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Neuro 2 > Neuro Oncology- Betsy > Flashcards

Neuro Oncology- Betsy Flashcards

1
Q

How are brain tumors classified

A

Benign vs. Malignant.
Then Malignant are either metastatic or primary (more metastatic than primary when they’re malignant)

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2
Q

What cancers are primary sites for metastatic spread

A
  1. Lung
  2. Breast
  3. Melanoma
  4. Colon
  5. Renal
    most located in cereburm
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3
Q

What are the most prevalent brain tumor types in adults

A
  1. Meningiomas — most common
  2. Gliomas (glioblastomas, ependymomas, astrocytomas, oliogdendrogliomas) these have a higher mortality rate
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4
Q

What are gliomas

A

primary tumor
1. Morphologically and biologically heterogeneous group of primary CNS tumors
2. Arise from precursors of astrocytes or oligodendrocytes —> astrocytomas and oligodendroglioma
3. Higher grade tumors arise from previously low grade lesions or de novo primary lesions.
4. Surgery is usually not possible.

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5
Q

Low grade or diffuse astrocytomas (grade II)

A
  • Uncommon, tend to be very slow growing
  • Found in cerebrum
  • Tumor progression is highly variable
  • Surgical resection — plus radiation if incomplete resection.
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6
Q

Anaplastic astrocytoma (grade III)

A
  • Anaplastic — Loss of differentiation of the cell
  • Malignant tumor, typically located in the cerebral hemisphere
  • Presents with seizure, symptom of increased intracranial pressure, focal neurological dysfunction
  • Surgical resection followed by radiation and chemotherapy.
  • Headache isn’t usually the first sign — seizures are.
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7
Q

Glioblastoma (Grade IV)

A
  • Most common primary malignant brain tumor, tumor cells are undifferentiated
  • Prognosis is poor
  • Tumor tends to be localized to the cerebral hemisphere — classic butterfly appearance on image which is a cardinal sign
  • Presents with focal symptoms of increased intracranial pressure and focal neurological dysfunction
  • Surgical resection to relieve mass effect, radiation, and chemo
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8
Q

What is pseudo progression

A

Can happen after radiation treatment = it appears to be worsening on radiographic imaging. Necrosis of the tissue where the tumor was which can present as the tumor itself.

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9
Q

Oligodendroglioma (Grade II or III)

A
  • Primary tumors tend to arise in the frontal love or white matter — tends to infiltrate the cortex making surgical cure difficult
  • On imaging — these tumors are not distinguishable from astrocytomas so imaging alone isn’t enough for dx
  • Slow growing = prolonged period of symptoms prior to dx
  • Low grade = respectable if in an accessible region of the brain but if not respectable there is controversy over best treatment.
  • Over time low grade oligodendrogliomas transform into Anaplastic tumors = deadly in most patients.
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10
Q

What are meningiomas

A
  • Usually benign
  • Intracranial tumors that arise from meningothelial arachnoid cap cells of the meninges
  • Majority are benign, slow growing tumors that compress brain tissue (rarely invades)
  • Surgical resection is difficult if they invade the sinuses and encase cerebral arteries
  • Can penetrate bone and present as a scalp mass
  • Presentation is dependent on location — focal seizures, neuro deficits from brain and cranial nerve compression
  • Surgery is gold standard if tumor is NOT invading the brain tissue. If unresectable then radiation
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11
Q

Presenting signs and symptoms of brain tumors

A
  1. Clinical signs and symptoms of primary tumors may be general or focal
  2. Initial symptoms are often focal —> generalized symptoms as the tumor increases in size and spreads
  3. General —> due to increased intracranial pressure
    — headache = tension type or migraine
    — epileptic seizures
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12
Q

Diagnosis of brain tumors

A
  1. Generally through a combo of history and physical examination finding — corroborated by imaging support.
  2. MRI of the brain is standard of care
    — determines the location of the tumor, extent of involvement, effect of compression due to edema on the brain parenchyma, vessels and other structures.
    — Intravenous contrast — enhancement of areas that have had disruption of the blood-brain barrier
    — contrast — differentiate between the actual primary mass and peri tumoral edema
    — Limitations: difficulty distinguishing between necrotic tissue and recurrent tumor.
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13
Q

Other ways of diagnosis for brain tumors

A
  1. CT — for those with contraindications to MRI and provides structural and anatomical characteristics of the intracranial tumors in question
  2. MR Spectroscopy and PET scans — further clues into the nature of intracranial tumors
  3. Sometimes need to identify the vascular supply to see if there is a blood supply to the bad tumor
    There is no imaging that differentiates between primary brain tumors and metastatic or non-neoplasticism disease.
    Primary brain tumors rarely spread beyond the brain or SC
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14
Q

