Brain Tumor

BRAIN TUMOR : INTRA KRANIAL, MED SPINALIS and MENINGENS

TWO TYPE : PRIMER AND SECUNDER

PRIMER TUMOR : ASTROCYTE, OLIGODENDROCYTE, EPENDEMOCYTE, ARACHNOID, NEUROBLAST and MEDULLOBLAST

SEKUNDER TUMOR : METASTATIK FROM LUNG, BREAST, COLON and SKIN

Intra Cranial Brain Tumor ( Zulch, Cushing, , Oliverconna ) in 15,000 adult cases..

Glioma:

-Glioblastoma multiform 20 %

-Astrositoma 10 %

-Ependimoma 6 %

-Medulloblastoma 4 %

-Oligodendrositoma 5 %

Meningioma 15 %

Pituitari adenoma 7 %

Neurinoma ( schwannoma ) 7 %

Metastatik karsinoma 6 %

Kraniofaringioma, dermoid, epidermoid, teratoma 4 %

Angioma 4 %

Sarkoma 4 %

Unklassifikasi 5 %

Misellaneous 3 %

CHILD INTRA CRANIAL TUMOR

ASTROSITOMA : 48 %

MEDULLOBLASTOMA : 44%

EPENDIMOMA : 8 %

ETIOLOGY

GENETIC : GENE DEVIATION

CONGENGITAL : TERATOMA, CHORDOMA

AGE : PINEALOMA, MEDULLOBLASTOMA (< 20 yr). MENINGIOMA (> 50yr)

CARSINOGEN : HYDROCARBON, NITROSAMIN, HEAD INYURY, INFECTION, TOKSIN, RADIATION, VIRUS

Risk factors related to CNS tumor

Definitive

-Ionizing radiation

-immune supression (HIV infection)

Possible

-Electromagnetic field (high tension wires, cellular telepon)

-Diets (N-nitroso compounds, Aspartame)

-Occupation (petroleum industry, agricultural pesticides)

-Household chemicals (hairdyes and sprays, household pesticides)

-Head injury

-Medication (vitamin)

-Infections (Cysticercosis, varicella zoster, SV 40

CONCEPT OF PATOGENESIS PRIMER TUMOR

HISTOGENIC THEORY (Bayley &Cushing) — EMBRIOLOGICAL OF NERVE CELL AND GLIA

RECENT THEORY — TUMOR ARISES FROM TRANSFORMATION OF ASTROCYTE, OLIGODENDROCYTE, MICROGLIOCYTE, EPENDYMOCYTE — NEOPLASM CELL — MULTIPLICATION AND DIFFRENTIATION

PATHOFISIOLOGY

NORMAL CAVUM CRANII CONSIST OF

-Brain tissue ( 1400 gr )

-Cerebro spinal fluid ( 75 cc )

-Blood ( 75 cc )

these component any time : stabil

Brain tumor — increase intracranial pressure

Brain tumor — cerebral edema — cerebral herniation

CLASSIFICATION

HISTOPATOLOGICAL PATTERN

Primary brain tumor — histological

Benign or malformative : meningioma, pituitary adenoma, acustic neuroma, craniopharyngioma, pilocytic astrocytom, hemangioblastoma

Hhistological malignant : glioma (anaplastic astrocytoma, glioblastoma multiform), ependymoma, oligodendroglioma, medulloblastoma, pineal cell tumor, chroid plexus carcinoma

METASTATIC BRAIN TUMORS

-BREAST

-LUNG

-GI TRACT

-PROSTAT

-SKIN

INTRA CRANIAL METASTASIS

Brain parenchyma : breast, lung, melanoma

Pituitary gland : breast, melanoma, germ cell

Dural based : lung, prostat, breast

Leptomeningeal disease : breast, lung

SKULL METASTASIS

Skull base : breast, prostat, osteosarcoma of skull, head and neck cancer

Calvarium : breast, prostat

SPINE METASTASIS

Epidural : lung, breast, prostat, neuroblastoma, lymphoma. Leukemia

Leptomeningeal : breast, lung

Intramedullary : breast, colon, lung, prostat

Brachial plexus : lung, breast, lymphoma

Lumbosacral plexus : pelvic tumor

CLASSIFICATION BASED ON TOPOGRAPHY (LOCATION)

