BRAIN TUMOR

YUNELDI ANWAR DEPARTMENT NEUROLOGY MEDICAL FACULTY UNIVERSITY OF NORTH SUMATERA

INTRODUCTION
BRAIN TUMOR
INTRA KRANIAL, MED SPINALIS AND MENINGES TWO TYPE PRIMER AND SECUNDER PRIMER TUMOR ASTROCYTE, OLIGODENDROCYTE, EPENDEMOCYTE, ARACHNOID, NEUROBLAST AND MEDULLUBLAST SEKUNDER TUMOR METASTATIK FROM LUNG, BREAST, COLON AND SKIN

ETIOLOGY
GENETIC GENE DEVIATION CONGENGITAL TERATOMA, CHORDOMA AGE PINEALOMA, MEDULLOBLASTOMA
(< 20 yr). MENINGIOMA (> 50yr) CARSINOGEN HYDROCARBON, NITROSAMIN HEAD INYURY, INFECTION, TOKSIN, RADIATION, VIRUS

Risk factors related to CNS tumor

Definitive ionizing radiation immune supression (HIV infection) Possible Electromagnetic field (high tension wires, cellular telepon) Diets (N-nitroso compounds, Aspartame) Occupation (petroleum industry, agricultural pesticides) Household chemicals (hairdyes and sprays, household pesticides) Head injury Medication (vitamin) Infections (Cysticercosis, varicella zoster, SV 40

CONCEPT OF PATOGENESIS PRIMER TUMOR

HISTOGENIC THEORY (Bayley &Cushing)
EMBRIOLOGICAL OF NERVE CELL AND GLIA RECENT THEORY TUMOR ARISES FROM TRANSFORMATION OF ASTROCYTE, OLIGODENDROCYTE, MICROGLIOCYTE, EPENDYMOCYTE NEOPLASM CELL MULTIPLICATION AND DIFFRENTIATION

PATHOFISIOLOGY
NORMAL CAVUM CRANII CONSIST OF
Brain tissue ( 1400 gr ) Cerebro spinal fluid ( 75 cc ) Blood ( 75 cc ) these component any time stabil Brain tumor increase intracranial pressure Brain tumor cerebral edema cerebral herniation

NORMAL BRAIN

Cerebral herniation
A. Subfacial/cingulate hern B. Uncal herniation C. Transtentorial/central hern D. External herniation E. Tonsillar herniation

CLASSIFICATION
HISTOPATOLOGICAL PATTERN
Primary brain tumor histological benign or malformative meningioma pituitary adenoma, acustic neuroma, craniopharyngioma, pilocytic astrocytoma hemangioblastoma histological malignant glioma (anaplas tic astrocytoma, glioblastoma multiform), ependymoma, oligodendroglioma, medulloblasto ma, pineal cell tumor, chroid plexus carcinoma

MENINGIOMA

GLIOBLASTOMA

CLASSIFICATION CONT
METASTATIC BRAIN TUMORS
BREAST LUNG GI TRACT PROSTAT SKIN

INTRA CRANIAL METASTASIS

Brain parenchyma
breast, lung, melanoma Pituitary gland breast, melanoma, germ cell Dural based lung, prostat, prostat, breast Leptomeningeal disease breast, lung

SKULL METASTASIS
Skull base
breast, prostat prostat, , osteosarcoma of skull, head and neck cancer Calvarium breast, prostat

SPINE METASTASIS
Epidural
lung, breast, prostat, prostat, neuroblastoma, neuroblastoma , lymphoma. Leukemia Leptomeningeal breast, lung Intramedullary breast, colon, lung, prostat Brachial plexus lung, breast, lymphoma Lumbosacral plexus pelvic tumor

CLASSIFICATION BASED ON TOPOGRAPHY (LOCATION)

SUPRA TENTORIAL TUMORS
Cerebral lobe and deep hemispheric glioma, meningioma, metastatic tumor Sella turcica tumor pituitary tumor, craniopharyngiomas INFRATENTORIAL TUMOR MEDULLASPINALIS TUMOR

INFRATENTORIAL TUMORS
ADULTS
Cerebellopontine angel acoustic schwannoma Others sites brainstem gliomas, metastase, hemangioblastoma, ependymoma CHILDRENS Midline tumors medulloblastomas Cerebellar lobes astrocytomas

MEDULLA SPINALIS TUMORS

EKSTRA DURAL INTRA DURAL
Ekstra medulla Intra medulla Metastatic tumor meningioma neurofibromas ependymoma astrositoma

SYMPTOMS AND SIGNS

Generalized symptoms caused by raised
intracranial pressure Focal symptoms caused by invasion, ischemia and compression False localizing symptoms caused by shifts of cerebral structures

GENERALIZED SYMPTOMS AND SIGNS

HEADACHE VOMITING DROWSINESS ( VERTIGO AND DIZZINESS) VISUAL OBSCURATION PERSONALITY CHANGE CONFUSION PAPILEDEMA APATHY

MECHANISM HEADACHE ASSOCIATED WITH BRAIN TUMOR

1.Traction on venous sinuses 2.Traction on meningeal arteries 3.Traction on large arteries at base of the brain 4.Pressure on cranial and cervical pain sensi tive structure 5.Dilatation of intracranial arteries 6.Inflamation of painpain-sensitive structures

