CNS neoplasms

Question 1

Risk factors for CNS neoplasms?

3

Answer 1

1. Genetic mutation
2. Neurofibromatosis
3. Exposure to high dose ionizing radiation (radiation therapy, atomic bomb survivors, CT scans etc)

Question 2

Studies show slight increase in incidence of brain tumors in the following groups
3

Answer 2

1. White collar professionals
   - –Laboratory researchers, healthcare professionals
2. Electrical workers
3. Prior head trauma

Question 3

Classification of CNS neoplasms
are based on what?

Describe Grade I-IV?

Answer 3

1. Based on cellular origin and histologic appearance

Grade I-IV
Grade I: benign
Grade II: malignant
Grade III: malignant tissue that has cells that are actively growing
Grade IV: malignant tissue has cells that look most abnormal and tend to grow quickly

Question 4

Tumor Classification

3

Answer 4

1. Neuroglial (Glioma)
2. Meningioma
3. Schwannoma

Question 5

What are the three types of Neuroglial subtypes of neoplasms?

Subtype of schwannoma?

Answer 5

1. Astrocytoma
2. Oligodendroglioma
3. Ependymoma
4. Acoustic neuroma

Question 6

1. Glial tissue is what?
2. Derived from? 3
3. These are what percent of all malignant brain tumors?

Answer 6

1. the supportive tissue of the brain
2. Derived from astrocytes, oligodendrocytes or ependymal cells
3. Encompasses 80% of all malignant brain tumors

Question 7

Astrocytic tumors

1. what are the two subtypes?

Answer 7

1. Glioblastomas

2. Astrocytomas

Question 8

What are the 4 stages of tumors that arise from the astrocyte?

Give the grades and describe each

Answer 8

1. Grade I - is benign (excision is curative) almost always diagnosed in childhood
2. Grade II – slow growing and invade surrounding tissue
3. Grade III – Rare and require aggressive treatment due to tentacle like growth are hard to resect
4. Grade IV – also called Glioblastoma. Aggressive fast growing cancer

Question 9

Grade IV astrocytoma AKA Glioblastoma

1. generally located where?
2. benign or malignant?
3. Why are they very difficult to remove?
4. Survival range?
5. Treatment? 3

Answer 9

1. Generally located within the cerebral hemispheres of the brain
2. Usually highly malignant
3. Most common malignant brain tumor
4. Very difficult to remove due to finger like tentacles
5. Survival average is about 2 years
6. Treatment:
   - surgery
   - radiation
   - chemotherapy

Question 10

Glioblastomas

1. Can be what grades?
2. are most common where? 2
3. Can have areas of what?
4. Growth rate and progression?
5. What are the little holes on the MRI?

Answer 10

1. Can be grade II-III
2. Most common in the frontal or temporal lobes
3. Can have areas of hemorrhage
4. Generally slow growing and present for years before diagnosis
5. necrosis

Question 11

Oligodendroglioma

1. Whats the most common presenting symptom?
2. Frontal lobe tumors may cause what? 4
3. Treatment? 3

Answer 11

1. Most common presenting symptom is seizure
2. • Weakness on one side of the body
   • Personality changes
   • Behavior changes
   • Difficulty with short term memory
3. Treatment
   - Surgery
   - Radiation
   - chemotherapy

Question 12

1. Prognosis of oligodendroglioma?

2. Median time of survival?

Answer 12

1. Better prognosis than compared to astrocytic tumors

2. From time of diagnosis the median time of survival is 4-10 years

Question 13

Ependymoma

1. Where are ependymal cells found? 2
2. More common in what population?
3. Describe the age distribution?

Answer 13

1. Ependymal cells line the ventricles of the brain and the center of the spinal cord
2. More common in children
3. Bimodal distribution peaks at age 5-6 and 20-30 years

Question 14

Compare and contrast Intracranial Ependymoma (3 fetaures) and Spinal cord ependymona (4 features)?

Answer 14

Intracranial

1. Most common in kids
2. Poor prognosis
3. Symptoms are from increased ICP

Spinal cord

1. Most common in adults
2. Better prognosis
3. May cause cord compression symptoms
4. Most common spinal cord tumor

Question 15

What symptoms are from ICP?

