Seminar Brain Tumors

7/31/2019 Seminar Brain Tumors

1/53

CLASSIFICATION ANDPRESENTATION OF

BRAIN TUMORS

PRESENTER: Dr. Asifa Andleeb

MODERATOR: Dr.NAZIR AHMED KHAN


2/53

Anatomy of brain

The brain is the center of thoughts, emotions,

memory and speech.

Brain also control muscle movements and

interpretation of sensory information (sight,

sound, touch, taste, pain etc)


3/53

MRI of brain


4/53

Compartments of brainSupratentorial

compartment

Cerebralhemispheres

Basal

ganglia Thalamic

nuclei Lateral

ventricles Hypothal

amus Corpus

callosum

Infratentorial

compartment

Cerebellum

Brainstem(MB/P/MO)

4thventricle


5/53

GENERAL CONSIDERATIONS 0F BRAIN TUMOURS

1. Comprise: 10% of all tumors

2. Most common childhood neoplasms3. Peak incidence at 5th decade

4. Supratentorial tumors in adults

5. Infratentorial in tumors in childhood

6. Different tumors in different ages

7. Primary tumors infiltrative, metastatic well-demarcated

8. Intraneural seeding occur, but no extraneuralmetastasis

9. Produce neurologic symptoms by size,location,invasiveness, and secondary effects


6/53

CLASSIFICATION OF BRAIN TUMORSBrain tumors include all tumors

inside the cranium or in the central spinal canal.

They are created by anabnormal anduncontrolled cell division,normally either in the

brain itselfneurons

glial cells (astrocytes,oligodendrocytes,ependymal cells,

myelin-producingSchwann cells),

lymphatic tissue, bloodvessels

in the cranialnerves,

in the brainenvelopes

(meninges), skull,

pituitary and pinealgland, or

spread from cancersprimarily located inother organs(metastatic tumors).


7/53

Classification of brain tumors

The WHO approach incorporates and interrelates

morphology,

cytogenetics, molecular genetics, and

immunologic markers

in an attempt to construct a cellular classification that isuniversally applicable and prognostically valid. Earlierattempts to develop a TNM-based classification status (N)does not apply because the brain and spinal cord have nolymphatics, and metastatic spread (M) rarely applies

because most patients with central nervous system (CNS)neoplasms do not live long enough to develop metastaticdisease.


8/53

.I.Glial tumors

a.Astrocytic tumors. Pilocytic

astrocytoma.

Diffuse astrocytoma(including fibrillary,protoplasmic, and

gemistocytic).

Anaplasticastrocytoma.

Glioblastoma(including giant cellglioblastoma, andgliosarcoma).

Pleomorphicxanthoastrocytoma.

Subependymal giantcell astrocytoma.

b.Oligodendroglial

tumors.

Oligodendroglioma

.

Anaplastic

oligodendroglioma.

c.Mixed gliomas. Oligoastrocytoma.

Anaplastic

oligoastrocytoma.


9/53

d.Ependymal

tumors.

Myxopapillary

ependymoma. Subependymoma.

Ependymoma

(including cellular,

papillary, clear cell,and tanycytic).

Anaplastic

ependymoma.

e.Neuroepitheli

al tumors ofuncertain

origin.

Astroblastoma

.

Chordoid

glioma of thethird ventricle.

Gliomatosis

cerebri.


10/53

II.Neuronal andmixed neuronal-glial tumors (some

glial componentmay be present).

Gangliocytoma.

Ganglioglioma.

Desmoplastic infantileastrocytoma/ganglioglioma.

Dysembryoplastic

neuroepithelial tumor. Central neurocytoma.

Cerebellarliponeurocytoma.

Paraganglioma.

III.Nonglial tumors.

a.Embryonal tumors. Ependymoblastoma.

Medulloblastoma.

Supratentorialprimitiveneuroectodermaltumor (PNET).

b.Choroid plexustumors.