Biopsy for brain tumors

A
  • Used in cases when diagnosis with imaging is inconclusive or needs to be confirmed
  • Intraoperative stereotactic biopsy: biopsy of intracranial lesions through a burr hole based on the stereotactic coordinates — minimally invasive.
  • Biopsy is guided by CT and MRI
  • Pretty minimally invasive
  • Good for deep seeded lesions
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15
Q

Management for brain tumors

A
  1. Observation
  2. Surveillance — like a watch and wait thing
  3. Surgical resection
  4. Chemo
  5. Radiation therapy
  6. Combo treatment
    You have to address the tumor itself as well as the neuro séquelas
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16
Q

Initial management of brain tumors (steroids)

A

Steroids — wanna reduce the amount of swelling around the tumor which can help minimize some of the impact. Want minimize the symptom burden due to associated vasogenic edema
— Dexamethasone = steroid of choice
— Complications and side effects: steroid-induced myopathy, anxiety, insomnia, psychosis, delirium, Cushing syndrome, steroid-induced hyperglycemia, fractures of the spine and hip, avascular necrosis of the hip

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17
Q

Initial management of brain tumors (Seizure management)

A
  1. Most common presenting symptoms in patients with brain tumors
  2. Surgical resection of malignancy effectively controls the seizures
  3. Administration of anti-epileptic drugs — standard of care in patients with intracranial malignancy
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18
Q

Initial management of brain tumors (Surgical resection)

A
  1. Considered for patients who have significant disease burden to minimize symptoms
  2. Extent of safe tumor resection dependent on: tumor location, patient performance status, patient age.
  3. Benefits of maximal tumor resection include: relief of mass effect, decreased tumor burden, improved diagnosis, possibility of prolonged survival.
    typically followed by radiation therapy and chemo
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19
Q

Initial management of brain tumors (Radiation therapy)

A
  1. Use as primary treatment or following surgical resection
  2. External beam radiation: most common for localized tumors, utilizes 3D imaging for radiation planning, allows for precise delivery of radiation beams from numerous angles.
  3. Gamma Knife Radiosurgery: treats without incision, concentrated radiation dose (201 beams of radiation interact to treat a small area of tissue in the brain), tends to spare the adjacent normal, healthy tissue so used more with metastatic lesion.
20
Q

Side effects of radiation therapy

A
  1. Acute radiation encephalopathy — onset is days to weeks after initiation of radiation.
    — Symptoms include: headache, nausea, lethargy, and new onset or worsening focal symptoms = responds to increased corticosteroids
  2. Early delayed encephalopathy
  3. Late delayed encephalopathy
  4. Long-term cognitive changes
21
Q

Acute Radiation Encephalopathy

A
  • Onset is days to weeks after initiation of radiation.
  • Symptoms include: headache, nausea, lethargy, and new onset or worsening focal symptoms = responds to increased corticosteroids
22
Q

Early Delayed Encephalopathy

A
  • Decline in status occurring 1-6 months after radiation
  • Produces a somnolence syndrome — extreme lethargy in conjunction with signs of increased intracranial pressure
  • May respond to corticosteroids.
23
Q

Late Delayed Encephalopathy

A
  • Occurs 6 months to a year after radiation, especially in high doses
  • Presents as a focal necrosis and can be life threatening
24
Q

Chemotherapy for brain tumors

A
  • Regimen based on the tumor subtype
  • Commonly used agents: Temozolomide, Bevacizumab, Irinotecan.
    *bigger issue is the tumor and resulting edema
25
Q

What do spinal tumors ultimately cause that leads to symptoms

A

Spinal cord compression

26
Q

Extramural spinal tumors

A
  1. Refer to lesions outside the dura mater, in the vertebral bodies and arches: osseous structures, paravertebral region including paraspinal musculature, epidural space.
  2. Primary or secondary due to metastatic disease which is usually more malignant.
27
Q

Where is most common site of osseous metastases

A

Spinal column
Lesions may be osteo lytic, osteoblastic, or mixed: lesions alter normal bone architecture and can result in deformity or collapse of the affected vertebral body = SPINAL CORD COMPRESSION

28
Q

Clinical manifestation for epidural spinal cord compression

A
  1. Pain — localized, mechanical, radicular
  2. Motor weakness
  3. Sensory impairments — often one of the first signs
  4. Autonomic symptoms — bowel and bladder is big concern
  5. Gait and trunk ataxia.
29
Q

Intradural Extramedullary Tumors

A
  • Primary tumors — located within the dura mater but outside of the spinal cord parenchyma.
    — tumors arise from peripheral nerves, nerve sheaths, and sympathetic ganglion
    — Most commonly benign
  • Can lead to spinal cord compression and vascular compromise.
30
Q

What is extramediullary metastases

A
  1. Common complication of cancer.
  2. Most common site of involvement — dorsal aspect of spinal cord at level of cauda equina
31
Q

Clinical manifestation of spinal cord compression from intradural extramedullary tumors?

