Post on 17-Nov-2014
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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