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CENTRAL NERVOUS SYSTEM TUMORS (symptoms (Cranial nerves palsy (Vestibular…
CENTRAL NERVOUS SYSTEM TUMORS
Ethiology
unknown
carcinogenes
: ionizing
radiation
, pesticides, herbicides, rubber compounds, N-nitroso-compounds, polyvinyl chloride, polycyclic hydrocarbons, elektromagnetic field
meningiomas: injury, EBV
lymphomas: HIV, immunosupression
Irradiation
– proffesional risk, radiologists
RR=6.0
Chemical
compounds – proffesional risk
RR=4.0
I
rradiation of head – RR=3.61
Elektromagnetic field used in telecommunication – RR=2.42
Radiodiagnostic procedures – RR=1.64
Genetic
risk, Use of
hair dies
, Mechanical injury
Noise
,
Parents’ profession
Epidemiology
Malignant
:
Glioblastoma
> all other glioma>
malignant meningioma
non
-malignant:
meningioma
>
pituitary
tumors>
nerve sheath
tumors
Most frequent intracranial tumors are brain metastases from different primaries,
About
two times as frequent as primary intracranial neoplasms
More than
50% of primary intracranial tumors are of neurooepithelial origin
symptoms
Elevated intracranial pressure symptoms
headache
, Quantitative impairment of
consciousness
,
vomiting
, blurred vision (
papilloedema
)
Focal symptoms: Paresis, Aphasia, Vision disturbances
(visual pathways),
Seizures
,
Gait
disturbances
personality disorders, mood disorders, psychoses
Cranial
nerves palsy
Vestibular schwannoma (VIII) vertigo, tinnitus, one sided hearing loss to deafness
,
facial weakness (VII)
pain, numbness of one half of the face (V)
Pituitary adenomas
Hormonally inactive
–
grow secretly, without symptoms,
can reach larger volume before becoming symptomatic, impression of pituitary (hormonal deficits), impression or infiltration of optic nerves (loss of visual fields)
Hormonally active (prolactin, GH, ACTH, FSH, LH TSH)
symptoms of brain tumors*
IMAGING
CT
:
CT
with CM
short acquisition time patients not cooperating, poor PS,
High
sensitivity in diagnosing calcifications, subacute haemorrhages, emergency situations
MRI
:
imaging
modality of choice in brain and spine tumors
Initial diagnosis,
before surgery
,
inoperable
patients
WHO III i IV glioma
48h after surgery to assess completeness of resection
MRI
for radiotherapy plannin
g
SPECT, PET
– may help in
differantiation of recurrence from postradiotherapy changes
commonly in frontal lobe
>
temporal
lobe >
parietal
lobe > cerebrum > sinal cord > brain stem > occipital lobe > cerebellum > ventricles> cranial nn. > menages > pineal
Classification of Primary Intracranial Tumors by Cell of Origin
Astrocyte: Astrocytomas, glioblastoma multiforme
Ependymocyte: Ependymoma, ependymoblastoma
Oligodendrocyte: Oligodendroglioma
Arachnoidal fibroblasts: Meningioma
Nerve cell or neuroblast retinoblastoma: Ganglioneuroma, neuroblastoma
External granular cell or neuroblast: Medulloblastoma
Schwann cell: Schwannoma (neurinoma)
Melanocyte: Melanotic carcinoma
Chorioid epithelial cell: Choroid plexus papilloma or carcinoma
Pituitary: Adenoma
Endothelial cell or stromal cell: Hemangioblastoma
Primitive germ cells: Germinoma, pinealoma, teratomas, cholesteatoma
Pineal parenchymal cells: Pinealcytoma
Notochordal remnants: Chordoma
Treatment
surgical techniques
The aim of surgery is as radical tumor resection as possible with acceptable risk of neurological complications. fMRI allows for identification of functionally important cortex regions before or during surgery
Radiosurgery (SRS)
Microsurgery, Navigation, Neurophysiologic monitoring, Ultrasound knife, Intraoperative imaging, Functional imaging, DTI
stereotactic fractionated radiotherapy
GLIOBLASTOMA
45-50% of gliomas
median age 50 to 60 years
Any region of CNS
possible, hemispheres predominate:
40%frontal, 25%temporal
,
25%parietal
, occasionaly
corpus callosum – butterfly glioma
Symptoms of
increased intracranial pressure: 86% headaches, 45% nausea and vomiting
Menthal status
changes 47%
Motor deficit
44%
Seizures
at presentation 32%
High grade gliomas
treatment
radiotherapy
dose escalation:
external beam
,
stereotactic
,
brachytherapy
Radiosensitizers
Radiochemotherapy
oligodendrogliomas
Adjuvant chemotherapy in WHO III
Better survival than in other WHO III gliomas
Median OS after rth about 60 months
Response rate to PCV chemotherapy 70%
Confirmed prognostic and predictive role of LOH 1p/19q
anaplastic oligodendroglial tumors
Adjuvant PCV improves Overall Survival in anaplastic oligodendroglial tumors
1p/19q co-deletion identifies patients with increased benefit after PCV
No proven benefit of PCV in non-deleted tumors
LOW GRADE GLIOMAS
radiotherapy after subtotal resection
in asymptomatic patients with tumors in posterior fossa observation is acceptable even after subtotal resection
dose 54 Gy, 1,8 Gy per fraction
conformal and stereotactic techniques
palliative chemotherapy drugs
Nitrosourea derivatives: Fotemustine, Carmustine, Lomustine, Nimustine, Procarbazine
Camptothecin derivatives: Irinothecan, Topothecan
Other: Vincristine, Cisplatin, Temozolomide
Meningioma
NF2 --> multiple meningiomas
majority - low grade
5% atypic, 2% malignant
small, asymptomatic lesions
Treatment of choice – surgery, SRS
Scull base tumors – often unresectable
Radiotherapy – after resection of recurrence
10-years OS benign - 70% - 80%
5-years OS malignant 0-30%
Indications for postoperative radiotherapy
:
anaplastic and sarcomatous meningiomas
malignant meningioma
(after radical surgery observation acceptable MRI every 3 months)
benign meningioma - subtotal resection in scull base region, recurrent tumors, angioblastic type, women
Ependymoma
15% risc of cerebro-spinal fluid involvement Especially anaplastic, infratentorial
Adjuvant, local RT, 56 Gy in all cases
(adjacent ventricule included)
Cerebro-spinal axis - 35 Gy
high grade infratentorial ependymomas in adults
all high grade ependymomas in children and adolescents
all cases of cerebrospinal fluid involvement (MRI of spinal cord and CSF cytology)
Brain metastases
CT after intravenous contrast media is usually sufficient
MRI (always with CM) if
:
-if
CT +/- or clinical symptoms present and CT (-)
-
number of metastases indicates treatment method
Typical metastases: multiple
strongly enhancing after CM lesions accompannied by large edema
MRI is method of choice in the diagnosis of spinal cord metastases
most frequent intracranial tumors
Diagnosis:
25% in clinically disseminated disease
50% on autopsy,
primary: lung, kidney, thyroid, breast
, melanoma, colon
focal lesions in patients with cancer diagnosis - always suspect metastases
Solitary brain metastases
treatment modality
surgery
:
BT +/- WBRT
SRS+/- WBRT