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BRAIN TUMOR
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What is it? Brain neoplasms are a diverse group of primary (nonmetastatic) tumors arising from one of the many different cell types within the central nervous system. Malignant brain tumors are defined by histopathologic features and a rapidly progressive pattern of growth Glioblastoma is the most common primary brain tumor in adults, accounting fo 50% to 60% of primary brain tumors
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Pathophysiology Nervous system tumors are clonal proliferations that develop secondary to changes in key growth regulatory genes These genetic changes result in powerful growth advantages that enable the cells to priloferate, evolve, and disseminate The etiologies of brain tumors remain unknown. To date, only radiation and hereditary predisposition are clearly implicated as etiological factors The WHO classification currently lists more than 100 types of nervous system tumors and their variants This classification system allows for consideration of key clinical and imaging characteristics which can narrow the differential diagnosis to only a few common possibilities
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Pathophysiology Only about 5% of primary brain tumors have known hereditary factors Li-Fraumeni syndrome, p53 defects, neurofibromatosis 1 (NF1) and 2 (NF2), tuberous sclerosis, von Hippel-Lindau disease, Turcot’s syndrome, and familial polyposis Meningiomas Strongest genetic link has been associated with NF2, an almost 50% incidence Known to express estrogen and progesterone receptors. High incidence of somatostatin receptors has also been found Significance of these findings is uncertain but has led to diagnostic tests and treatment strategies Radiation is only definite cause Oligodendrogliomas Viral infections (specifically the JC virus) has been implicated, but data are inconclusive
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Incidence Glioblastomas occur in approximately 2-3 cases/100,000 persons Most commonly diagnosed primary brain tumor of adults is glioblastoma mulitforme (grade IV) Slightly more common in whites than blacks, Latinos, and Asians Slightly more common in men than women with a male:female ration of 3:2 Peak incidence is between 45 and 70 years. Approximately 10% of glioblastomas occur in children
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Risk Factors Prior radiation may increase risk for primary brain tumor
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Signs and Symptoms Headache Most common presenting complaint – reported by approximately 50% of the patients Seizures (occur in 30%-60% of cases) Signs and symptoms of hydrocephalus (headache, vomiting, clouding of consciousness, papilledema) Memory loss Focal motor weakness Visual changes Language deficits Cognitive disturbances Memory changes
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Clinical Presentation Worsening headache Present for weeks to months Classic triad of brain tumor headache: Sleep disturbances Severe pain Nausea and vomiting Headache is often bilateral and worsened by coughing, sneezing, bending, defecation, and sexual intercourse
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Imaging MRI with and without contrast is the imaging study of choice CT scanning is useful if calcification or hemorrhage is suspected PET scan is helpful to distinguish neoplastic lesions (with high rate of metabolism) from other lesions such as demyelination or radiation necrosis (with a much lower metabolic rate)
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Treatment Surgery Radiation Palliative chemotherapy
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References Bradley W G. Neurology in Clinical Practice. 5th edition ed. Philadelphia: Butterworth Heinemann Elsevier; 2008. Carey WD. Cleveland Clinic: Current Clinical Medicine. 2nd edition ed. Philadelphia: Saunders Elsevier; 2010. Ferri F F. Ferri's Clinical Advisor 2011: Instant Diagnosis and Treatment. 1st ed. Philadelphia: Elsevier; 2011. Marx J A. Rosen's Emergency Medicine. Vol 1. 7th edition ed. Philadelphia: Mosby Elsevier; 2010.
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