Choroid plexuspapilloma.

Choroid plexuscarcinoma.

c.Pineal parenchymaltumors. Pineoblastoma.

Pineocytoma.

Pineal parenchymaltumor of intermediatedifferentiation.


11/53

2.MENINGEAL

TUMORS. Meningioma.(be

nign,atypical&mali

gnant)

Melanocyticlesion.

5.MESENCHYMAL TUMORS BENIGN

MESENCHYMAL TUMORSMALIGNANT

- Hemangiopericytoma

chondrosarcomaMalignant fibrous histiocytoma

Rhabdomyosarcoma

6.GERM CELL TUMORS.

Germinoma.

Embryonal carcinoma.

Yolk-sac tumor (endodermal-sinustumor).

Choriocarcinoma.

Teratoma.

Mixed germ cell tumor.

3.TUMORS OR UNCERTAINHISTOGENESIS.

Capillary hemangioblastoma

4.HEMATOPOIETIC

NEOPLASMA

Malignant lymphomas(primary CNSlymphoma)

Plasmacytoma


12/53

7.TUMORS OF THE SELLAR REGION.Pituitary adenoma.

Pituitary carcinoma.

Craniopharyngioma.

8.CYSTS/TUMOR LIKE LESIONS

Rathke cyst

Epidermoid cyst

Dermoid cyst

9.TUMORS OF PERIPHERAL NERVES THAT AFFECT THE CNS.

Schwannoma.

Neurofibfoma

10.METASTATIC TUMORS


13/53

supratentorial & infratentorial Tumors

SUPRATENTORI

AL TUMORS Meningiomas

Gliomas

Astrocytomas

GlioblastomaMultiforme

Oligodendrogli

omas

Germinomas

Colloid Cysts of

Third Ventricle

INFRATENT

ORIAL

TUMORS Choroid plexus

papillomas

Cerebellar

astrocytomas Medulloblastomas

Hemangioblastomas

Ependymomas

Brainstem gliomas

Schwannomas

Pituitary adenomas

Craniopharyngioma

s

WHO G d F t t di t


14/53

WHO Grade:Four-category tumor grading system

Grade I tumors:Slow growing

Nonmalignanttumors

Patients havelong-termsurvival

Grade III

Malignant

tumorsOften recur

as highergrade

tumors

Grade II tumors:

Relatively slowgrowing

Sometimes recur ashigher grade tumors

May benonmalignant ormalignant

Grade IV

Highlymalignantandaggressive

ernohan Grade D t t


15/53

ernohan Grade:De nes progress ve ma gnancy or astrocytom

Grade 1 benign astrocytoma

Grade 2 low-grade astrocytoma

Grade 3 anaplastic astrocytomaGrade 4 glioblastoma multiformis

St. Anne/Mayo

Grade Used for

astrocytomas

Uses fourmorphologic

criteria1.Nuclear-

atypia

2.Mitosis

3.Endothelial

proliferation

St. Anne/Mayo Grade Grade 1 = 0 criterion

Grade 2 = 1criterion, usuallynuclear atypia

Grade 3 = 2 criteria,usually nuclearatypia and mitosis

Grade 4 = 3 or 4

criteria


16/53

PRESENTATION OF BRAIN TUMORS

Any brain tumor is inherently serious and life-threateningbecause of its

invasive

and infiltrative character

in the limited space of the intracranial cavity. . Becausethe brain is well protected by the skull, the earlydetection of a brain tumor only occurs when diagnostictools are directed at the intracranial cavity. Usuallydetection occurs in advanced stages when the presence

of the tumor has side effects that cause unexplainedsymptoms.


