DR.

IGN PURNA PUTRA, SPS(K)

 The brain is the center
of thoughts, emotions,
memory and speech.
 Brain also control
muscle movements and
interpretation of
sensory information
(sight, sound, touch,
taste, pain etc)
 Tumors can effect any part of the brain and
depending on what part(s) of the brain it affects can
have a number of symptoms.
 Seizures
 Difficulty with language
 Mood changes
 Change of personality
 Changes in vision, hearing, and sensation.
 Difficulty with muscle movement
 Difficulty with coordination control
 Common childhood tumor.
 Comprise: 10% of all tumors
 Peak incidence at 5th decade
 Supratentorial tumors in adults
 Infratentorial tumors in childhood
 Primary – children - 50% infiltrative
 Metastatic – adults - well-demarcated.
 Limited space, Vital structures –
 Location determines prognosis.
 Rare extra neural metastasis.
Tumor Suppressor Genes & Proto-oncogenes

Proto-oncogenes normally promote

cell division:
When expressed these genes promote cell
division. To stop mitosis, these genes or their
products must be inactivated.
 If mutated, these genes become permanently
switched on, then uncontrolled cell division occurs 

cancer.
 Mutant forms of proto-oncogenes are called
oncogenes
Tumor suppressor genes suppress cell
division:
 When expressed, these genes stop passage
through the cell cycle and prevent mitosis.
 If these genes become inactivated or deleted
through mutation, control over cell division is
lost  cancer.
Characteristics of Cancer
Activated proto-
oncogene
Inactivated tumour
suppressor gene
TUMOR GROWTH
FACTOR TUMOR SUPPRESSING
 pro onco-genesis FACTOR/ NECROSING
FACTOR
pro appoptosis
 Oncogenes

Stimulate Proliferation
Inhibit Differentiation
Inhibit Apoptosis

Tumor Suppressor
Genes

Inhibit Proliferation
Promote
Differentiation
Stimulate Apoptosis
 Process in which new blood vessels are formed
 Occurs in
 healthy body
▪ healing wounds
▪ restoring blood flow to tissues
after injury
 tumors/cancers
 Controlled by
 Stimulating growth factors
 Inhibitors

http://www.angio.org/understanding/understanding.html
 These tumors can be detected through a MRI,
CT scan or a PET scan.
 Once detected, depending on where the
tumor is located, a biopsy officially is used to
diagnosis cancer.
 Most brain cancers happen for reasons
unknown, however some small risk factors
are
 Radiation exposure
 Exposure to vinyl chloride
 Immune system disorders
 For people ages 15-44 five year survival rate is
55%
 For people ages 45-64 five year survival rate
is 16%
 For people over 65 five year survival rate is
5%
 Primary neural tumors - Rare
(Neuroblastoma, ganglioneuroma)
 Common - Tumors of supporting structures.
 Glia, Meninges, Blood vessels, fibrous tissue.
 Secondary – Metastasis (50%)
 Meninges: meningioma, hemangiopericytoma
 Glia: astrocytoma, oligodendroglioma,
ependymoma, choroid plexus papilloma..
 Vascular: hemangioblastoma.
 Primitive cells: neuroblastoma, germinoma,
medulloblastoma, pineoblastoma, retinoblastoma
 Neuronal: ganglioglioma, gangliocytoma
 Pituitary: adenoma, craniopharyngioma
 Nerves: schwannoma, neurofibroma, MPNST
 Arise from meningothelial cells of arachnoid
granulations.
 Adjacent to venous sinuses.
 Nodular, capsulated, slow growing-Benign.
 Form whorls of cells, Psammoma bodies in
the center.
 Effect by pressure.
 No infiltration or metastasis (Benign).
 Gliomas are neoplasms of glial cells.
1. Astrocytoma – Commonest benign
tumor with malignant behavior.
2. Ependymoma – Rare, 4th ventricle.
3. Oligodendroglioma – Benign, adults,
rare.
 Fibrillary or diffuse astrocytoma - 80%
 Anaplastic/high grade astrocytoma
 Glioblastoma multiforme
 Gemistocytic astrocytoma
 Pilocytic astrocytoma(Juvenile)
 Pleomorphic astrocytoma
 Xanthastrocytoma
 Gliomatosis cerebri. Others..
 Cerebrum, 4th to 6th decade.
 Headache, seizures & neurological deficits.
 3 tier or 4 tier grading system.
 Anaplasia,
 Mitotic activity,
 Necrosis &
 Endothelial proliferation.
 Well differentiated, anaplastic & Glioblastoma
multiforme.
Adults: Supratentorial
Solid
Malignant
Fibrillary

Childhood: Infratentorial
Cystic
Benign
Pilocytic
 Low grade- hypercellularity, pleomorphism

