Brainscape's Knowledge GenomeTM


Top Flashcards (Certified)
All Flashcards

FRCR2 > CNS > Flashcards

CNS Flashcards

(101 cards)

Start Studying
1
Q

When is surgery considered as treatment for intracranial mets

A

Solitary or large met (>3cm)
Mets causing obstruction - hydrocephalus or raised ICP
Cystic or necrotic mets where SRS is less likely to be effective
Where histology / diagnosis will be helpful

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
2
Q

What are the criteria for SRS

A

An established diagnosis of cancer
Karnofsky performance status (KPS) >70
Absent or controllable primary disease (staging scans within last 3 months)
No previous SRS/SRT in the last 3 months
Life expectancy from extracranial disease >6 months
No pressure symptoms best relieved by surgery
Contrast enhanced MRI to evaluate cerebral metastases
Maximum combined treatment volume <20cc
Discussion at an MDT meeting

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
3
Q

What are the histological signs of a GBM

A

Epithelial / vascular proliferation
Necrosis

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
4
Q

What is the pathognomic mutation of an oligodendroglioma

A

1p19q co-deletion

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
5
Q

What is the pathognomic mutation of an astrocytoma (presuming high grade ancestry)

A

ATRX loss
(ATRX retained = GBM)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
6
Q

What is bright on a T1 MRI

A

T1 -> CSF dark & Tumour dark

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
7
Q

What is bright on T2 MRI & FLAIR

A

T2 -> CSF white & Tumour bright
T2 FLAIR -> CSF dark & Tumour bright with Oedema

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
8
Q

How do low & high grade tumours enhance with contrast

A

Low grade tumours tend not to enhance. High grade tumours enhance (due to endothelial / vascular proliferation)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
9
Q

Where and for whom do pilocytic astrocytomas occur, and how do they present

A

Typically in children, low grade tumour
Tend to occur in cerebellum, causing obstruction and obstructive symptoms (pressure sx and headache)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
10
Q

What is the dose fractionation for craniospinal irradiation for a non-germinoma

A

overall 54Gy/30#
36Gy/20# to whole CSA and 18Gy/10# boost to tumour bed

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
11
Q

What are the most common mutations seen in a pleomorphic xanthoastrocytoma

A

CDKN2A/B deletions (>90 percent)
BRAF V600E mutations (60-80 percent)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
12
Q

What is the benefit of adjuvant PCV in grade 2 gliomas

A

Buckner - 2016 NEJM
high risk Gr2 gliomas (<40yrs and subtotal resection or >40yrs) randomised to 6x adj PCV or not
PCV increased mOS to 13.3yrs from 7.8, and 10yr OS from 40% to 60%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
13
Q

When is immediate post-op RT indicated for a grade 2 glioma, vs at progression?

A

2 of:
Age >40
>6cm
Enhancement
Astrocytic
Crossing midline
Symptomatic

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
14
Q

What is the adjuvant RT dose for a low grade glioma

A

54Gy/30#

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
15
Q

What is the adjuvant dose for a grade 3 anaplastic oligodendroglioma

What adjuvant chemotherapy regime would typically follow

A

59.4/33#

Followed by 6x PCV adjuvant chemotherapy

12mth OS benefit to PCV adjuvantly

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
16
Q

What is the adjuvant dose for a grade 3 anaplastic astrocytoma

What adjuvant chemotherapy regime would typically follow

A

59.4Gy/33#

Temozolamide x12 cycles adjuvantly
Based on the catnon trial

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
17
Q

What is the post-operative RT regimen for a Gr4 GBM if <70 and PS0-1

And if <70 & PS2

And if >70

A

Concomitant CRT
60Gy/30# + concurrent TMZ (75mg/m2) & Co-trimoxazole prophylaxis 480mg M/W/F

Adjuvant chemotherapy
Adjuvant TMZ 150 - 200mg/m2 - D1-5 Q28 for 6 cycles

If <70 but PS2 - give RT only, without temozolamide

> 70: 40Gy/15# +/- concomitant tmz, and based on methylation status (based on Perry trial)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
18
Q