17/53

PRESENTATION OF BRAIN TUMORSThe visibility

of signs andsymptoms ofbrain tumorsmainly

depends ontwo factors:

I.tumor size

(volume)and

II. tumorlocation

Symptoms of solidneoplasms of the

brain (primarybrain tumors andsecondary tumorsalike) can be

divided in 3 maincategories

1. Consequences of

intracranialhypertension

2. Dysfunction

3. Irritation


18/53

I)CONSEQUENCES OF INTRACRANIAL

HYPERTENSION :

The symptoms thatoften occur first arethose that are theconsequences ofincreased intracranial

pressure: Largetumors or tumorswith extensiveperifocal swelling(edema) inevitablylead to elevatedintracranial pressure(intracranialhypertension), whichtranslates clinicallyinto;

Headaches,

vomiting (sometimes

without nausea), altered state ofconsciousness(somnolence, coma),

dilatation of the pupil othe side of the lesion(anisocoria),

papilledema (prominenoptic disc at thefunduscopic eyeexamination)


19/53

small tumors obstructing the passage ofcerebrospinal fluid (CSF) may cause early signs ofincreased intracranial pressure.

Increased intracranial pressure may result in

herniation (i.e. displacement) of certain parts ofthe brain, such as the cerebellar tonsils or thetemporal uncus, resulting in lethal brainstemcompression.

In very young children, elevated intracranialpressure may cause an increase in the diameterof the skull and bulging of the fontanelles.

) d di l i d ( i


20/53

II)DYSFUNCTION : depending on tumor location, damage( it may

have caused to surrounding brainstructures), either through

compressionor infiltration,

any type of focal

neurologic

symptoms may

occur, such ascognitive and

behavioral

impairment

(including

impaired judgment

memory loss,

lack of recognition,

spatial orientation

personality or emotional

changes,

hemiparesis,

hypoesthesia,

aphasia, ataxia,

visual field impairment,

impaired sense of smell,

impaired hearing,

facial paralysis,

double vision


21/53

And more severe symptoms like

Hemiplegia impairment to swallow. A bilateral temporal visual field defect

(bitemporal hemianopiadue to compression

of the optic chiasm), often associated with

endocrine disfunction

either hypopituitarism or

hyperproduction of pituitary hormones

and hyperprolactinemia is suggestive of a

pituitary tumor.


22/53

III)IRRITATION :

signs abnormal fatigue,

weariness,

absences and tremors, also epileptic seizures


23/53

Infratentorial vs Supratentorial TumorsSUPRATEN

TORIAL

TUMORS

Meningiomas

Gliomas

Astrocytomas Glioblastoma

Multiforme

Oligodendrogli

omas

Germinomas

Colloid Cysts of

Third Ventricle

INFRATENT

ORIAL

TUMORS Choroid plexus

papillomas

Cerebellar

astrocytomas Medulloblastomas

Hemangioblastomas

Ependymomas

Brainstem gliomas

Schwannomas

Pituitary adenomas

Craniopharyngioma

s

Epi:


24/53

MENINGIOMA

Epi: 2nd most common primary brain

tumor after gliomas, incidence of ~6/100,000

Usual age 40-70 F>M

Facts: Arise from arachnoidal cap cell type

from the arachnoid membrane

Usually non-invasive Associated with NF-2

Location: Parasagittal region

Sphenoid wing Parasellar region

Presentation: Asymptomatic Symptomatic: focal or generalized

seizure or gradually worseningneurolo ic deficit


25/53


26/53


27/53

Astrocytes- astrocytomas

Fibrillary

Pilocytic

Oligodendrocytes- oligodendrogliomas

Ependyma- ependymomas

Gliomas


28/53

GLIOMASArise from Glial Cells

AstrocytomasAstocytomas fall on a gradient that ranges from benign to malignant

Oligodendrogliomas

Low Grade Pilocytic

Astocytomas

Glioblastoma

multiforme

Benign Malignant

Diffuse Low Grade

Astrocytomas


29/53

ASTROCYTOMADiffuse Low Grade Astrocytoma

Epi: 15% of Astrocytomas

Young Adults

Facts: Widely Infiltrate surrounding tissue

Location: Frontal Region

Subcortical white matter

Presentation: Seizures

Headache

Slowly progressive neurologic deficits

Cyst

T1 weighted T2 weighted


30/53

ASTROCYTOMA:High Grade Astrocytoma: Glioblastoma

Epi: Most common type of primary brain tumor in adults Age of presentation: 40-60, M>F

