Neuro Oncology

Question 1

Spatial impairment / “getting lost in a familiar area” suggests . . .

Answer 1

. . . parietal involvement

Question 2

Brain tumor headache

Answer 2

Usually dull, intermittent, non-throbbing, frontal

May mimic tension-type OR migraine type

Classically “worse in the morning” and progressive

Question 3

“Hiccups” may indicate . . .

Answer 3

. . . phrenic nerve irritation

Question 4

Non-contrast CT in brain tumors

Answer 4

~90% sensitive

Suprisingly helpful

Question 5

Magic Dr for Ring enhancing lesions on MRI

Answer 5

• Metastasis
• Abscess
• Glioma
• Infarct (Resolving)
• Contusion (resolving hematoma)
• Demyelinating disease (tumefactive MS, because it looks like a tumor)
• Radiation necrosis

Question 6

Brain abscesses on MRI

Answer 6

Central restricted diffusion

Basically all the pus is what enhances

Question 7

“Multiple ring enhaning lesions”

Answer 7

Toxo should be high on the differential

Question 8

Smooth and thin borders of a ring enhancing lesion

Answer 8

abscess

Question 9

When to steroids and when not to steroids in brain tumors

Answer 9

• Dexamethasone is the preferred steroid
• We avoid in possible lymphoma or in immunocompromised patients
• But, for most other solid brain tumors, they are indicated

Question 10

Surgery in brain cancer

Answer 10

Surgery virtually never cures adult glioma

Biopsy is usually the indication for surgery in the setting of brain tumor

Question 11

A meningioma often has a ___, which can be seen on imaging

Answer 11

A meningioma often has a dural tail, which can be seen on imaging

Question 12

“CSF cleft”

Answer 12

Thin ribbon of CSF that can be seen around a meningioma, indicating that it is NOT attached to the brain parenchyma

Question 13

Risk factors for meningioma

Answer 13

NF2

Radiation exposure

Question 14

CNS lymphoma has a ___ distribution on MRI

Answer 14

CNS lymphoma has a paintbrush splatter distribution on MRI

Question 15

When patients are immunocompromised, CNS lymphoma looks. . .

Answer 15

. . . ring-enhancing, rather than blotchy otherwise

It looks a lot more like an abscess.

Question 16

Induction and maintenance therapy for brain tumors

Answer 16

Induction: Methotrexate or rituximab + methotrexate

Question 17

Complications of treatment for brain tumors

Answer 17

Radiation and methotrexate can both cause leukoencephalopathy as a complication

Question 18

Foster-Kennedy syndrome

Answer 18

A clinical syndrome of ipsilateral atrophy of the optic nerve (due to nerve compression), contralateral papilledema (due to elevated ICP), and anosmia.

Usually caused by frontal lobe tumors, most commonly meningiomas.

Question 19

In women, prolactinomas often present with ___.

In men, prolactinomas often present with ___.

Answer 19

In women, prolactinomas often present with galactorrhea.

In men, prolactinomas often present with erectile dysfunction, gynecomastia, and loss of axillary hair.

Question 20

“Thyrotropic” pituitary adenoma

Answer 20

Caused by secondary hyperthyroidism (TSHoma)

Primary hypothyroidism with secondarily increased TSH does not technically count under this diagnosis.

Question 21

Can aripiprazole cause hyperprolactinemia?

Answer 21

NO!

Because it is special among the dopamine blockers.

. Aripiprazole acts as an agonist under hypodopaminergic conditions (thereby preventing hyperprolactinemia) but antagonizes D2 receptors under hyperdopaminergic conditions (thus retaining its antipsychotic effect).

Question 22

Typical locations of various brain tumors

Answer 22

Question 23

Most common cause of acquired hypopituitarism in children

Answer 23

Craniopharyngioma

Question 24

What is going on in this image?

Answer 24

Medulloblastoma

Note the solid and cystic components (cystic is the inferior-most) and the location

Commonly in kids. They present with truncal ataxia, generalized cerebellar abnormalities, and double vision/oculomotor abnormalities

Question 25

“Multiple round lesions at the gray-white junction”

Answer 25

In other words, “metastatic malignancy”

Question 26

What is going on in this image?

Answer 26

A pilocytic astrocytoma

It is the most common brain tumor found in children and is usually located within the posterior fossa

Question 27

Most common pinealoma in children

Answer 27

A germinoma, which secretes β-hCG

Increased β-hCG stimulates the Leydig cells of the testes to produce excessive testosterone, which causes precocious puberty in boys

Question 28

Parinaud syndrome

Answer 28

• Syndrome of four ocular anomalies:
  
  • Vertical gaze palsy with nystagmus on upward gaze
  • Argyll Robertson pupils
  • Light-near dissociations
  • Unilateral/Bilateral lid retraction (Collier’s sign)
• These symptoms are due to compression of the superior/inferior colliculi and Edinger-Westphal nuclei
  
  • May be caused by: pinealoma, MS, hydrocephalus, stroke

Question 29

A medulloblastoma classically presents in __ in a young child.

An ependymoma classically presents in __ in a young child.

Answer 29

A medulloblastoma classically presents in the cerebellar vermis in a young child.

An ependymoma classically presents in the fourth ventricle in a young child.

Question 30

“Headache that is worse in the morning” + “Babinski sign” = ___

Answer 30

“Headache that is worse in the morning” + “Babinski sign” = Frontal lobe tumor

Question 31

Options for treatment in metastatic brain cancer

Answer 31

• Steroids to reduce intracranial edema
• If there is a single brain lesion (oligometastatic disease), surgery or whole brain radiation (preferably gamma knife) improves survival
  
  • Stereotactic radiation is used in tumors that are surgically inaccessible

Question 32

Favorable prognostic factors in metastatic brain cancer

Answer 32

• Age < 60
• Two or less brain mets
• Good baseline function
• Successful surgical resection

Question 33

Two most common cancers to metastasize to the brain, in order

Answer 33

1. Lung cancer
2. Breast cancer