 Anaplastic- high grade – plus will have more

mitosis & vascular endothelial proliferation

 Glioblastoma multiforme- plus necrosis and

pseudopalisades. Grossly variegated
appearance (multiforme)
 If tumors have not infiltrated normal brain
tissue then surgery can be a cure
 Low-grade Astrocytomas are not curable by
surgery. However through surgery as much
of the tumor as possible is removed and then
the patient usually goes through radiation
treatment.
 High-grade Astrocytomas are not curable by
surgery. After surgery has removed as much
of the tumor as possible the patient can go
through radiation treatment and
chemotherapy.
 Most common drug given to these patients
after chemotherapy is BCNU
 Cells of origin: Oligodendrocytes
 Common in cerebral hemispheres
 Calcifications common among all
gliomas

 Grades:
Low grade
Anaplastic
 Because these tumors infiltrate normal brain
tissue these tumors are not cured through
surgery. However removal of part of the
tumors can relieve some symptoms and
prolong life.
 If the tumor is causing disabilities to the
patient after surgery the patient may go
through chemotherapy, perhaps followed by
radiation treatments.
 Mutated ependymal cells
 Ependymal cells line the ventricles in the central
area of the brain and they line part of the pathway
through which the cerebrospinal fluid travels
 Theses mutated cells may block the cerebrospinal
fluid from exiting the ventricles causing the
ventricles to enlarge (hydrocephalus)
 These tumors do not usually infiltrate normal
brain tissue and are therefore curable
through surgery.
 If surgery is unable to completely remove the
tumors the patient may try radiation therapy.
 Origin from primitive blast cells.
 Rosettes - attempted nerve formation.
1. Medulloblastoma – Cerebellum
2. Retinoblastoma - Retina
3. Neuroblastoma – Adrenal glands
4. Ganglioneuroma - Mediastinum
 Origin: primitive neuroectodermal cells
 Age: 1st decade of life. Most common
brain tumor at this age.
 Site: vermis of cerebellum
 May cause hydrocephalus
 Subarachnoid dissemination
Medulloblastoma
 Most common brain tumor in adults.
 Common primary sites: melanoma, lung,
breast, GI tract, kidney.
 Most are in cerebrum (MCA territory).
 In gray-white junctions due to rich
capillarity
 Discrete, globoid, sharply demarcated
tumors. Amenable to surgical resection.
 Single or multiple.
 Brain edema frequent.
Supportive
Metastatic tumors
Neurofibroma
Schwannoma
Case 10.1: A young adult with neck pain, numbness, and a weak right arm.

C
D.

A. B. C.

Findings: : An inhomogeneously enhancing tumor (red arrow in B) is seen

within the upper cervical cord. Large cysts (C) are seen both above and
below the tumor, best seen on T2 wtd. image C. Eccentric location of the
tumor, more to the right of the cervical cord (yellow arrow) is shown on axial
image D.

Diagnosis: Astrocytoma
Astrocytoma of the Spinal Cord
Incidence: Common intramedullary tumor particularly in children
and young adults.
Pathology: Usually low grade
MRI Findings:
 Eccentric location of tumor within the spinal cord
 Multisegmental involvement
 Variable degree of tumoral enhancement
 Cysts are common
 Hemorrhage is rare
Treatment:
 Complete resection of tumor is not possible due to infiltrative
nature.
Radiation therapy is also used for recurrence or growing tumors.
Case 10.2: A middle-aged male with gradual weakness of both arms.

Diagnosis: Ependymoma
10.2 A 10.2 B 10.2 C
Post contrast Sagittal T2 wtd. Axial T1 wtd. MRI (C+)
(C+) sagittal T1 MR image of
wtd. MRI the C-spine

Findings: : A sausage-shaped intensely enhancing tumor (yellow arrow in

A) is seen within the upper cervical cord extending from just above the
cranio-cervical junction with involvement of the dorsal medulla (black arrow
in A) down to C5 level. Small amount of old blood is better seen on T2 wtd.
image as an area of dark signal intensity within the tip of the tumor (white
arrow in B). Central location of tumor (yellow arrows in C) is better
appreciated on axial post contrast image.
Ependymoma of the Spinal Cord

Incidence: Common intramedullary tumor in adults

Pathology: Cellular tumors that originate from ependymal cells lining the
central canal.

Clinical Symptoms: Nuchal pain/radicular pain, Paresthesia, Motor

weakness

MRI Findings: Moderate to markedly enhancing tumor, Blood products

from hemorrhage within the tumor is common, Tumor can also contain
intrinsic cysts.

Treatment: Surgery. Ependymoma have a well-defined cleavage plane

between the tumor and adjacent spinal cord. Thus, the tumor can be
completely resected with modern neurosurgical techniques with relief of
clinical symptomatology. Recurrence is rare following complete resection.
Case 10.3: A 50-year-old patient with renal cell carcinoma with back pain and leg
weakness.

10.3 A 10.3 B 10.3 C 10.3 D

Sagittal T1 wtd. MRI Post contrast (C+) Sagittal T2 wtd. MRI Axial T1 wtd. MRI (C+)
of the lumbar spine sagittal T1 wtd. MRI

Findings: : Bony metastasis (yellow arrow in A, B, C) is seen involving the

T12 vertebral body. Intramedullary location of metastasis within the distal
thoracic cord, is verified on post contrast sagittal image (red arrow in B) and
axial image (red arrow in D). Edema (green arrow in C) within the thoracic
cord is best shown on T2 wtd. image C.