Facts: May arise de novo or evolve from a low-grade glioma Tumor infiltrates along white matter tract and can cross

corpus callosum Poor Prognosis Can look like a butterfly lesion

Location: Frontal & Temporal Lobes Basal Ganglia

Presentation: Seizures, Headache Slowly progressive neurologic deficits


31/53


32/53

Astrocytomas

ADULTS

Supratentorial

Solid

Malignant; fibrillary.

CHILDHOOD

Infratentorial

Cystic

Benign ; pilocytic ,


33/53

astrocytomas


34/53

OLIGODENDROGLIOMA

Epi:

5-10% of primary brain tumors Mean age of onset 40 years

Facts:

Distinguished pathologically from astrocytomas by thecharacteristic fried egg appearance. Arises from Myelin

Location: Superficially in Frontal Lobes

Presentation: Seizures most common Headache Slowly progressive neurologic deficits


35/53

Oligodendroglioma Slow growing tumor

Potentially malignant

Calcifications

GERMINOMA


36/53

GERMINOMA

Facts: Germ Cell Tumors

Causes Parinauds Syndrome

disorder characterized by fixed upward gaze

Location:

Commonly in Pineal Region (>50%)

Overlies tectum of midbrain

Presentation: Obstructive Hydrocephalus due to aqueductal stenosis

T1 Images


37/53

COLLOID CYST OF THE VENTRICLE

Epi:

Usually in Adults

1% of all intracranial tumors

Facts:

Managed Surgically

Causes hydrocephalus

by obstructive flow Endodermal origin

Location:

Foramen of Monro

Anterior aspect of third

ventricle Presentation:

Headaches

Vertigo

Memory deficits

CHOROID PLEXUS PAPILLOMAS


38/53

CHOROID PLEXUS PAPILLOMAS Epi

Represents 2% of gliomas One of the most common

brain tumors in patients


39/53

CEREBELLAR ASTROCYTOMA

Epi: Most often occurs in

childhood

Facts: Most potentially curable

of the astrocytomas

Location: Posterior Fossa

Presentation: Headaches

Nausea/Vomiting

Gait Unsteadiness Posterior head tilt with

caudal

tonsillar herniation

Cyst

Tumor arising from vermis or cerebellar

hemispheres

MEDULLOBLASTOMAS


40/53

MEDULLOBLASTOMAS Epi

Represent 7% of primary brain tumors

2

nd

most common posterior fossa tumor in children 70% of patients are diagnosed prior to age 20 with peak incidence

between 5-9 years of age;

Facts Primitive neuroectodermal tumors (PNET)

Soft, friable tumors, often necrotic Can metastasize via CSF tracts

Highly radiosensitive

Location About 75% arise within the cerebellar vermis

Presentation Most frequently present with signs of intracranial pressure

May cause hydrocephalus

Cranial nerve deficits may also occure


41/53

HEMANGIOBLASTOMA


42/53

HEMANGIOBLASTOMA

Epi 2% of primary intracranial tumors and 10% of posterior fossa

tumors Most found in young adults and children

Facts Characterized by abundant capillary blood vessels If found in cerebellum and retina, may represent part of von

Hippel-Lindau syndrome. Acute hemorrhage can be fatal 15-20% of patients with hemangioblastomas can present

with erythrocytosis

Presentation

Usually present with neurologic deficits by directcompression or hemorrhage Neurologic deficits may include cerebellar ataxia, oculomotor

nerve dysfunction, motor weakness, or sensory deficits

Location

Most often found in cerebellum and spinal cord

Epi


43/53

EPENDYMOMASImaging Usually well demarcatedwith frequent areas of calcification,

hemorrhage, and cysts;

Epi

Accounts for 10% of CNS lesions;

Male=Female

Median age at diagnosis is 5 yearsold

Facts

Derived from primitive glia

Overall survival at 10 years is 45-55%

Presentation

Most patients present withsymptoms of increased intracranialpressure

Location

Typically arise within or adjacent tothe ependymal lining of theventricular system.

