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Brain Tumors
- 1. BRAIN TUMORS DR. HARDIK PATEL MCHRESIDENT DEPARTMENT OF NEUROSUREGRY
- 2. When most normalcells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong. New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The build-up of extra cells often forms a mass of tissue called a growth or tumor
- 3. Brain tumour :Defination known as an intracranial tumour, is an abnormal mass of tissue in which cells grow and multiply uncontrollably, seemingly unchecked by the mechanisms that control normal cells
- 4. CNS TumorsTumors of the nervous system may arise from Cells of the coverings – meninges, bone, subcutaneous Cells intrinsic to the brain Other cell populations within the skull Metastases (spread from elsewhere in the body )
- 5. Classification Based onsource Primary – originates from CNS Secondary / metastatic – originates elsewhere in body Based on location Supratentorial m/c in adults Infratentorial m/c in pediatric age group Tissue of origin Glial : Meningial : Embryonal; Mixed Vascular Bony origin Tissue of origin Children Adults Astrocytes Pilocytic Astrocytoma (PCA) Glioblastoma Multiforme (GBM) Oligodendrocytes Oligodendroglioma Ependyma Ependymoma Neurons Medulloblastoma Meninges Meningioma
- 6. Intra cranial/intra axial Extra dural Intra dural (but outside parenchymal) Intra parenchymal Intra ventricular Extra cranial Calvarial bony tumours Tumour arising from Skin and subcutaneous tissue.
- 7. Benign brain tumours Benign brain tumours do not contain cancer cells : ‒ Usually, benign tumours can be removed and the rarely grow back. ‒ Benign brain tumours have an obvious border or edge. They dont spread to other parts of the body They don't invade tissues around them However, benign tumours can press on sensitive area of brain and can cause serious neurological deficits. Unlike benign tumour of other parts of the body, benign tumour of the brain are sometimes life threatening with time benign brain tumours can become malignant.
- 8. Malignant brain tumors. contain cancer cells : More serious and often are threat to life Rapid Growth Invade or crowd nearby healthy brain tissue Cancer cell may spread to other parts of the brain or to the spinal cord rarely spread to other parts of the body.
- 9. Metastatic Brain Tumor Originates from malignancies outside of the CNS and spread to the brain, typically through arterial circulation. Approx. 25% of individual with systemic cancer develop metastatic brain tumor approx. 80% in cerebral hemisphere and 20% in the posterior fossa. 1/3rd of brain metastases orginate in Lungs→ Breast→ Skin→ GI tract→ Kidney Frontal lobe is the most common site Average survival with the treatment is approx. 6 months but varies widely by the extent of other systemic metastases.
- 10. CNS Tumors: General Features 10% of all tumors. Commonest solid cancers in children.(2nd to Leuk for all malignancies) Age: double peak 1st& 6th decade Adults - 70% supratentorial Children - 70% infratentorial No/very rare extra neural spread Metastasis most common Adults M/C location supratentorial Children M/C location infratentorial
- 11. CLASSIFICATION OF CNSTUMOURS 1. TUMOURS OF THE GLIAL TISSUE – (GLIOMAS) 2. TUMOURS OF NEURONS 3. MIXED TUMOURS WITH GLIAL & NEURONAL COMPONENTS 4. POORLY DIFFERENTIATED AND EMBRYONAL TUMOURS 5. TUMOURS OF THE MENINGES 6. PERIPHERAL NERVE SHEATH TUMOURS 7. METASTATIC TUMOURS 8. PRIMARY CNS LYMPHOMA 9. Miscellaneous TUMOURS: angioma (vascular origin), pituitary adenoma,
- 12. WHO Classification Basis Increasedcellularity Nuclear atypia Endothelial proliferation Necrosis
- 13. RISK FACTOR Arisk factor is something that may increase the chance of getting a disease. Ionizing Radiations : especially from high dose x-rays and other sources can cause cell damage that leads to a tumor. most common types are meningioma or glioma. Family History : It is rare for brain tumors to run in a family. only a very few number of families have several member with brain tumors
- 14. Most common primary brain tumors Gliomas(50.4%) Meningiomas (20.8%) Pituitary adenomas (15%) Nerve sheath tumors (8%)