Diagnosis: Bony Metastasis and metastasis to the Spinal Cord

Metastasis to the Spinal Cord

Incidence: Rare

Primary Sites: Intracerebral Tumors:

•Lung •Medulloblastoma
•Breast •Ependymoma
•Melanoma •Glioblastoma
•Kidney •Germ Cell Tumor
•Lymphoma/Leukemia

Route of Spread: Arterial seeding, Batson’s venous plexus, Drop

metastasis (from intracerebral tumor)
Case 10.4: A 55-year-old lady with gradual lower extremity weakness.

10.4 A 10.4 B 10.4 C 10.4 D

Post contrast (C+) Sagittal T2 wtd. MRI Precontrast sagittal Axial CT image of
sagittal T1 wtd. MRI of thoracic spine T1 wtd. MRI the thoracic spine

Findings: : An intradural enhancing meningioma (arrow in A), the ventrally

located tumor has produced cord compression and with displacement of the
thoracic cord (red arrow in D) to the right side. Calcified nature of the tumor
is identified on sagittal T2 wtd. image as an area of dark signal intensity
(yellow arrow in B) and confirmed by CT imaging (yellow arrow in D) as an
area of high attenuation density.

Diagnosis: Classic example of calcified intradural meningioma

Intraspinal Meningioma

Incidence:
• Second common intradural tumor
• Middle-aged females (80%)
• Thoracic spine (80%), cervical spine (15%)

MRI Findings:
• Intensely enhancing intradural tumor
• Calcification, when seen, clinches the diagnosis

Treatment:
• Surgery
 Case 10.5: A 24-year-old male with neck pain and right arm weakness.

10.5 A 10.5 B 10.5 C 10.5 D

Precontrast sagittal Post contrast (C+) Precontrast axial T1 Axial T1 wtd. MRI
T1 wtd. MRI of sagittal T1 wtd. MRI wtd. MRI (C+)
C.spine

Findings: An enhancing intradural nerve sheath tumor (Schwannoma) is

shown (red arrow in B and D). Dumbbell shape of tumor with intraspinal
component (red arrow in D) producing cord compression (yellow arrow in D)
and paraspinal tumor extension through an enlarged neural foramen (green
arrow in C & D) following the exiting nerve root is best shown on axial post
contrast image D.

Diagnosis: Schwannoma arising from the spinal nerve root

Intraspinal Nerve Sheath Tumors

Incidence: Most common intradural tumor

• Solitary nerve sheath tumor is usually Schwannoma and commonly
seen in adults.
• Multiple nerve sheath tumors are usually neurofibromas and
commonly seen in the pediatric age group with neurofibromatosis

MRI Findings:
• Dumbbell shaped enhancing intradural tumor with paraspinal
extension through enlarged neural foramen is a characteristic
feature of nerve sheath tumor.
• Can cause cord compression.

Treatment: Surgrey
Case 10.6: A 42-year-old patient, developed acute bilateral paraparesis following
placement of an epidural catheter for drug delivery to relive constant severe back pain.

10.6 A 10.6 B
Post contrast sagittal T1 wtd. MRI of Post contrast Axial
the thoracic spine T1 wtd. MRI Diagnosis: Epidural abscess

Findings: The central portion of the midthoracic cord is compressed and

displaced anteriorly (red arrows in A outline the thoracic cord both above
and below the level of cord compression) by an epidural abscess (yellow
arrows in A, B). The capsule of the abscess enhances intensely with central
low signal intensity produced by pus. Figure B demonstrates ventrally
displaced thoracic cord (red arrow) by dorsally located epidural abscess
(yellow arrows).

Treatment: Surgical drainage and antibiotics.

Case 10.7: A 68 yr. Old male with renal cell carcinoma with progressive difficulty in
walking and weakness involving both legs.

10.7 A 10.7 B 10.7 C 10.7 D

Pre-contrast Sagittal T2 wtd. Post contrast sagittal Pre contrast axial T1 wtd. MRI
sagittal T1 wtd. MRI MRI T1 wtd. MRI
of the thoracic
spine

Findings: Bony metastasis involving the T8 vertebral body, right

pedicle/transverse process and spinous process (arrow in A,B,C,D) with
epidural tumor producing marked degree of cord compression (red arrow).

Diagnosis: Bony metastasis from renal cell carcinoma with epidural tumor
producing cord compression
1. Schwannoma
viii Cranial nerve (Acoustic sch.)
Spinal roots, posterior
Peripheral nerves

2. Neurofibroma
Spinal Roots, rare
Peripheral nerves

3. Malignant variants
Malignant peripheral nerve sheath tumor
(MPNT)
Rare
 Schwannoma Neurofibroma
Schwann cells Schwann cells, neurites,
fibroblasts
Compress the nerve
trunk Fusiform and involves
nerve trunk
Encapsulated
Not encapsulated
Easily resectable without
nerve damage Not resectable without
sacrificing nerve
Microscopic:
Micro- Intermingled cells
 Antony A and B fibers with wavy nuclei
 Verocay bodies