SUPRA TENTORIAL TUMORS

— Cerebral lobe and deep hemispheric : glioma, meningioma, metastatic tumor

— Sella turcica tumor : pituitary tumor, craniopharyngiomas

INFRATENTORIAL TUMOR

MEDULLASPINALIS TUMOR

INFRATENTORIAL TUMORS

ADULTS

— Cerebellopontine angel acoustic, schwannoma

— Others sites : brainstem gliomas, metastase, hemangioblastoma, ependymoma

CHILDRENS

— Midline tumors : medulloblastomas

— Cerebellar lobes : astrocytomas

MEDULLA SPINALIS TUMORS

EKSTRA DURAL : Metastatic tumor

INTRA DURAL

— Ekstra medulla : meningioma, neurofibromas

— Intra medulla : ependymoma, astrositoma

SYMPTOMS AND SIGNS

Generalized symptoms caused by raised intracranial pressure

Focal symptoms caused by invasion, ischemia and compression

False localizing symptoms caused by shifts of cerebral structures

GENERALIZED SYMPTOMS AND SIGNS

HEADACHE

VOMITING

DROWSINESS ( VERTIGO AND DIZZINESS)

VISUAL OBSCURATION

PERSONALITY CHANGE

CONFUSION

PAPILEDEMA

APATHY

MECHANISM HEADACHE ASSOCIATED WITH BRAIN TUMOR

1.Traction on venous sinuses

2.Traction on meningeal arteries

3.Traction on large arteries at base of the brain

4.Pressure on cranial and cervical pain sensitive structure

5.Dilatation of intracranial arteries

6.Inflamation of pain-sensitive structures

FOCAL SYMPTOMS AND SIGNS

FRONTAL LOBE

è Generalized seizure

è Focal motor seizure (contra lateral)

è Expressive aphasia (dominant size)

è Behavioral changes

è Dementia

è Gait disorders, incotinence

è Hemiparese

BASAL GANGLIA

è Hemiparesis (contralateral)

è Movement disorders (rare)

PARIETAL LOBE

è Receptive aphasia (dominant size)

è Spatial disorientation (non dominant)

è Cortical sensory dysfungtion (contralat)

èAgnosias

OCCIPITAL LOBE

è Hemiparesis (contralateral)

è Visual disturbance

TEMPORAL LOBE

è Complex partial (psychomotor) seizures

è Generalized seizures

è Behavioral changes

è Olfactory and complex seizures

è Visual auras

è Visual field defect

CORPUS COLLOSUM

è Dementia (anterior)

è Behavioral changes

è Memory loss (posterior)

è Asymptomatic (mid)

THALAMUS

è Sensory loss (contralateral)

è Behavioral changes (posterior)

è Languange disorders (dominant size)

MIDBRAINS/PINEAL

è Paresis of vertical eyemovement

è Pupillary abnormalities

è Precocious puberity (boys)

SELLA/OPTIC NERVE/PITUITARY

è Endocrinopathy

è Bitemporal hemianopia

è Monocular visual defect

è Opthalmoplegia (cavernous sinus)

PONS/MEDULLA

è Cranial nerve dysfungtion

è Ataxia, nystagmus, spasticity

è Weakness, sensory loss

CERBELLO PONTINE ANGLE

è Deafness (ipsilateral)

è Loss of facial sensation (ipsilateral)

è Facial weakness (ipsilateral), ataxia

CEREBELLUM

è Ataxia (ipsilateral)

è Nystagmus

CRANIAL NERVE

è Anosmia

è Diplopia, ptosis, anisocoria

è Face pain, numbness, and weakness

è Tnnitus, hearing loss

PARENCHYMAL SIGNS

è Ipsilateral hemiparesis

è Ipsilateral gaze palsy

è Visual field defect, cortical blindness

è Ataxia

OTHER SIGNS

è Nuchal rigidity

SYMPTOM AND SIGN SPINAL CORD TUMOR

INTRAMEDULLARY

à Sensory loss

à Early spinchter dysfungtion

à Pain +

à Decreased rectal tone

à spasticity

à upper motor neuron signs

Common tumor : Ependymoma, astrositoma

Intradural and extramedullary

à Pain, metastase +++

à Pain, primary tumor +

à Radicular or local sensory loss

à Radicular or segmental weakness and

sensory loss

à Upper motor neuron signs

Common tumors : Meningioma

EPIDURAL

à Pain +++

à Radicular or local pain

Common tumors à Metastasis

DIAGNOSIS BRAIN TUMOR

HISTORY

GENERAL PHYSICAL EXAMINATION

NEUROLOGIC EXAMINATION

LABORATORY FINDING, ESPECIALLY IMAGING

Laboratory findings

IMAGING

è CT Scan

è MRI

è Magnetic resonance spectroscopy (MRS)