What RT dose is given to a butterfly glioma

A

30Gy/6# over 2wks, treating M/W/F

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
19
Q

What is the mOS for a GBM? and based on what trial

A

Stupp trial
CRT & adj tmz vs RT alone
Median OS: 14.6m vs 12m and PFS 6.9m vs 5m
2yr OS: 26.5% vs 10.4%

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
20
Q

Diffuse midline H3 K27-altered midline gliomas area considered what grade

Where are they typically located

How do they typically present

A

Always grade 4

most commonly in the pons, or other midline structures
(thalamus, brainstem - mesencephalon, pons, medulla, spinal cord)

Present with CN palsies, raised ICP and cerebellar sx.

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
21
Q

What is the dose objective & constraint to brainstem

A

54Gy (objective)
59Gy (constraint)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
22
Q

What is the dose constraint to spinal cord

A

48Gy (objective)
50Gy (constraint)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
23
Q

What is the dose objective & constraint to optic nerves

A

50Gy (objective)
54Gy (constraint)

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
24
Q

What is the dose objective & constraint to optic chiasm

A

50Gy - objective
54Gy - constraint

How well did you know this?
1
Not at all
2
3
4
5
Perfectly
25
What is the dose objective & constraint to lens
6Gy objective 10Gy constraint
26
What is the dose objective & constraint to globes
O - 40Gy C - 45Gy
27
What is the dose constraint to cornea
30Gy
28
What is the dose objective & constraint to retina
O - 45Gy C - 50Gy
29
What is the dose constraint to lacrimal gland
Mean <26Gy
30
What is the dose constraint to cochlea
Mean <45Gy
31
What are the acute side effects of brain RT
Alopecia Headache Nausea/vomiting
32
What are the late side effects of brain RT
Neurocognitive effect – memory loss Pituitary hypofunction Optic chiasm damage – may cause blindness Cataracts 2nd malignancies = 1%
33
What is the most common malignant tumour of the eye and ocular adenexa.
Non-hodgkin lymphoma - treat as primary CNS lymphoma
34
Where do ependymomas originate from Where is the commonest site How do they present
Ventricles - can occur anywhere within the neuraxis, and most commonly in the spine. Most common intracranial site is the posterior fossa Commonly cause obstruction, so tend to present with hydrocephalus
35
How are ependymomas graded
G1 - subependymomas or myxopapillary ependymomas G2 - cellular, papillary, clear cell and tanycytic G3 - anaplastic
36
What are the investigations for an ependymoma
MRI brain and whole spine MRI post op for extent of resection CSF 14 days post op to exclude circulating tumour cells
37
How is an ependymoma treated, and what determines adjuvant tx
surgery - resection of primary and mets adjuvant tx if incompletely resected if completely resected: G1 - surveillance only Gr2 - consider adjuvant tx Gr3 - RT (adults = involved field only, children = whole CSA) disseminated - CSRT with boost to all disease sites
38
How is the radio sensitivity of germinomas Where in the CNS do they tend to occur
very radiosensitive midline - pineal gland, suprasellar
39
What ix are required prior to starting treatment for a germ cell tumour
Ophthalmological assessment Audiogram GFR for patients due chemotherapy Endocrine assessment as indicated Fertility preservation
40
How is the management of germ cell tumour categorised?
Non-secreting germ cell tumour NS-GCT - 80% secreting
41
For a non-secreting germ cell tumour, how is treatment divided
Localised Metastatic
42
What is the treatment for a non-secreting localised germ cell tumour
Localised - 4x PIE chemotherapy (cisplatin, ifosfamide, etoposide), followed by CSRT 40Gy/25# overall, 24Gy/15# to CSA with 16Gy/10# boost to primary site
43