- 15. Common types of brain tumors GLIOMAS Most common primary brain tumor 50% of all symptomatic brain tumors Incidence increases with advancing age Peak in 8th and 9th decades No known environmental factors No behavioural lifestyle choices Ionizing radiation: the only clear risk factor Originate from glial cells or their stem cell precursors GLIOMAS Include a. Astrocytoma b. Oligodendroglioma c. Ependymoma
- 16. Astrocytoma Most commonglioma Cerebral astrocytoma (more in adults) Behavioral changes Seizures Hemiparesis Language difficulty Cerebellar astrocytoma (more in children) Hemiparesis Ataxia Brain stem (children Pons CN deficits
- 17. WHO Grading of Astrocytoma Grade1 Pilocystic astrocytoma Bening cytological feactures Survival >10 years Grade 2 Low grade astrocytoma Moderate cellularity – no aplasia or increase mitotic aactivity Survival >5 years Grade 3 Anaplastic astrocytoma Increased cellularity, aplasia and mitotic activity Survival 3 years Grade 4 Glioblastoma multiforme Fertures of grade 3 and microvascular proliferation and necrosis Survival <1years
- 18. Radiological andpathological
- 19. Oligodendroglioma Derived fromoligodendrocytes or their precursors Oligodendrocytes produce the white matter in the brain 5-7% of all intracranial gliomas Most often in the 3rd and 4th decades Males:females = 2:1 Found primarily in cerebral hemispheres, within the brain parenchyma Highly infiltrative May metastasize distantly in ventricular & subarachnoid spaces like the GBM (CSF seeding Round regular “fried-egg” cells on histology
- 20. Prognosis of Oligodendroglioma Median Survival Low-grade oligodendrogliomas: 8-16 years Anaplastic oligodendrogliomas: 5 years Tumours that have 1p/19q LOH—best prognosis Many pts die from malignant transformation of the tumour
- 21. Ependymoma Arise fromependymal cells (an intraventricular tumor) More common in children 10% pediatric intracranial tumors 5% of adult intracranial tumors Most common in the 4th ventricle Ataxia, vertigo, increased ICP May grow in brain parenchyma without obvious attachment to the ventricular system Spinal lesions more common in adults Intracranial ependymomas predominate in children
- 22. Prognosis 5-year survival:40-50 10-year survival: 47-68 Better prognosis Young age Infratentorial Gross total excision Low-grade histology
- 23. MENINGIOMA Second mostcommon primary brain tumor Originate from arachnoid cells (meningoepithelial cap cells normally seen in arachnoid villi 20% of all intracranial tumors (with asymptomatic cases—40% or more 7% of all posterior fossa tumors 3-12% of cerebellopontine angle tumors Most diagnosed in 6th % 7th decades Female: Male—3:2 to 2:1 Multiple in 5-15% (NF-2 90% intracranial 10% intraspinal Spinal meningioma: 10x in women All familial meningiomas occur with NF-2 Rare in children (more in boys Rare without dural attachments Usually Intraventricular or posterior fossa Commonly with sarcomatous changes Frequently with NF-2
- 24. Etiology of Meningioma Progesteronereceptors Expressed in 80% of women with meningiomas Expressed in 40% of men with meningiomas
- 25. Sites of predilection Cerebral convexity (Sylvian & parasagittal areas Falxcerebri Skull base Olfactory groove Sphenoid ridge CP angle Tuberculumsella
- 26. Pathology Nodular tumorsoccasionally meningiomas en plaque(sheer-like formation) Highly vascular Encapsulated and attached in the dura (blood supply from external carotid artery) Hyperostosis of adjacent bone (bone proliferation Histological Characteristics Benign Typical features: Whorls of arachnoid cells surrounding a central hyaline material that eventually calcifies to form PSAMMOMABODIES
- 27. Signs and symptoms Depend on tumor size, type and location. Symptoms may be caused when a tumor presses on the nerve or harms the part of the brain Most common symptoms of brain tumors are : Headaches (usually worse in the morning) Nausea and vomiting Changes in speech, vision, or hearing Problems balancing or walking Changes in mood, personality, or ability to concentrate Problems with memory Muscle jerking or twitching (seizures or convulsions) Numbness or tingling in the arms or legs
