1. Brain Tumors Maria Rountree

2. Most common types of brain tumors The most common childhood tumors are: The most common childhood tumors are: 1. Astrocytoma 1. Astrocytoma 2. Medulloblastoma 2. Medulloblastoma 3. Ependymoma 3. Ependymoma The most common adult tumors are: The most common adult tumors are: 1. Metastatic brain tumors from lung, breast, melanoma, and other cancers 1. Metastatic brain tumors from lung, breast, melanoma, and other cancers 2. Glioblastoma Multiforme 2. Glioblastoma Multiforme 3. Anaplastic (Malignant) Astrocytoma 3. Anaplastic (Malignant) Astrocytoma 4. Meningioma 4. Meningioma

3. Incidence of brain tumors Annual incidence ~15–20 cases per 100,000 people. Annual incidence primary brain cancer in children is about 3 per 100,000. Annual incidence ~15–20 cases per 100,000 people. Annual incidence primary brain cancer in children is about 3 per 100,000. Leading cause of cancer-related death in patients younger than age 35. Leading cause of cancer-related death in patients younger than age 35. Primary brain tumors /secondary ~ 50/50 Primary brain tumors /secondary ~ 50/50 ~17,000 people in the United States are diagnosed with primary cancer each year. Secondary brain cancer occurs in 20–30% of patients with metastatic disease. ~17,000 people in the United States are diagnosed with primary cancer each year. Secondary brain cancer occurs in 20–30% of patients with metastatic disease.

4. Clinical Presentation of brain tumors Headaches Headaches Seizures Seizures Nausea & vomiting Nausea & vomiting Loss of consciousness Loss of consciousness Cognitive dysfunction Cognitive dysfunction Neurological dysfx- weakness, sensory loss, aphasia, visual spatial dysfunction Neurological dysfx- weakness, sensory loss, aphasia, visual spatial dysfunction

5. Cognitive dysfunction Includes memory problem, mood or personality disorders Includes memory problem, mood or personality disorders It is the presenting symptom in 30-35% of patients with brain metastasis. It is the presenting symptom in 30-35% of patients with brain metastasis. Patients symptoms often subtle, complain of fatigue, urge to sleep and loss of interest in daily activities. Confused with depression. Patients symptoms often subtle, complain of fatigue, urge to sleep and loss of interest in daily activities. Confused with depression. Consider neuroimaging in patients who present with new onset of depressive symptoms or without obvious cause. Consider neuroimaging in patients who present with new onset of depressive symptoms or without obvious cause.

6. Case: 76 yo old female presented with increased irritability with her family, sleeplessness and reckless spending. 76 yo old female presented with increased irritability with her family, sleeplessness and reckless spending. PMH: HTN, breast cancer PMH: HTN, breast cancer PE, labs –wnl PE, labs –wnl MSE notable for loud rapid speech, flight of ideas, no delusions or hallucinations MSE notable for loud rapid speech, flight of ideas, no delusions or hallucinations CT revealed a 3 cm intraventricular lesion CT revealed a 3 cm intraventricular lesion Meningioma was removed and sxs slowly abated Meningioma was removed and sxs slowly abated

7. Brain Meningioma CT

8. Meningioma MRI /T2

11. Neuroimaging of brain tumors Major diagnostic modality. Useful for preoperative planning Major diagnostic modality. Useful for preoperative planning The diagnosis of a primary brain tumor is best made by cranial MRI. This should be the first test obtained in a patient with signs or symptoms suggestive of an intracranial mass. The MRI scan should always be obtained both with and without contrast material (gadolinium). The diagnosis of a primary brain tumor is best made by cranial MRI. This should be the first test obtained in a patient with signs or symptoms suggestive of an intracranial mass. The MRI scan should always be obtained both with and without contrast material (gadolinium). MRI superior to CT scan for evaluating meninges, subarachnoid space, posterior fossa and defining the vascular abnormality of the lesion MRI superior to CT scan for evaluating meninges, subarachnoid space, posterior fossa and defining the vascular abnormality of the lesion

12. Neuroimaging High-grade or malignant gliomas appear as contrast- enhancing mass lesions, which arise in white matter and are surrounded by edema High-grade or malignant gliomas appear as contrast- enhancing mass lesions, which arise in white matter and are surrounded by edema Multifocal malignant gliomas are seen in ~ 5% of patients. Multifocal malignant gliomas are seen in ~ 5% of patients. Low-grade gliomas typically are nonenhancing lesions that diffusely infiltrate brain tissue and may involve a large region of brain. Low-grade gliomas are usually best appreciated on T2-weighted MRI scans. Low-grade gliomas typically are nonenhancing lesions that diffusely infiltrate brain tissue and may involve a large region of brain. Low-grade gliomas are usually best appreciated on T2-weighted MRI scans.

14. Neuroimaging A contrast-enhanced CT scan may be used if MRI is unavailable. CT may be false-negative in patients with a low-grade tumor and can have significant artifact through the posterior fossa, which may obscure a lesion in this area. A contrast-enhanced CT scan may be used if MRI is unavailable. CT may be false-negative in patients with a low-grade tumor and can have significant artifact through the posterior fossa, which may obscure a lesion in this area. Calcification, which may suggest the diagnosis of an oligodendroglioma, is often better appreciated on CT than on MRI. Calcification, which may suggest the diagnosis of an oligodendroglioma, is often better appreciated on CT than on MRI. CT useful if there is a question of bone or vascular involvement, or for detecting mets to skull base. Also, in ER situation or if MRI is contraindicated. CT useful if there is a question of bone or vascular involvement, or for detecting mets to skull base. Also, in ER situation or if MRI is contraindicated.

15. Radiologic features of metastatic disease -Multiple lesions -Localization at the grey-white junction -More circumscribed margins -Relatively large amount of edema compared to size of lesion

16. Sources Wen, Patrick Y. Overview of Brain Metastases. UptoDate version 13.3. Wen, Patrick Y. Overview of Brain Metastases. UptoDate version 13.3. Wong, Eric T. Clinical presentation and diagnosis of brain tumors. UptoDate version 13.3. Wong, Eric T. Clinical presentation and diagnosis of brain tumors. UptoDate version 13.3. Ma, Julie. Mania Resulting from Brain Tumor. Clinical Vignette UCLA Department of Medicine. Ma, Julie. Mania Resulting from Brain Tumor. Clinical Vignette UCLA Department of Medicine.