What is the treatment for a non-secreting metastatic germ cell tumour
No chemo 24Gy/15# CSA + tumour site boosts
44
For a secreting germ cell tumour, how is treatment divided
Localised Metastatic
45
What is the treatment for a secreting localised germ cell tumour
4 x PIE (neo-adjuvant) RT - 54Gy in 30# to primary (consider surgery for residual disease)
46
What is the treatment for a secreting metastatic germ cell tumour
Phase 1 CSA - 30Gy in 20# Phase 2 boost - brain sites - 24Gy in 15#; spinal sites - 16Gy in 10#
47
Where do medulloblastomas tend to occur How do they tend to present
Posterior fossa - midline for children, more likely lateralised for adults Tend to present with symptoms of obstruction / raised ICP, or cerebellar symptoms
48
What are the four subtypes of medulloblastoma
WNT, SHH, Group 3, Group 4
49
How are medulloblastomas investigated / worked up
1/3 metastasise through the CNS, so pts need a spinal MRI and LP pre-operatively, or 14 days post op, to exclude circulating tumour cells
50
What investigations are done post-op
MRI for possible residual disease If resectable, further surgeries are done for the most complete resection possible
51
How are medulloblastomas pts categorised post operatively
Standard or high risk Standard risk >3yrs age <1.5 cm residual disease  CSF cytology negative M0 (no metastases) on spinal staging WNT and SHH groups High risk  >1.5cm residual disease CSF cytology positive (LP) Metastases on staging imaging Group 3 or 4 histology 
52
What adjuvant treatment is given for medulloblastoma
CSA RT followed by chemotherapy
53
How is the CSA dose for medulloblastoma split What adjuvant treatment is given following RT
High risk: 36Gy/20# to whole CSA followed by 18Gy/10# boost to primary site, with vincristine Standard risk: 23.4Gy/13#, followed by primary site boost of 30.6Gy/17#, with vincristine Overall primary tumour receives 54Gy/30#, with standard risk receiving less to the CSA Following RT, adjuvant chemo is given High risk - 8x PACKER chemotherapy Lomustine, cisplatin, vincristine Standard risk - modified PNET5 regime Alternating cycles x8 of platinum/vincristine/lomustine, and cyclophosphamide
54
What is the prognosis of treated medulloblastoma
5YS approx 80% 10YS 60%
55
When is CSA RT indicated, and to what dose
All primitive neuroectodermal tumours (PNET): Medulloblastoma - 54Gy/30# overall, according to risk Supratentorial PNET Pineoblastoma Germ cell tumours: Germinoma Disseminated pilocytic astrocytoma Ependymoma: Gr3 adjuvantly for limited disease, or disseminated
56
What is the RT dose to the pituitary What is the CTV, and margins
Primary RT: 45Gy/25# or 54Gy/30# if functioning Adjuvant RT for macroscopic residual disease: 50.4Gy/28# GTV = residual disease, and reconstructed pre-op disease CTV = GTV +5mm, and whole pituitary fossa PTV = CTV +3mm
57
How do low grade gliomas appear on MRI
T1 - typically hypo intense and do not take up contrast T2 - Tumour is hyperintense, but no oedema Hyperintense on FLAIR
58
How do high grade gliomas appear on MRI
Hyper-intense on T1, take up contrast
59
How does a pilocytic astrocytoma typically present
Most commonly occurs in children/TYA, and cerebellum, presenting with obstructive sx
60
How is a pilocytic astrocytoma treated
Localised Tx: Surgery Disseminated Rare, usually arise in cerebellum, hypothalamic region, optic chiasm, near brainstem Tx: Craniospinal RT To start within 4 weeks of diagnosis Ph1 - CSRT - 24Gy/12# over 4 weeks (1.8Gy/#) Brain boost to tumour bed - 18Gy in 10# over 2 weeks +/- SC boost to disease sites - 14.4Gy in 10# over 2 weeks GTV - All visible enhancing tumour on T1W + gad CTV - GTV + 5mm, and include all meningeal reflections throughout CSA PTV - CTV + 5mm (but CTV-PTV margin depends on site within CSA - larger margins lower down the spine)
61