A
  1. Presents similarly to epidural spinal cord compression BUT with a higher incidence of neurological symptoms
  2. Pain = typically the initial symptom. Pain worse in recumbent poistions
  3. Weakness
  4. Motor deficits may manifest in the absence of pain
  5. Sensory involvement
  6. Bowel, bladder, and sexual dysfunction can be an early finding.
32
Q

Intradural Intramedullary tumors

A
  • Primary tumors — located within the spinal cord parenchyma, arises from glial cells, neuronal cells and other connective tissue
    — typically benign
    — Can be found anywhere in the spinal cord, cervical and cervico-thoracic are more favored locations
  • Intramedullary lesions cause neurological injury through direct compression of the surrounding spinal cord and vascular compromise
33
Q

What is Intramedullary spinal cord metastases

A

Very rare but usually occurs in the setting of extensive metastatic disease. Rarely the first manifestation of systemic malignancy.

34
Q

Clinical manifestation of Intradural Intramedullary spinal cord compression

A

*similar to extramural tumors
1. Pain = most common symptom
2. Neurological deficits = common — not like motor weakness but more neuro signs
3. Sensory deficits
4. Bowel, bladder, and sexual dysfunction

35
Q

Diagnosis of spinal tumors

A
  • Physical exam should include: assessment of strength, sensation, reflexes, and sphincter function
  • MRI is gold standard — gives accurate anatomic assessment of the soft tissue structures.
  • X RAY is useful in screening for lytic or sclerotic lesions, pathological fractures, spinal deformities, and large masses.
  • CT gives detailed imaging of osseous anatomy of the spine and degree of tumor involvement. Helpful if there is a suspected metastatic disease
36
Q

Management of spinal tumors

A

Management varies based on tumor type, treatment history, spinal stability, neurological status, and pain intensity
Management options: surgical resection, chemo, radiation, and combo treatment
- Neuro status prior to treatment is an important predictor of neurologic and functional status following treatment.

37
Q

Surgery for spinal tumors

A
  • mainstay of treatment as long as the predicted lifespan >3 months
  • Surgical options are aimed at preventing or reducing spinal cord compression
    — If indirect decompression: reduce pressure on spinal cord/nerve roots by removing bone
    — If direct decompression: removing tumor
38
Q

Indications for surgery for spinal tumors

A
  1. Paraplegia lasting more than 12-24 hours in patients with prior radiation to the spine
  2. Spinal instability
  3. Bones compression of the spinal cord.
39
Q

Goals of surgery for spinal tumors

A
  1. Preserve neurologic function
  2. Reduce pain
  3. Ensure mechanical stability
40
Q

Radiation for spinal tumors

A
  • Allows for pain relief, prevention of pathological fracture, stabilization of neurologic function
  • Side effects: damage and fibrosis to the spinal cord, exiting roots, and nerves and surrounding musculature, GI toxicity, mucositis, fatigue
    clinical manifestation of side effects = myelopathy, radiculopathy, neuropathy, plexopathy, myopathy
41
Q

What are radiation myelopathy subtypes

A
  1. Acute complete paralysis
  2. Acute transient radiation myelopathy
  3. Chronic progressive radiation myelopathy
42
Q

What is acute complete paralysis

A

Rare, related to radiation-induced vascular damage resulting in spinal cord infarction

43
Q

Acute transient radiation myelopathy

A
  • Most common form
  • Occurs 1-29 months after completion of radiation therapy
  • Due to demyelination of the dorsal columns
  • Clinical manifestation include: Lhermitte sign without neuro changes on exam
  • Treatment — reassurance as symptoms resolve over weeks/months
44
Q

What is chronic progressive radiation myelopathy

A
  • Most feared form
  • Occurs 9-15 months after radiation therapy
  • characterized by a latent period during which patients are asymptomatic.
  • Clinical manifestation: ascending weakness, diminished sensation, and clumsiness, brown-sequard pattern of deficits, tends to be a steady progression of neuro deficits over the course of weeks to months
  • No effective treatment
45
Q

Pharma management for spinal tumors

A
  1. Role of chemo in spinal tumors is unclear
  2. Corticosteroids
    — may be an initial part of treatment in spinal tumors
    — Reduce tumor and spinal cord vasogenic edema resulting in improvement/stabilization of neuro deficits
    — Provide analgesia for pain
  3. Bisphosphates
    — Inhibit osteoclast activity and suppress bone reabsorption associated with spinal metastases
    — Effective in reducing the risk of pathological fractures, relieving pain, and reducing malignancy-associated hypercalcemia

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