Brain TumorsLindsay A Wilson, pgy2AM Report1/27/2010

Outline.1. Review cancers that are metastatic to the brain.2.Review classification of brain tumors confined to the meninges andbrain parenchyma (Glial versus Non-glial). 3. Review common brain tumors.4.Mention brain tumors found mainly in kids

MetsMetastatic brain tumors (cancer that spreads from other parts of the body to the brain) occur at some point in 10 to 15% of persons with cancer and are the most common type of brain tumor. BreastMelanomaKidneyGIThyroidLungOvarianTesticular

Primary Brain Tumor BasicsAdults=supratentorial vsKids=InfratentorialBrain tumors rarely metastasizeBenign can be bad due to mass effectsEasy way to divide types of brain tumors is glial versus non-glial (50/50). Glial cells= astrocytes, oligodendrocytes, and ependymal cells. Of primary CNS tumors=80%"Alarm symptoms" that point to brain tumor: Headache recurs frequently, is severe, starts in someone who hasn't had headaches before, occurs at night, is present upon awakening, is accompanied by nausea, vomiting, poor balance/coordination, double vision, and/or dizziness.The third leading cause of cancer death in young adults ages 20-39.

WHO ClassificationTumours of neuroepithelial tissue (glial)Astrocytic tumours*** Oligodendroglial tumours*** Mixed gliomas*** Ependymal tumours*** Choroid plexus tumours*** Neuronal and mixed neuronal-glial tumoursNeuroblastic tumours** Pineal parenchymal tumours **Embryonal tumoursTumours of peripheral nervesSchwannoma (Neurinoma)** Neurofibroma** PerineuriomaMalignant peripheral nerve sheath tumour (MPNST)Tumours of the meninges Tumours of meningothelial cells: Meningioma (WHO grade I) Atypical meningioma (WHO grade II) Anaplastic meningioma (WHO grade III) Mesenchymal, non-meningothelial tumours: Primary melanocytic lesions Lymphomas and haemopoietic neoplasms Malignant lymphomas** Plasmacytoma** Granulocytic sarcoma** Germ cell tumours Germinoma** Embryonal carcinoma** Yolk sac tumour Choriocarcinoma** Teratoma** Mixed germ cell Tumors of the sellar regionCraniopharyngioma** Granular cell tumour** Metastatic tumours Data from Louis, DN, Ohgaki, H, Wiestler, OD, Cavenee,WK. WHO Classification of Tumours of the Nervous System. IARC Press, Lyon 2007.

GLIAL TUMORSAstrocytoma:20% primary intracranial neoplasmsLife expectancy approximates 5 years, worse prognosis if transformation to glioblastoma multiforme occurs (10% of cases)Four grades...with grade IV being GBMIf low grade:Difficult to resect but complete resection is better than debulking aloneOften follow surgery w/ RTIf really small, will delay surgery until symptoms or signs of growth

GLIAL TUMORSHigh grade= Glioblastoma multiformeMost common brain tumorPoor prognosis, often death < 1 yearTumor crosses the corpus callosum=butterflyKey path: Pseudopalisades and pseudorosettes

GLIAL TUMORSOligodendrogliomas5% of glial tumorsfrontal lobepath=fried eggsurgery +/- adj. therapy RTchemo sensitiveEpendymomas5% of glial tumors, kids>adults4th ventricle--obstruct flow of CSFrsxn, then radiation, chemoin adults, see in spinal cord (75%)

NON-GLIALMeningiomaSecond most common primary intracranial neoplasm (account for 20%) Tumor is external to the brain (displaces brain tissue) More common in women than menMost often occurs after the age of 40Originates in the arachnoidal cellsConsidered a benign, slowly growing tumor Can erode contiguous boneCan be seen in association with NF-2Can be induced by radiation therapy (1960s tinea capitus)

Treatment:-Can be conservative (ie no treatment)-Surgery (either full or partial resection depending on tumor location), sometimes preceded by embolization-Radiation can be primary treatment or adjunct to surgery

NON-GLIALSchwanomma (acoustic neuroma)Tumor derived from Schwann cellsAcoustic neuromas may cause tinnitus, deafness, compression of other CNsSurgery usually results in cure (RT also used, can observe too)NF2 (neurofibromatosis) is characterized by bilateral acoustic neuromas (autosomal dominant syndrome)

NON-GLIALLymphomaPrimary B-cellAIDSimmunosupp.link to EBVMTXbased chemoRTOcular involv.slit lamp exam

NON-GLIALHemangioblastomaOften syndromic and hereditary (Lindau, von Hippel-Lindau=mutations in tumor suppressor gene VHL)Can secrete erythropoitin and induce polycythemiaHighly vascularizedOriginates in the cerebellumEmbolization then surgery

Brain tumors that are more common in kids (and therefore not discussed any further)

Choroid plexus papillomaNeuroblastomaRetinoblastomaMedulloblastomaGangliogliomaGerm cell tumors (can be in young men)

Works citedRubinsUptodateWikipediaMerck ManualPathology Board Review SeriesNMS Medicine