When should temozolamide and co-trimoxazole be held for deranged LFTs
ALT >148, ALP >325, bili >32 - hold co-trimox and tmp, until LFTs improved ALT >245 / ALP >650 / Bilirubin >63 - discontinue both and continue RT alone
62
How does a craniopharyngioma typically present
Visual defect: lower quadrantanopia (tumour pushes down from above) Hormone deficiency & Raised prolactin due to compression of pituitary stalk Headaches Obstructive hydrocephalus Diabetes insipidus - loss of ADH
63
How is a craniopharyngioma treated
Surgery if possible Primary RT if inoperable , or incomplete resection / recurrence. RT 75-90% effective for local control Dose: Adjuvant - 50Gy/30# Primary dose - 54Gy/30# GTV-CTV: 5mm Need to include all areas contacted by the tumour in the CTV CTV-PTV: 3mm"
64
When is RT indicated for an ependymoma And at what dose How is metastatic ependymoma treated
Indications: Incomplete resection if pt >3 yrs old. G3 tumours or high risk grade 2 Relapsed disease if no previous RT Adjuvant: Intracranial - 54Gy in 30# (protons for children) Spinal cord - 50-55Gy in 30-33# Cauda equina - 54Gy in 30# - 59.4Gy in 33# Metastatic: CSRT -> 36Gy in 20# to CSA & Boost to individual sites of spinal disease up to 50.4Gy If there is positive cytology and no gross visible disease outside the primary location, give craniospinal fields 45Gy/25# over 5 weeks followed by boost of 14.4Gy/8#"
65
What is the grading of ependymoma
G1-3
66
What proportion of pituitary macro adenomas are non-secreting
25%
67
What CNs are affected for a cavernous sinus tumour
III, IV, Va, Vb, VI
68
What are the treatment options for a pituitary tumour
If non-secreting and no threat to vision - observation If secretary and threat to vision: Medical - cabergoline/bromocriptin/lanreotide Surgical - indicated if threat to vision or failure of medical mx Surgical approach is typically trans-sphenoidal, but can be transcranial if there is superior extension RT: failure of medical mx but not fit for surgery, recurrence or residual disease, or persistent hormone secretion
69
What is the outcome of surgery + RT to a pituitary tumour
80% relapse free survival at 20 years
70
What is the rate of optic neuropathy for pituitary RT
1%
71
How would a VS typically present
Unilateral sensorineural hearing loss Balance problems Involvement of the trigeminal nerve - facial pain or altered sensation May expand into posterior fossa to occupy cerebellopontine angle -> compression of CN V, VII, VIII
72
What is the treatment for a VS
Only 50% grow - monitor for serial growth Surgery for young pts and large / cystic tumours RT - SRS 12Gy/1# or 50Gy/30# fractionated
73
What margin is used for VS SRS & fractionated
SRS: GTV-CTV = 0mm CTV - PTV=1mm Fractionated: GTV = CTV = visible tumour CTV-PTV = 3mm
74
where are the typical sites of chordoma What marker is sent What is the complication
Spheno-occipital Sacral spine Brachyury Chordomas tend not to metastasise but can be locally invasive and have a high rate of recurrence
75
What is the management of a skull base chordoma
Surgery and adjuvant RT, typically protons given location at the skull base Chordomas receive 70Gy, chondrosarcomas 72Gy CTV: Clival lesion - GTV + entire clivus / sphenoid bone Vertebral lesion - GTV + entire vertebral body PTV: CTV +3mm for skull base, 7mm elsewhere
76
Where do paragangliomas tend to occur What investigation is needed before treatment What mutation is associated
Paravertebral - tend to be chromatin positive and release catecholamines In relation to the great vessels of the head and neck eg carotid bodies - tend to be chromatin negative and don't release catecholamines Need MRI brain and whole spine to exclude phaeochromocytoma 10% are associated with SDH-mutation
77
What is a glomus jugulare tumour
Paraganglioma arising from jugular foramen Affect CN IX, X and XI
78
How are meningiomas classified