è Fungtional MRI

BIOPSY : Defenitive diagnosis

CT and MRI Scan of Brain and Spinal tumors

Advantage Disadvantage

CT

Rapid Lower resolution

identifies calcification and poor visualization of posterior fossa

hemorrhage and spinal cord

Patient movement degrad IV contras allergy

es less than for MRI seizure following contrast

MRI

Higher resolution Require cooperative pasient

Better image of fossa post Patient movement degrades degrade

Best image of spine Image quality

More costly

DIFFRENTIAL DIAGNOSIS OF BRAIN TUMORS

HEMATOMA

ABCESS

GRANULOMA

PARASITIC INFECTION : CYSTYCIRCOSIS

VASCULAR MALFORMATION

MULTIPLE SCLEROSIS

CEREBRAL INFARCS

Diffrential diagnosis of intra cranial lesion by Radiographic features

Fibrillary astrocytoma CT / MRI

Glioblastoma CT : Low density, enhancement, usually

heterogeneous or ring enhancing,

significant mass effect

MRI :Hypointense on T1,hyperintense T2

significant mass effect, ++ enhance

Anaplastic astrocytoma CT : Low density mass, +/- enhancemen

MRI :Iso-or hypointen on T1, increase T2

signal, some mass effect, +/- enhan

Low grade astrocytoma CT : Low density mass, no enhancement

MRI: Iso-or hypointen on T1, hyperintense

on T2, minimal mass effect, no enhancemen

Oligodendroglioma CT / MRI

Anaplastic CT : Hypodense, +/- enhancement

heterogeneous, or ring, sometime

enhancement

MRI :Hypo or isointen T1, hyperintense

T2, +/- enhancement

Low grade CT :Low density mass, minimal

enhancement, calcified

MRI :Iso-or hypointense on T1, hyperin

tense on T2, minimal enhancement

CT / MRI

Ependymoma CT : Isodense, calcified 50 %, cystic

MRI :Heterogeneous signal, enhancem

Meningioma CT : Dura base mass, hyper or isoden

homogeneous, and +++ enhanc

MRI :Dura-base mass, hyper-or iso in

tense on T1, +/- surrounding

increase signal on T2

Hemorrhage with CNS Tumors

Therapy of Intra Cranial Tumors

Definitive therapy

–Surgery : Biopsi, resection

–Radiation : External beam, Streotactic radiosurgery, Heavy particles, Brachytherapy

–Chemotherapy : Parentral, local

–Experimental modalities

Supportive therapy

Experimental modalities

Angiogenesis inhibitor

Growth factor inhibitor

Diffrentiating agents

Immunotherapy

Gene therapy

Antisense oligonucleotide

Supportive Therapy

Anticonvulsant

Corticosteroids

Anti-thrombosis agent

Psychotropic agents

Physical therapy

Goals of Surgery

Establish the diagnosis

Cure the patient

Decrease tumor burden

Relieve symptoms

Improve neurologic fungtion

Extend duration and quality of live

Basic concepts in cancer chemotherapy

-Chemotherapeutic agent kill only a percentage of cancer cell

-Some drugs kill only dividing cells

-Multiple drugs with differing site of action are better than a single drugs

-High dosee are better than low doses

Brain tumors anticonvulsant

Prophylaxis

— does not prevent first seizure

— probably useful in perioperative period

Treatment

— efficacy unclear

— side effects more commons

— hard to control levels

— best drug unknown

Advantages and Disadvantages of corticosteroid

Advantages

— control neurologic symptom by reduce

edema

— decrease acute RT toxicity

— relieve emesis from chemotherapy

— oncolytic (lymphoma)

Disadvantages

— side effects common

— decrease chemotherapy entry

 

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