surgery - NEURO neurological malignancy

Question 1

what is a glioma?

Answer 1

includes all primary brain tumours that originate from neuroepithelial glial cells (including ependymal cells, astrocytes, oligodendrocytes and astrocytes)

both adults and children affected.

Question 2

which type of glioma most common in kids?

Answer 2

low grade glioma

Question 3

main types of gliomas?

Answer 3

ependymomas, astrocytomas, and oligodendrogliomas.

Question 4

how are gliomas classified?

Answer 4

Gliomas can be classified by histological cell type (as above), location* (infratentorial vs supratentorial) or grade (grade I to IV).

Question 5

what is low/high grade glioma?

Answer 5

low grade (Grade I and II)
High grade tumours (Grade III and IV) - poorer prognosis

Question 6

features of gliomas?

Answer 6

same as space-occupying lesion
seizures*, cranial nerve palsies or visual field defects, language dysfunction, or features of raised intracranial pressure

Question 7

ix for gliomas?

Answer 7

CT head imaging with IV contrast
MRI
angiography
biopsy through stereotactic or open exploration

Question 8

what dis?

Answer 8

glioma L parietal lobe

Question 9

mx of low grade gliomas?

Answer 9

watch and wait approach through radiological surveillance
regular MRI scans

surgery = total or partial tumour debulking
radio + chemotherapy

Question 10

mx of high grade gliomas?

Answer 10

Surgery = total or partial decompressive tumour debulking
radiotherapy and chemotherapy - temozolomide

Question 11

what is meningioma?

Answer 11

non-glial cell growth arising from the arachnoid meningothelial cells within the meninges

benign and slow growing

Question 12

who are meningitis more common in?

Answer 12

females

Question 13

how are meningiomas classified?

Answer 13

Question 14

RF for meningiomas?

Answer 14

ncreasing age, previous cranial irradiation, or certain genetic disorders (e.g. neurofibromatosis type II)

Question 15

features of meningiomas?

Answer 15

space-occupying lesion features
seizures, cranial nerve palsies or visual field defects, language dysfunction, or features of raised intracranial pressure

Question 16

ix for meningiomas

Answer 16

CT head imaging with IV contrast - well-circumscribed (globose) extra-axial masses, dural thickening
MRI
angiography
biopsy

Question 17

what dis?

Answer 17

A = meningioma with surrounding oedema on CT
B = meningioma on MRI

Question 18

mx of meningioma

Answer 18

endovascular embolisation, surgical removal, radiotherapy
chemo

Question 19

classification of pituitary tumours?

Answer 19

Microadenoma = <1cm diameter
Macroadenoma = >1cm diameter
Giant adenomas = prolactinoma with >4cm diameter

Question 20

features of pituitary tumours?

Answer 20

hormonal effects (hyper- or hypo-secretion) of the tumour.

headaches

visual field defects (classically a bitemporal hemianopia, as growth superiorly leads to compression of the optic chiasm)

cranial nerve palsies (through compression on the cavernous sinus (affecting cranial nerves V1, V2, III, IV, and VI).

CSF rhinorrhoea
pituitary apoplexy

Question 21

what is pituitary apoplexy?
symptoms
mx

Answer 21

Question 22

features of hyper+hyposecretion of the following hormone:
prolactin

Answer 22

hyper = Infertility, galactorrhoea, amenorrhoea (women) / impotence (men)

hypo = Failure of lactation (rare)

Question 23

features of hyper+hyposecretion of the following hormone:
ACTH

Answer 23

hyper = Weight gain, fatigue, purple striae, osteoporosis, hypertension*

hypo = Fatigue, skin pigmentation, vomiting, weight loss; features of an Addisonian crisis (rare)

Question 24

features of hyper+hyposecretion of the following hormone:
GH

Answer 24

hyper = Acromegaly in adult and gigantism in children

hypo = Fatigue, reduced strength, weight gain. Dwarfism in children.

Question 25

features of hyper+hyposecretion of the following hormone: FSH and LH

Answer 25

hyper = Usually asymptomatic hypo = Amenorrhoea, infertility, loss of libido

Question 26

features of hyper+hyposecretion of the following hormone: TSH

Answer 26

hyper = Palpitations, anxiety, weight loss, heat intolerance, shortness of breathØ hypo = Fatigue, constipation, weight gain, hair loss, swelling of extremitiesØ

Question 27

ix of pituitary tumours? general

Answer 27

high-resolution CT scan or a MRI scan hormones

Question 28

ix for prolactin

Answer 28

Serum prolactin >2000 mU/l is indicative of a prolactinoma

Question 29

ix for GH?