- 28. Headache presenting symptomin 30 % of the cases & devlops during the course of the disease in 70% of the cases It is important to identify the specific nature of the headaches, because certain features often indicate the presence of a brain tumor. these feature include : 1. The headache that interrupts sleep or is worse on waking and improves throughout the day 2. The headache that is elicited by postural changes, coughing, or exercise 3. The headache of recent onset that is more severe or of a different type than usual 4. The new onset of headache in a previously asymptomatic person 5. The headache associated with nausea and vomiting, papilledema, or focal neurological signs
- 29. Seizure Presenting symptomin 1/3rd of cases and is present in 50%-70% of cases at some stage of the disease. Approx 10%-20% adults with new onset seizure activity have brain tumors. Seizures produce by glioma in Frontal Lobe (59%) Parietal Lobe (42%) Temporal Lobe (35%) Occipital Lobe (33%)
- 30. Altered Mental Status The initial symptom in 15% to 20% of individuals. Slight changes in concentration, memory, affect, personality, initiative, & abstract reasoning to severe cognitive problems & confusion
- 31. Papilledema (Swelling ofoptic nerve) less frequent now-a- days because brain tumors are being diagnosed earlier with the use of sensitive imaging techniques. It is more common in children with slow growing tumors and posterior fossa tumors. Other less common symptoms are vomiting and frank positional vertigo, usually accompanying tumors found in the posterior fossa
- 32. Specific Signs &Symptoms Few Clinical features are related to functional areas of the brain thus have a specific localizing value in medically diagnosing a brain tumor. FRONTAL LOBE Functions : Motor functioning, initiation of action, and interpretention of emotion, including motor speech. motor praxis, attention, cognition, emotions, intellegence, judgement, motivation and memory. Disorders : Hemiparesis, Seizures, Aphasia & Gait Difficulties. With gowth of tumor there may be personality changes like Disinhibition, Irritability, Impaired Judgement, & Lack of Initiation
- 33. PARITAL LOBEFunctions : General Condition : Contralateral Sensory loss & hemiparesis, Homonymous visual deficits or neglect, agnosia's, apraxia's & visual-spatial disorders. If Dominant Parietal Lobe is involved, Aphasia & Seizures may be present. If Non-Dominant Parietal Lobe is Involved, Contralateral neglect & decreased awareness of impairments can commonly be found.
- 34. OCCIPITAL LOBEFunctions : It is primary processing area of visual information. General Condition : Dysfunction of the eye movement & Homonymous hemianopsia. If parieto- occipital junction is involved, visual agnosia & agraphia are often present. Bilateral tumour may cause Cortical Blindness
- 35. TEMPORAL LOBEFunctions : Auditory and limbic processing. Condition : Ant. lesion - clinically silent until they become very large and causing seizes. Lateral Side - Auditory and perceptual changes Medial Side - Changes in cognitive integration, long-term memory, learning, and emotions may be seen. Dominant Temporal lobe - Aphasia Left Temporal lobe lesion - Anomia, agraphia, acalculia, Wernicke aphasia (Fluent, nonsensical speech) Bitemporal involvement - It is rare and causes memory deficits & possible dementia.
- 36. CEREBELLUM Function: Coordination & Equilibrium. Common Symptoms : In adults, headache, nausea and vomiting present in 40% of condition & ataxia in 25% of Cases. Lesion of midline - Truncal & Gait Ataxia Lesion of Hemispheres - Uni. Appendicular ataxia mostly in UE Lesion of either Hemisphere - Ipsilateral dysmetria, dysdiadochokinesia, and intention tremor. Lesion in cerebellopontine angle - hearing loss, headache, ataxia, dizziness, tinnitus and facial palsy may occur. If tumor invades meninges the at foramen magnum causes cerebellar tonsil herniation, nuchal rigidity and head tilt away from lesion may be seen. ** As cerebellum is located in an extremely confined space, even minimal increases in pressure can cause death from cerebellar tonsil herniation.
