Lindsay A Wilson, pgy2 AM Report 1/27/2010

Brain Tumors

Outline.
1. Review cancers that are metastatic to the brain. 2. Review classification of brain tumors confined to the meninges and brain parenchyma (Glial versus Non-glial). 3. Review common brain tumors. 4. Mention brain tumors found mainly in kids

Mets

Metastatic brain tumors (cancer that spreads from other parts of the body to the brain) occur at some point in 10 to 15% of persons with cancer and are the most common type of brain tumor. Breast Melanoma Kidney GI Thyroid Lung
Ovarian Testicular

Primary Brain Tumor Basics

Adults=supratentorial vs Kids=Infratentorial Brain tumors rarely metastasize Benign can be bad due to mass effects Easy way to divide types of brain tumors is glial versus nonglial (50/50). Glial cells = astrocytes, oligodendrocytes, and ependymal cells. Of primary CNS tumors=80% "Alarm symptoms" that point to brain tumor: Headache recurs frequently, is severe, starts in someone who hasn't had headaches before, occurs at night, is present upon awakening, is accompanied by nausea, vomiting, poor balance/coordination, double vision, and/or dizziness. The third leading cause of cancer death in young adults ages 20-39.

WHO Classification

Tumours of neuroepithelial tissue (glial) Astrocytic tumours*** Oligodendroglial tumours*** Mixed gliomas*** Ependymal umours*** Choroid plexus tumours*** Neuronal and mixed neuronal-glial tumours Neuroblastic tumours** Pineal parenchymal tumours **Embryonal tumours Tumours of peripheral nerves Schwannoma (Neurinoma)** Neurofibroma** Perineurioma Malignant peripheral nerve sheath tumour (MPNST) Tumours of the meninges Tumours of meningothelial cells: Meningioma (WHO grade I) Atypical meningioma WHO grade II) Anaplastic meningioma (WHO grade III) Mesenchymal, non-meningothelial tumours: Primary melanocytic lesions Lymphomas and haemopoietic neoplasms Malignant lymphomas** Plasmacytoma** Granulocytic sarcoma** Germ cell tumours Germinoma** Embryonal carcinoma** Yolk sac tumour Choriocarcinoma** Teratoma** Mixed germ cell Tumors of the sellar region Craniopharyngioma** Granular cell tumour** Metastatic tumours

Data from Louis, DN, Ohgaki, H, Wiestler, OD, Cavenee,WK. WHO Classification of Tumours of

he Nervous System. IARC Press, Lyon 2007.

GLIAL TUMORS
Astrocytoma: 20% primary intracranial neoplasms Life expectancy approximates 5 years, worse prognosis if transformation to glioblastoma multiforme occurs (10% of cases) Four grades...with grade IV being GBM If low grade: Difficult to resect but complete resection is better than debulking alone Often follow surgery w/ RT If really small, will delay surgery until symptoms or signs of growth

GLIAL TUMORS
High grade= Glioblastoma multiforme Most common brain tumor Poor prognosis, often death < 1 year Tumor crosses the corpus callosum=butterfly Key path: Pseudopalisades and pseudorosettes

GLIAL TUMORS
Oligodendrogliomas 5% of glial tumors frontal lobe path=fried egg surgery +/- adj. therapy RT chemo sensitive Ependymomas 5% of glial tumors, kids>adults 4th ventricle--obstruct flow of CSF rsxn, then radiation, chemo in adults, see in spinal cord (75%)

NON-GLIAL
Meningioma Second most common primary intracranial neoplasm (account for 20%) Tumor is external to the brain (displaces brain tissue) More common in women than men Most often occurs after the age of 40 Originates in the arachnoidal cells Considered a benign, slowly growing tumor Can erode contiguous bone Can be seen in association with NF-2 Can be induced by radiation therapy (1960s tinea capitus)

Treatment: -Can be conservative (ie no treatment) -Surgery (either full or partial resection depending on tumor location), sometimes preceded by embolization -Radiation can be primary treatment or adjunct to surgery

NON-GLIAL

Schwanomma (acoustic neuroma) Tumor derived from Schwann cells Acoustic neuromas may cause tinnitus, deafness, compression of other CNs Surgery usually results in cure (RT also used, can observe too) NF2 (neurofibromatosis) is characterized by bilateral acoustic neuromas (autosomal dominant syndrome)

NON-GLIAL
Lymphoma Primary B-cell AIDS immunosupp. link to EBV MTXbased chemo RT Ocular involv. slit lamp exam

NON-GLIAL
Hemangioblastoma Often syndromic and hereditary (Lindau, von HippelLindau=mutations in tumor suppressor gene VHL) Can secrete erythropoitin and induce polycythemia Highly vascularized Originates in the cerebellum Embolization then surgery

Brain tumors that are more common in kids (and therefore not discussed any further)
Choroid plexus papilloma Neuroblastoma Retinoblastoma Medulloblastoma Ganglioglioma Germ cell tumors (can be in young men)

Works cited
Rubins Uptodate Wikipedia Merck Manual Pathology Board Review Series NMS Medicine