Gr1-3
79
How is a meningioma resection classified
Simpson classification Stage 1 - Complete excision including dura and bone (tumour + dura + bone) Stage 2 - Complete excision with co-angulation of dural attachment (tumour + dura) Stage 3 - Excision of intradural tumour, without resection of it’s dural attachment (tumour alone) Stage 4 - Partial removal, leaving intradural tumour in-situ Stage 5 - Decompression only +/- biopsy
80
What are the indications for RT for a meningioma
Primary RT: Option for Grade 1 Inoperable Recurrence Adjuvant RT: Incomplete resection Grade 3 Atypical histology
81
What RT dose is given to meningioma
SRS - 12-15Gy/1# Fractionated: G1 - 50Gy/30# G2 - 55Gy/33# if Grade 2 G3 or sarcomatoid - 60Gy in 30#
82
What dose is given to an optic nerve sheath meningioma
54Gy in 30#
83
What are the RT volumes for a meningioma
Residual disease GTV - Residual meningioma, hyperostotic bone and dural extension CTV - GTV +1cm in plane of dura If brain invasion present -> add 1cm into brain from brain/meningioma margin Include all abnormal, hyperostotic bone not in GTV PTV - CTV + 3mm No residual disease GTV - Pre-op MRI -> define largest extent of dural/bone thickening CTV - GTV + 1cm in plane of dura, if documented brain invasion add 1cm into brain Include all abnormal, hyperostotic bone PTV - CTV + 3mm
84
What is the treatment algorithm for a low grade glioma
Maximal surgery +/- RT (50.4Gy/30#) & 6x PCV
85
What are the indications for upfront RT & ChT for a low grade glioma
Large initial tumour, >4cm Incomplete resection / residual disease >40yrs New or worsening neurological deficit
86
Does vincristine need dose adjustment for renal or hepatic impairment
No renal dose adjustment Adjusted for hepatic impairment if bili >51 or ALT/AST >60
87
What is the prognosis of a Gr3 oligo
5-yr OS: 30-35% mOS 42mths with RT and PCV (oligo)
88
What is the prognosis of a Gr3 astro IDH mut
60-100mths
89
What is the prognosis of a Gr4 astro IDH mut
36mths
90
What is the prognosis of a GBM IDH WT, mgmt methylated
20mths
91
What is the prognosis of a GBM IDH WT, mgmt unmethylated
12mths
92
What is the prognosis of a Gr1 tumour
Curable 80% 10yr survival
93
What is the prognosis of a Gr2 tumour
med survival 5-10yrs Buckner - mOS 13.3yrs with RT & PCV
94
What is the prognosis of a Gr4 tumour
Stupp trial (age <70yrs) - mOS 14.6 for GBM with tx 2yr OS 26% Pts with complete resection did better, and methylated MGMT vs unmethylated
95
What is the prognosis of a GBM if age >70
Perry 2017 - 9.3mths with treatment (up to 12 cycles adj tmz) for all comers If methylated - mOS 13.5mths Most benefit in those with MGMT methylation. No statistically significant benefit for tmz if unmethylated
96
How is a pineoblastoma treated
NA vinc/carbo/etopo x3-4 (treat like neuroendocrine) CSA RT
97
what factors should be considered when considering RT treatment of brain mets
Controlled or treatable extracranial disease PS 0-1 (KPS ≥70) Prognosis of at least 6mths
98
When should fractionated intracranial RT be considered over SRS What dose is typically used for fractionated RT
Lesions larger 2-3cm, lesions close to a critical OAR or where V12Gy ≥10cm3 (the volume of normal tissue, excluding GTV, that receives at least 12Gy) V12Gy of 5, 10 and >15cm3 = risk of radio necrosis of 10%, 15% and 20% 27Gy/3# or 30Gy/5#
99
What is the commonest primary brain tumour in adults
meningiomas, followed closely by astrocytomas
100
What is the commonest malignant brain tumour in adults
glioblastoma multiforme.
101
What is the commonest brain tumour and malignant brain tumour in children
low grade pilocytic astrocytomas commonest malignant primary brain tumours -medulloblastomas

FRCR2 (38 decks)

Brainscape helps you reach your goals faster, through stronger study habits.
© 2025 Bold Learning Solutions. Terms and Conditions