Supischa Theerasasawat
Outline
Epidemiology Classification Primary brain tumor and metastasis : nature , histological and radiological findings Treatment
Epidemiology
Central Brain Tumor Registry of the United States (CBTRUS), the annual rate was 11.47 per 100,000 persons Annual incidence (1995-1999) - Malignant brain cancer : 6.8 per 100,000 person-years - Benign brain tumor : 4.2 per 100,000 personyears
Epidemiology
Glioma : most common brain tumor astrocyte (astrocytoma), oligodendrocytes (oligodendroglioma), or ependymal cells (ependymoma) Astrocytomas : 80% of all malignant brain tumors
Types of intracranial tumor in the combined series of Zuch, Cushing and Olivecronav
The 2007 Revised World Health Organization (WHO) Classification of Tumours of the Central Nervous System: Newly Codified Entities
Clinical features
Headache : referred frontal headache , cervical pain (CN IX and X) Seizure ~35%, focal and/or 2 GTC Cognitive dysfunction Nausea and vomiting Related to endocrine dysfunction Visual symptoms plateau wave : transient altered consciousness and visual disturbances
Tumor-related complications
Seizure Cerebral edema Venous thrombosis (DVT)
Investigation
CT or MRI EEG Evaluation of primary tumor (metastasis) Lumbar puncture
GBM
Neuraxis seeding, meninges Heterogeneous signal on T1W, T2W and irregular ring enhancement (necrosis)+ mass effect and vasogenic edema Variants : giant cell glioblastoma, small cell glioblastoma, gliosarcoma (temporal) Genetically best characterized brain tumor Less TP53 mutation EGFR amplification, PTEN mutation
Neuronal/Glioneuronal tumors
Small blue cell tumors - Medulloblastoma (prototype) - peripheral nervous system PNET - CNS variants : supratentorial PNET (sPNET) : pineoblastoma, central neuroblastoma,
ependymoblastoma, medulloepithiloma - PNETs of special sensory organ : retinoblastoma, olfactory neuroblastoma - AT/RT
Meningeal/extra-axial tumors
Most common : meningiomas Hemangiopericytoma, sarcoma, lymphoma, schwannoma
Anaplastic meningioma (WHO grade III) : mitotic index > 20 per 10 HPFs, highly aggressive and infiltrative
Miscellaneous tumors
CNS lymphoma
Primary lymphoma : multifocal, deep parenchyma, perivantricular, spare leptomeninges Systemic (2nd) lymphoma : leptomeninges, spare parenchyma Common site : epidural spine Immunocompromise : associated with EBV Diffuse large B cell lymphoma MRI : hypointense T2W, strong homogeneous enhancement, vasogenic edema
Management
Surgery : primary modality Biopsy : stereotactic , <2% seizure, ICH, infection Resection : complete resection - ganglioglioma, choroid plexus papilloma, PXA, pilocytic astrocytoma, DNT, pituitary adenoma, meningioma - subtotal resection : infiltrative increase ICP. ICH
Management
Radiotherapy - improve survival and symptoms - target : break DNA by ionization, free radical production - dividing cell : M (mitotic) and G2 phase - Photon Chemotherapy
Metastatic tumors
Epidemiology
Incidence varies among tumor type Lung 18-63% Breast 20-30% Melanoma 18-90% Ovarian 3% Prostate 1% Supratentorial : cerebral blood flow
Pathophysiology
Hematogenous spread (tumor emboli) Gray-white junction (narrowing caliber of vessels) Enlarge in a spherical fashion, Central necrosis, edema Intratumoral hemorrhage : melanoma, choriocarcinoma, RCC, NSCLC
Management
Supportive care : corticosteroid and AEDs AAN recommends against prophylactic AEDs in brain metastasis without seizure Exception - metastatic melanoma - motor cortex - concomitant parenchymal and leptomeningeal brain metastasis
Management
Radiotherapy Surgery : single brain metastasis + absent or controlled systemic cancer Chemotherapy