Answer 29

Insulin-like growth factor 1 (IGF-1) as the screening test, then confirmed by failure to suppress growth hormone levels in a glucose tolerance test is diagnosti

Question 30

ix for ACTH?

Answer 30

confirm raised cortisol levels (via 24-hour urine cortisol), then check plasma ACTH levels, then confirm pituitary source via short Synacthen test

Question 31

ix for gonadotrophin?

Answer 31

Check LH and FSH levels

Question 32

ix for TSH?

Answer 32

TFTs

Question 33

mx for pituitary tumours?

Answer 33

Prolactinoma can be managed by via dopamine agonists (e.g. cabergoline), reducing both prolactin levels and the size of the tumour. Somatostatin analogues (e.g. ocreotide) and GH receptor antagonists can also be used to inhibit GH seceretion.

Question 34

surgical mx for pituitary tumours

Answer 34

trans-sphenoidal removal of the sellar mass Highly focal radiotherapy

Question 35

post op complications for trans-sphenoidal surgery?

Answer 35

CSF leak + meningitis DI

Question 36

classifications of spinal tumours?

Answer 36

intramedullary, extramedullary, and extradural benign or malignant.

Question 37

what are extradural spinal tumours?

Answer 37

arising within the vertebrae themselves Enneking staging

Question 38

what are intramedullary spinal tumours?

Answer 38

arise from within the spinal cord itself slow growing high risk of iatrogenic injury

Question 39

what are extra medullary spinal tumours?

Answer 39

arise from a range of tissues, such as nerves, blood vessels, meningeal layers, located within the space between the dura and spinal cord PAINFUL surgical resected

Question 40

features of spinal tumours?

Answer 40

pain, aggravated by supine position motor symptoms (weakness or paralysis, loss of sphincter function) sensory symptoms (paraesthesia) weight loss, fatigue

Question 41

red flags of back pain?

Answer 41

Age <16 years or >55 years first episode History of cancer Night pain Progressive neurology Persistent or unrelenting symptoms History of trauma (especially if known osteoporotic) Known immunocompromised

Question 42

RF for spinal tumours?

Answer 42

Neurofibromatosis type 1 and type 2 (schwannomas), Tuberous Sclerosis (astrocytomas), Von Hippel-Lindau disease (hemangioblastomas), and Li-Fraumeni syndrome (gliomas) radiation exposure

Question 43

ix for spinal tumours?

Answer 43

FBC, LFTs, CRP and ESR, and bone profile xray PET CT spinal MRI biopsy of primary tumour

Question 44

mx of spinal tumour

Answer 44

surgery - decompression + excision, adjuvant chemotherapy, and adjuvant radiotherapy steroids oral pain management

Question 45

what are oligodendrogliomas? who do they occur in?

Answer 45

primary brain tumours derived from oligodendrocytes 30-50yo

Question 46

where are oligodendrogliomas found in the brain? impact on symptoms?

Answer 46

frontal lobes personality changes, disinhibition, loss of social inhibitions, and executive dysfunction, reflecting frontal lobe involvement

Question 47

progression of oligodendrogliomas?

Answer 47

6m

Question 48

MRI findings in oligodendrogliomas?

Answer 48

mass lesion in the frontal lobe, sometimes with areas of calcification or cystic changes

Question 49

what is glioblastoma multiform? who does it affect?

Answer 49

highest-grade astrocytic tumour (WHO Grade IV) and is highly aggressive >50yo

Question 50

how do glioblastoma multiform present?

Answer 50

rapid onset of symptoms, including motor deficits, headaches, and seizures. The rapid symptom progression over weeks rather than months is characteristic of GBM.

Question 51

GBM on imaging?

Answer 51

a ring-enhancing lesion with central necrosis due to its aggressive nature

Question 52

what signs + symptoms in trigeminal neuralgia raise suspicion of serious underlying cause?

Answer 52

Sensory changes Deafness or other ear problems History of skin or oral lesions that could spread perineurally Pain only in the ophthalmic division of the trigeminal nerve (eye socket, forehead, and nose), or bilaterally Optic neuritis A family history of multiple sclerosis Age of onset before 40 years