In children, 90% are intracranial with60% arising in posterior fossa (4thventricle is the most commoninfratentorial site)

Most common spinal cord glioma (inadults, 75% arise within spinalcord);;


44/53


45/53

BRAINSTEM GLIOMAS

Epi Male=Female

Account for 10-20% on all CNS tumors

More common in children (account for 20% of all intracranialneoplasms under the age 15);

In children, median age at diagnosis is 5-9 years of age.

Facts NF-1 is the only known risk factor

Mostly benign (but range from benign to very aggressive);

Long term survival for low-grade gliomas is near 100%.

Location In peds, 80% arise in pons, with 20% arise in medula, midbrain, and

cervicomedulary junction;


46/53

BRAINSTEM GLIOMAS

Presentation Most patients with low-grade

brainstem gliomas have along history of minor signsand symptoms;

May present with neck painor torticollis;

Medulary tumors maypresent with cranial nervepalsies, dysphagia, nasalspeech and apnea, n/v,ataxia,or weakness;

May cause locked-insyndrome

SCHWANNOMAS


47/53

SCHWANNOMAS Epi

Female>male Median age at diagnosis is 50

Account for 80-90% of cerebellopontine angle tumors Comprise 8% of intracranial tumors in adults; rare in children

(except with NF-2) Facts

Unilateral in 90% of cases (R=L); Bilateral acoustic neuromas are diagnostic of NF-2;

Presentation Patients may present with asymmetric sensorineural hearing

loss, tinnitus Fluctuating unsteadiness while walking, vertigo (although only

1% of patients with vertigo had schwannomas);

If CN V nerve is affected, facial numbness, pain, andhyperesthesia may be present; If CN VII is affected, facial paresis may be present. Tumor progression may lead to compression of brainstem or

cerebellum leading to ataxia, tonsil herniation, andhydrocephalus

Location Arise from vestibular division of CN VIII; majority benign


48/53

SCHWANNOMAS

PITUITARY Imaging:


49/53

PITUITARYADENOMAS

Epi

Most common tumors ofpituitary gland

Represent 8% of primary braintumors

Facts Out of pituitary adenomas,

prolactinomas are the mostcommon;

Presentation

May cause hypopituitarism andvisual field defects;

Patients should have endocrine,radiographic, andophthalmologic assessments.

Imaging:

Plain x-ray may show an enlargedsella turcica;

MRI is the imaging of choice;

Imaging


50/53

CRANIOPHARYNGIOMAS

Epi

Represent 1-3% of primary braintumors

Bimodal distribution: first peak infantsand children; second peak 55-65 yearold

Facts

Derived from epithelial remnants ofRathkes pouch; slow growing; benign

Tend to recur even after completeremoval

20-year survival rate of children withcraniopharyngiomas is about 60%.

Location Located in suprasellar fossa and

inferior to optic chiasm

Presentation Cause bitemporal hemianopsia and

hypopituitarism;

frequently present with headache;

g g

Cystic calcified

parasellar lesion could

be seen on radiograph;


51/53

Metastatic brain tumors

Most common brain tumor in adults.

Common primary sites: melanoma, lung, breast, GItract, kidney.

Most are in cerebrum (MCA territory).

In gray-white junctions due to rich capillarityDiscrete, globoid, sharply demarcated tumors.

Amenable to surgical resection.

Single or multiple.

Brain edema frequent.


52/53


53/53

thankyou

Seminar Brain Tumors

Documents

Transcript of Seminar Brain Tumors