7

Answer 15

• Hydrocephalus
• Headache
• Nausea, vomiting
• Ataxia
• Strabismus
• Irritability
• Altered mental status

Question 16

What are the most common primary brain tumor?

Answer 16

Meningioma

Question 17

Meningioma neoplasms are derived from what?

Answer 17

Derived from the meningothelial cells that arise from the coverings of the brain and spinal cord

Question 18

Meningioma

1. often benign or malignant?
2. Describe their growth pattern? 2
3. Treatment?

Answer 18

1. Often benign
2. • Usually grow inward putting pressure on the brain and spinal cord
   • Can grow outward and cause thickening of the skull
3. Treatment:
   - surgery
   - radiation

Question 19

Meningioma prognosis

1. 5 year survival rate?
2. Treatment? 2

Answer 19

1. Estimated 5 year survival rate is 73-94%
   Difficult to estimate due to many people found to have meningiomas die from other causes
2. Treatment:
   - Surgery
   - radiation

Question 20

Meningioma symptoms for the following pathophysiology?

1. Irritation? 1
2. Compression? 5
3. Sterotypic? 6
4. Vascular? 1
5. Misc? 2

Answer 20

1. Irritation:
   - seizures
2. Compression:
   - HA;
   - focal weakness;
   - dysphagia;
   - apathy;
   - somnolence
3. Stereotypic:
   - CN deficits;
   - change in mentation;
   - visual changes;
   - anosmia,
   - exopthalmos;
   - tongue atrophy
4. Vascular:
   - compression of cerebral arteries
5. Misc:
   - hydrocephalus;
   - panhypopituitarism

Question 21

Tumors of the cranial and paraspinal nerves

4

Answer 21

1. Schwannoma
2. Neurofibroma
3. Perineurioma
4. Malignant peripheral nerve sheath tumor

Question 22

1. What are schwannomas?
2. Describe their growth?
3. Benign or malignant?
4. Where do the tumor cells always stay?

Answer 22

1. Nerve sheath tumor composed of Schwann cells
2. Relatively slow growing
3. Mostly benign and less than 1% become malignant
4. The tumor cells always stay on the outside of the nerve

Question 23

So what is damaging about schwannomas because they dont go inside the nerve?

Answer 23

tumor itself may either push the nerve aside and/or up against a bony structure thereby possibly causing damage

Question 24

What is the most common schwannoma?

Answer 24

Acoustic neuromas are the most common schwannoma

Question 25

Acoustic neuroma 1. Arises from where? 2. Benign or malignant? 3. Describe its growth? 4. How can they cause serious complications? 5. What are other locations that this could be affecting?

Answer 25

1. Arises from the eighth cranial nerve 2. Benign 3. Usually slow growing 4. Can cause serious complications and even death if they grow and exert pressure on nerves and eventually on the brain 5. Other locations include the spine and, more rarely, along nerves that go to the limbs.

Question 26

Acoustic neuroma symptoms | 7

Answer 26

1. Unilateral hearing loss 2. Tinnitus 3. Occasional dizziness 4. Difficulty swallowing 5. Impaired eye movement 6. Taste disturbance 7. Unsteadiness

Question 27

Treatment of acoustic neuromas? | 3

Answer 27

1. Surgical excision 2. Stereotactic radiation surgery to arrest growth 3. In some cases they are followed by observation for growth

Question 28

acoustic neuromas: When would we observe the tumor without treatment? 5

Answer 28

1. Small tumor size, 2. not significantly symptomatic, 3. elderly, 4. poor surgical candidates or if the 5. patient declines other treatment

Question 29

Primary CNS lymphoma 1. Typically occurs in pts with what? 2. Derived from where? 3. Most often occurs where? 4. What structures may it involve? 3

Answer 29

1. Typically occurs in patients with immunodeficiency syndromes - --Organ transplant, HIV, autoimmune disease 2. Derived from the B lymphocytes 3. Most often occurs in the cerebral hemispheres 4. May involve the - eyes, - CSF or - spinal cord

Question 30

Treatment of CNS lymphoma 2 What do we usually not do in these patients?

