1. Lindsay A Wilson, pgy2 AM Report 1/27/2010
        Brain Tumors
Lindsay A Wilson, pgy2
AM Report
1/27/2010

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

4. Mets
Metastatic 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.
Breast
Melanoma
Kidney GI
Thyroid
Lung
Ovarian
Testicular

5. Primary Brain Tumor Basics
Adults=supratentorial vs Kids=Infratentorial
Brain tumors rarely metastasize
Benign can be bad due to mass effects
Easy 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

6. WHO Classification Tumours of neuroepithelial tissue (glial)
Astrocytic tumours*** Oligodendroglial tumours*** Mixed gliomas*** Ependymal tumours*** Choroid plexus tumours***
Neuronal and mixed neuronal-glial tumours
Neuroblastic tumours** Pineal parenchymal tumours **Embryonal tumours
Tumours of peripheral nerves
Schwannoma (Neurinoma)** Neurofibroma** Perineurioma
Malignant 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 region
Craniopharyngioma** 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.

8. GLIAL TUMORS Astrocytoma: 20% primary intracranial neoplasms
Life expectancy approximates 5 years, worse prognosis if transformation to glioblastoma multiforme occurs (10% of cases) 
Four grades...with grade IV being GBM
If low grade:
Difficult to resect but complete resection is better than debulking alone
Often follow surgery w/ RT
If really small, will delay surgery until symptoms or signs of growth

9. GLIAL TUMORS High grade= Glioblastoma multiforme
Most common brain tumor
Poor prognosis, often death < 1 year
Tumor crosses the corpus callosum=butterfly
Key path:  Pseudopalisades and pseudorosettes

10. GLIAL TUMORS Oligodendrogliomas 5% of glial tumors frontal lobe
path=fried egg
surgery +/- adj. therapy RT
chemo sensitive
Ependymomas 
5% of glial tumors, kids>adults
4th ventricle--obstruct flow of CSF
rsxn, then radiation, chemo
in adults, see in spinal cord (75%)

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

13. Treatment: -Can be conservative (ie no treatment)
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

15. NON-GLIAL Schwanomma (acoustic neuroma)
Tumor derived from Schwann cells
Acoustic neuromas may cause tinnitus, deafness, compression of other CNs
Surgery usually results in cure (RT also used, can observe too)
 NF2 (neurofibromatosis) is characterized by bilateral acoustic neuromas (autosomal dominant syndrome)

16. NON-GLIAL Lymphoma Primary B-cell AIDS immunosupp. link to EBV
MTXbased chemo RT
Ocular involv.
slit lamp exam

17. NON-GLIAL Hemangioblastoma
Often syndromic and hereditary (Lindau, von Hippel-Lindau=mutations in tumor suppressor gene VHL)
Can secrete erythropoitin and induce polycythemia
Highly vascularized
Originates in the cerebellum
Embolization then surgery

18. Brain tumors that are more common in kids (and therefore not discussed any further)
Choroid plexus papilloma 
Neuroblastoma
Retinoblastoma
Medulloblastoma
Ganglioglioma
Germ cell tumors (can be in young men)

19. Works cited Rubins Uptodate Wikipedia Merck Manual
Pathology Board Review Series
NMS Medicine