotherapy are likely to have relapse in the brain than those who did not (they will develop a relapse in the primary site of cancer

4. Non metastatic complications of systemic cancer related to the nervous system are increasing due to RT and CX complications

Neurologic Complications of Systemic Cancer

1. Intracerebral and spinal metastasis – 12 – 24%

Neurologic Complications of Systemic Cancer

1. Intracerebral and spinal metastasis – 12 – 24%

2. Vascular disorders - 8%

Vascular Disorders

1. Coagulation disorders leading to IC or SC Hemorrhage

2. Melanoma and choriocarcinoma are the frequent causes of IC Bleed

3. Infarcts 2° to thrombotic endocarditis or tumor emboli

4. Hypercoagulability is a more common cause of small vessel disease

5. Occlusion of dural sinuses common in leukemia and lymphomas

Neurologic Complications of Systemic Cancer

1. Intracerebral and spinal metastasis – 12 – 24%

2. Vascular disorders - 8%

3. Infections

Infections

Immune responses are altered due to cancer itself and therapies

1. Meningitis- Listeria monocytogenes and Cryptococcus neoformans as vs, Pneumococcal meningococcal and H. Influenza

2. Brain abscesses a) Due to fungi – mucormycosis or aspergillosis

b) Parasites – Toxoplasma

c) Unusual organisms like nocardia

3. Viral encephalitisa) Due to Herpes Zoster or JC (PML) vs. HSV

Neurologic Complications of Systemic Cancer

1. Intracerebral and spinal metastasis – 12 – 24%

2. Vascular disorders - 8%

3. Infectious

4. Metabolic and Nutritional Disorders

Metabolic and Nutritional Disorders

1. Hypercalcemia

2. Thyroid failure due to RT

3. Hormonal failure due to CT

4. Poor appetite

Paraneoplastic Syndromes/ RECONS

All neurologic abnormalities not caused by cancer spread to the nervous system

Characteristic of Recons

1. Neurologic symptoms of RECONS precede the identification of the 1° cancer

2. RECONS related cancer is usually small, non-metastatic or indolently growing

3. Neurologic disability of RECONS is often profound in the absence of any other cancer symptom

4. RECONS are generally but not always irreversible

Supratentorial tumors

• Cerebral hemispheres– Gliomas

• Malignant glioma

• Astrocytoma

• Oligodendroglioma

– Meningioma– Metastatic Tumors

Supratentorial tumors

• Midline Tumors– Pituitary adenomas– Pineal Tumors– Craniopharyngiomas

Infratentorial Tumors

• Adults– Acoustic Schwannomas– Metastases– Meningiomas– Hemangioblastomas

Infratentorial Tumors

• Children– Cerebellar atrocytomas– Medulloblastomas– Ependymomas– Brainstem glioma

Spinal cord tumors

• Extradural– Metastases

• Intradural– Extramedullary

• Meningiomas• Scwannomas neurofibromas

– Intramedullary• Ependymomas• Astrocytomas

Symptoms

• Progressive neurologic signs and symptoms

• Increased intracranial pressure

• Focal neurologic deficits

• Seizures

• Occasional sudden onset due to hemorrhage into the necrotic tissue

Diagnosis

• Clinical diagnosis

• Confirm diagnosis by:– CT Scan– MRI– Cerebral angiography– Lumbar puncture (potentially dangerous due to

risk of herniation)

Tumors causing mainly increased intracranial pressure, hydrocephalus

with little or no lateralizing signs

• Medulloblastoma and cystic astrocytoma of the cerebellum

• Ependymoma and papilloma• Hemangioblastoma of the cerebellum (Von

Hippel Landau disease)• Colloid cyst of the third ventricle• Craniopharyngioma

Tumors presenting first with focal neurologic deficits, seizures, impaired

mental function, headaches; late increased ICP

• Glioblastoma multiforme

• Astrocytomas• Oligodendrogliomas• Ependymomas

• Meningiomas

• Primary cerebral lymphomas

• Metastatic Carcinoma

Distinctive tumor syndromes: with prominent deficits and late or absent ICP

• Acoustic Neuroma: – Unilateral deafness,

– loss of balance,

– facial weakness and loss of sensation,

– later ataxia of ipsilateral limbs and gait and

– increased ICP

Distinctive tumor syndromes: with prominent deficits and late or absent ICP

• Carotid body tumor– Painless mass at bifurcation of common carotid

– grows slowly

– affects CN IX to XII

• Pituitary adenomas– Prolactinomas (chromophobe adenoma)

– Acromegaly/gigantism (eosinophilic adenoma

– Cushing’s Disease(basophil adenoma)

Distinctive tumor syndromes: with prominent deficits and late or absent ICP

• Meningiomas – Sphenoid ridge– Olfactory groove– Tuberculum sella

• Glioma of the brainstem• Glioma of the optic nerve and chiasm• Chordoma• Nasopharyngeal tumors• Tumors of the foramen magnum

Gemistocytic and Fibrillary Astrocytoma

Case 2: Brainstem fibrillary astrocytoma - Astrocytoma fibrillare pontis et medullae oblongatae

Gemistocytic and Fibrillary Astrocytoma

• Case 1: Frontal gemistocytic astrocytoma - Astrocytoma gemistocellulare lobi frontalis dextri

Intraventricular tumor: Central neurocytomaNeurocytoma (centrale) ventriculi lateralis

Primary multiform glioblastoma in the cerebellum

Single metastasis from a bronchus carcinoma in the right cerebellar

hemisphere

Colloid Cyst Colloid Cyst of the third of the third

ventricleventricle

Tumors of the Sellar Region: Craniopharyngioma

FOURTH VENTRICLE

PULVINAR THALAMIPULVINAR THALAMI

CEREBRAL PEDUNCLECEREBRAL PEDUNCLE

Ependymoma of the third ventricle

Temporal lobe Glioblastoma multiforme

NECROSIS WITH PSEUDOPALISADES

Treatment

• Tumor related brain edema– Corticosteroids– Osmotic agents

• Chemotherapy (Anticancer drugs)

• Medical Management– specific drugs which can reduce tumors, i.e.

bromocriptine

Treatment

• Radiotherapy– Cobalt Therapy– Linear accelerator– Stereotactic radiosurgery

• Gamma Knife

• Surgical management– Extirpation/resection– Shunting procedures

Treatment

• Supportive measures

• Counseling of patient and family

• Physical therapy