Answer 30

1. Steroids to decrease brain edema - --May cause tumor regression 2. Chemotherapy and/or radiation Usually inoperable due to location deep in the brain

Question 31

1. Why can't you give steriods before the diagnosis of CNS lymphoma? 2. What is the most common brain tumor?

Answer 31

1. because the steriods will degreade and change the tumor enough so that you will get an incorrect diagnosis 2. metastatic tumors

Question 32

Metastatic tumors 1. What are the most common cancers to metastasize to the brain? 5

Answer 32

1. Lung 16-20% 2. Renal cell cancer 7-10% 3. Malignant melanoma 7% 4. Breast 5% 5. Colon 1-2%

Question 33

Treatment of metastatic tumors?

Answer 33

radiation or chemotherapy

Question 34

Clinical presentation is variable depending on what? 2 In general symptoms start with 3.____________ and move to more generalized symptoms as the 4.__________?

Answer 34

1. tumor size 2. origin 3. focal neurologic signs 4. tumor size increases

Question 35

What are the generalized symptoms of brain tumors? 5 What are the focal symptoms of brain tumors? 5

Answer 35

1. Headaches 2. Seizures 3. N/V 4. Depressed level of consciousness 5. Neurocohnitive dysfunction 1. Seizures 2. Weakness 3. Sensory loss 4. Ahpasia 5. Visual spatial dysfunction

Question 36

Symptoms of brain tumors | 7

Answer 36

1. Headache 2. Seizures 3 Syncope 4. Nausea and vomiting 5.Numbness, tingling, weakness 6. Balance issues 7. Cognitive dysfunction

Question 37

Congnitive dysfunction caused by brain tumors? | 5

Answer 37

1. Personality changes 2. Changes in memory, attention 3. Altered language ability 4. Problems with executive functioning 5. Change in daily patterns of eating and sleeping

Question 38

Describe tumor headaches 8 (which one is a big indicator)

Answer 38

1. Dull, constant 2. Usually bilateral and not throbbing 3. Occipital or frontal lobes 4. Increased with coughing or straining 5. Worse with change in body position or after lying down to rest 6. Tend to be worse at night and may awaken the patient from sleep**** 7. Nausea and vomiting 8. Change in pattern from usual headache 48% of patients with brain tumors have headaches

Question 39

According to American Family Physician "Any patient with chronic, persistent headache in association with what 5 things should be evaluated for a brain tumor"?

Answer 39

1. protracted nausea, vomiting, 2. seizures, 3. change in headache pattern, 4. neurologic symptoms, or 5. positional worsening

Question 40

Seizures are the most common symtpoms of what tumors? | 2

Answer 40

1. gliomas | 2. cerebral metastases

Question 41

Medical management of symptoms: 1. Headaches/Brain edema? 2. Seizures?

Answer 41

2. Headache/Brain edema - -Steroids * ****Decadron 2. Seizures Anti-seizure medications

Question 42

1. What is a tumor hemorrhage? 2. They can bleed a lot when given what? 3. In patients with WHAT? always be on the lookout for signs and symptoms of cerebral metastasis or hemorrhage.

Answer 42

1. Brain tumors bleed 2. They can bleed a lot when given anticoagulation - -They are a contraindication to thrombolytics 3. known cancer (example lung or renal cell)

Question 43

Primary care work up for brain tumors 1. History 2. PE includes? 3. Imaging? 1

Answer 43

2. Physical exam to include - complete neurologic evaluation - Include complete visual exam 3. Imaging - MRI with gadolinium - CT is not as detailed and difficult to see posterior fossa structures

Question 44

Complete neurologic exam to include what? | 3

Answer 44

1. stereognosis, 2. graphesthesia and 3. testing of CN I

Question 45

If you are going to do a CT scan looking for brain tumors what must you do?

Answer 45

give contrast!

Question 46

Neurosurgical workup: Whats involved? | 3

Answer 46

1. +/- Lumbar puncture to examine cells in certain cases 2. +/- cerebral angiogram 3. Biopsy

Question 47

Treatment? | 3

Answer 47

Surgical resection Chemotherapy Radiation

Question 48

Primary brain tumors stay where?

Answer 48

Primary brain tumors stay within the CNS