Neurological Neoplasm FOM, KFMC 28-5-2015 Dr. Abdulrahman Sabbagh M.D., FRCS(C) Neurosurgery, Neuro-Oncology, Consultant

Intracranial mass Differential diagnosis: Tumor, Pus Blood cyst, ??? Air

Intracranial mass primary tumors History important for localizing and differentiating mass lesions Tumor: primary versus metastatic primary tumors benign or malignant (rarely metastasize)

Presenting Symptoms local effects raised ICP consider by dependent on site: focal deficits, lobe syndromes, seizures, headaches raised ICP acute or chronic depending on tumor growth rate sudden onset of symptoms after hemorrhage (5-10%) consider by location (supratentorial vs. infratentorial) age (adult vs. child)

Clinical presentation

Management Admission (?) Symptom relieving medications Investigations Treatment

Classification according to cell type Neuroepithelial Gliomas Astrocytoma (including Glioblastoma) Oligodendroglioma Ependymoma Choroid plexus tumor Pineal tumors Neuronal tumors Ganglioglioma Neuroblastoma Medulloblastoma

Classification according to cell type Nerve sheath tumor Vestibular schwannoma Meningeal tumors Meningioma Pituitary tumors adenoma Germ cell tumors Germinoma Teratoma Lymphoma Metastatic tumors

Classification according to cell type Mal-development origin Craniopharyngioma Dermoid/epidermoid cyst Colloid cyst Local extension Chordoma Glomus jugulare Blood vessels Hemangioblastoma

Astrocytoma Most common group of CNS tumors Grading (WHO) Grade I (well differentiated) Juvenile Pilocytic Astrocytoma Grade II (Diffuse) fibrillary Grade III (Anaplastic) Grade IV (undifferentiated) GBM: glioblastoma multiforme

Metastatic Most common brain tumour seen clinically 15% of cancer patients present with cerebral mets Source Lung 44% (especially bronchogenic cancer) Breast 10% Kidney 7% (renal cell carcinoma (RCC)) GI 6% Melanoma 3% Route of spread – hematogenous Location – 3/4 are supratentorial, often at grey-white matter junction Diagnosis: Metastatic work-up (CXR, CT chest/abdo, abdominal U/S) CT with contrast (round, well-circumscribed uniformly lesion) Biopsy (as up to 10% may not be cerebral met in patient with cancer history) and patient may not have a cancer history Prognosis: median survival with optimal Rx 26-32 weeks but varies depending on primary Treatment: palliative Single accessible lesion ––> surgical excision + radiation Multiple lesions ––> whole brain radiation

Meningioma Mostly benign (1% malignant) Slow-growing, non-infiltrative Common locations: Parasagittal convexity Sphenoid wing Falx Presentation: middle aged, symptoms of increased ICP, focal symptoms depend on location Diagnosis: MRI, CT with contrast Therapy Conservative management for slow-growing lesions Surgery is treatment of choice (curative if complete resection) Radiotherapy – ineffective Prognosis: > 90% 5-yr survival

Cerebral edema @ capillary wall in normal brain, tight junctions retain protein-rich serum within the capillary Vasogenic : develops when tight junction maintenance is deranged, and protein-fluid leaks into the interstitium, drawing free water along with it Cytotoxic : develops when cellular energy metabolic failure leads to  intracellular sodium, free water follows, and tissue swells as its cells take on water

Paraneoplastic syndrome A disease or symptom that is the consequence of the presence of cancer in the body, but is NOT due to the local presence of cancer cells Mediated by humoral factors (hormones or cytokines) excreted by tumor cells or by an immune response against tumor Most commonly present with cancers of the: Lung Breast Ovaries Lymphatic system (lymphoma) Sometimes the symptoms of paraneoplastic syndromes show even before the diagnosis of a malignancy.

Paraneoplastic syndrome divided into 4 main categories of syndromes: Endocrine Neurological Mucocutaneous Hematological

Paraneoplastic Neurological Disorders (PND) Affect the central or peripheral nervous system and they are degenerative. Symptoms of paraneoplastic neurological disorders may include: Ataxia Dizziness Nystagmus Loss of Muscle tone Coordination Memory Slurred speech Vision problems Dementia Seizures

Paraneoplastic Neurological Disorders (PND) The most common cancers associated with paraneoplastic neurological disorders are: Breast Ovarian Lung cancer Treatment options include: Eliminate the underlying cancer such as chemotherapy, radiation and surgery Reduce or slow neurological degeneration. Rapid diagnosis and treatment are critical for the patient to have the best chance of recovery.