FOCAL SYMPTOMS AND SIGNS

FRONTAL LOBE
Generalized seizure Focal motor seizure (contra lateral) Expressive aphasia (dominant size) Behavioral changes Dementia Gait disorders, incotinence Hemiparese

Frontal lobe tumor

FOCAL SYMPTOMS & SIGNS

BASAL GANGLIA
Hemiparesis (contralateral) Movement disorders (rare) PARIETAL LOBE Receptive aphasia (dominant size) Spatial disorientation (non dominant) Cortical sensory dysfungtion (contralat) Agnosias

Metastase parietal lobe tumor

FOCAL SYMPTOMS & SIGNS

OCCIPITAL LOBE
Hemiparesis (contralateral) Visual disturbance TEMPORAL LOBE Complex partial (psychomotor) seizures Generalized seizures Behavioral changes Olfactory and complex seizures Visual auras Visual field defect

Occipital lobe tumor

Temporal lobe tumor

FOCAL SYMPTOMS & SIGNS

CORPUS COLLOSUM
Dementia (anterior) Behavioral changes Memory loss (posterior) Asymptomatic (mid) THALAMUS Sensory loss (contralateral) Behavioral changes (posterior) Languange disorders (dominant size)

FOCAL SYMPTOMS & SIGNS

MIDBRAINS/PINEAL
Paresis of vertical eyemovement Pupillary abnormalities Precocious puberity (boys) SELLA/OPTIC NERVE/PITUITARY Endocrinopathy Bitemporal hemianopia Monocular visual defect Opthalmoplegia (cavernous sinus)

Pineal tumor

Pituitary tumor

FOCAL SYMPYOMS & SIGNS

PONS/MEDULLA
Cranial nerve dysfungtion Ataxia, nystagmus, spasticity Weakness, sensory loss CERBELLO PONTINE ANGLE Deafness (ipsilateral) Loss of facial sensation (ipsilateral) Facial weakness (ipsilateral), ataxia CEREBELLUM Ataxia (ipsilateral) Nystagmus

Cerebellum tumor

FALSE LOCALIZING SIGNS

CRANIAL NERVE
Anosmia Diplopia, ptosis, anisocoria Face pain, numbness, and weakness Tnnitus, hearing loss

FALSE LOCALIZING SIGNS

PARENCHYMAL SIGNS
Ipsilateral hemiparesis Ipsilateral gaze palsy Visual field defect, cortical blindness Ataxia OTHER SIGNS Nuchal rigidity

SYMPTOM AND SIGN SPINAL CORD TUMOR

INTRAMEDULLARY
Sensory loss Early spinchter dysfungtion Pain + Decreased rectal tone spasticity upper motor neuron signs Common tumor -> Ependymoma, Ependymoma, astrositoma

Symptom and signs spinal cord tumor

Intradural and extramedullary
Pain, metastase +++ Pain, primary tumor + Radicular or local sensory loss Radicular or segmental weakness and sensory loss Upper motor neuron signs Common tumors Meningioma

Symptom and sign spinal cord tumor

EPIDURAL
Pain +++ Radicular or local pain Common tumors Metastasis

DIAGNOSIS BRAIN TUMOR

HISTORY GENERAL PHYSICAL EXAMINATION NEUROLOGIC EXAMINATION LABORATORY FINDING, ESPECIALLY
IMAGING

Laboratory findings
IMAGING
CT Scan MRI Magnetic resonance spectroscopy (MRS) Fungtional MRI BIOPSY Defenitive diagnosis

DIFFRENTIAL DIAGNOSIS OF BRAIN TUMORS

HEMATOMA ABCESS GRANULOMA PARASITIC INFECTION CYSTYCIRCOSIS VASCULAR MALFORMATION MULTIPLE SCLEROSIS CEREBRAL INFARCS

Therapy of Intra Cranial Tumors

Definitive therapy
Surgery Radiation Biopsi, resection
External beam Streotactic radiosurgery Heavy particles Brachytherapy

Chemotherapy Parentral, lokal Experimental modalities Supportive therapy

Experimental modalities
Angiogenesis inhibitor Growth factor inhibitor Diffrentiating agents Immunotherapy Gene therapy Antisense oligonucleotide

Supportive Therapy
Anticonvulsant Corticosteroids Anti Anti-thrombosis agent Psychotropic agents Physical therapy

Goals of Surgery
Establish the diagnosis Cure the patient Decrease tumor burden Relieve symptoms Improve neurologic fungtion Extend duration and quality of live

Basic concepts in cancer chemotherapy

Chemotherapeutic agent kill only a
percentage of cancer cell Some drugs kill only dividing cells Multiple drugs with differing site of action are better than a single drugs High dosee are better than low doses

Brain tumors anticonvulsant

Prophylaxis
-- does not prevent first seizure -- probably useful in perioperative period Treatment -- efficacy unclear -- side effects more commons -- hard to control levels -- best drug unknown

Advantages and Disadvantages of corticosteroid

Advantages
-- control neurologic symptom by reduce edema -- decrease acute RT toxicity -- relieve emesis from chemotherapy -- oncolytic (lymphoma) Disadvantages -- side effects common -- decrease chemotherapy entry