- 37. BRAIN STEMFunction : It communicates information to and from the cerebral cortex via fiber tracts, control basic life function. Reticular formation specifically controls consciousness and attention. Symptoms : Tumor have an insidious onset and may include gait disturbances, diplopia, focal weakness, headache, vomiting, facial numbness and weakness, and perrsonality changes. Dorsal Midbrain - Parinaud Syndrome(Loss of upward gaze, pupillary areflexia to light, and loss of convergence) Reticular System of Pons & Medulla - Apnea, hypo- or hyper- ventilation, orthostic hypotension or syncope
- 38. PITUITARY GLANDFunctions : It secretes hormones that regulate many bodily process Condition : Tumors are typically large and affect pitutary function by compressing its structure or hypersecreting hormones. Enlarging tumor decreases the hormone production resulting in Pituitary disorders are specific to type of hormones involved e.g. Cushings disease, hypothyroidism, Addison disease, diabetes etc. As tumor enlarge it compresses nearby area : Lateral Extension – 3rd & 4th cranial nerve - Diplopia 5th Nerve - Ipsilateral Facial Numbeness Internal Carotid artery occlusion - Cerebral Infarction Upward Extension - Compresses Optic Chiasma & Hypothalamus Downward Extension - Compresses Sphenoid Sinus
- 40. Diagnosis A clinicaldiagnosis consist of information the physician gathers during a comprehensive examination. Medical History including the specific nature of S&S Neurological Examination - Testing of reflexes & assess visual, cognitive, sensory, and motor function. Opthalmic examination – papiloedema, pupillary light reflex, visual acuity and Visual Feild After clinical diagnosis suspects the tumor the next diagnostic step is Tumor Imaging
- 41. Radiological Diagnosis Staticneurological imaging includes CT and MRI, Noninvasive techniques Provide accurate anatomical and functional analysis of intracranial structures. CT Scan : CT uses ionizing radiation, thin bands of x-rays, to produce images of slices of brain tissue. It was the first brain imaging technique to allow determination of tumor size. Contrast enhancement helps to identify isodense tumor from surrounding parenchyma, hypodense lesions in edematous areas, and optimal sites for tumor biopsy. After surgical intervention, CT can be used to confirm the proper tissue biopsy site and determine the success of tumor resection. Although MRI has become the preferred method, CT scanning offers lower cost, a shorter scanning time, and a more sensitive method to detect calcification and bony involvement.
- 42. Magnetic ResonanceImaging : MRI is the imaging procedure of choice MRI uses magnetic fields MRI is superior to CT in detecting & localizing tumor as well as evaluating edema, hydrocephalus or hemorrhage. MRI is more sensitive imaging modality Contrast enhancement with gadolinium sharpens the definition of lesion MRI enhanced with gadolinium can distinguish between edema and tumor MRI also cannot accurately predict tumor type or grade of malignancy, for which we need to biopsy the lesion
- 43. Dynamic Imaging. Positron emission tomography (PET) Single photon emission CT (SPECT) Magnetic Resonance Spectroscopy (MRS) Functional MRI PET Scan It is non-invasive and uses cyclotron and specific isotopes to obtain info about metabolism and physiology of the tumor and surrounding tissue. It uses radioactive markers to measure glucose metabolism which is useful to determine the grade of primary brain tumor. It also helps in study of metabolic effect of chemotherrapy, Radiation therapy and steroids on the tumor. It is expensive & less reliable in patient with heavy dose of chemo therapy
- 44. SPECT Scan: It is functional imaging technique evolved from PET scan & uses isotopes w/o cyclotron to assess cerebral blood flow and determining tumor location. It is used to identify high- & low- grade tumor to differentiate between tumor recurrence and radiation necrosis. It is used pre-op with static imaging to localize highest metabolic area of tumor for biopsy. SPECT is less sensitive method to obtain physiological information on tumors. It is more readily available and less expensive.
- 45. Magnetic ResonanceSpectroscopy : It is a non-invasive technique used in conjunction with static MRI to measure the metabolism of brain tumors. It has been proved to differentiate successfully normal brain from malignant tumor and recurrent tumor from radiation necrosis. It also has been used to document early treatment response and provide information regarding histological grade of astrocytomas. Magnetic resonance angiography (MRA) generates images of blood vessels without dye or ionizing radiation to evaluate the blood flow and position of vessels leading to the brain tumor.
- 46. Functional MagneticResonance Imaging : It uses a conventional MRI scanner fitted with echo planar technology to map cerebral blood flow at the capillary level. Its intended purpose is to provide information regarding the diffusion of contrast into tumor, resulting in better resolution of tumor and edema. It can also be used to identify the motor, sensory, and language areas of the brain or the functional eloquent cortex
- 47. Biopsy Surgicalbiopsy is performed to obtain tumor tissue as part of tumor resection or as a separate diagnostic procedure. Stereotactic biopsy is a computer-directed needle biopsy. When guided by advanced imaging tools, stereotactic biopsy yields the lowest surgical morbidity and highest degree of diagnostic information. This technique is frequently used with deep-seated tumors in functionally important or inaccessible areas of the brain in order to preserve function.
- 48. Laboratory Diagnosis Laboratorytesting is often used to further assess focal deficits during the diagnosis and management of brain tumors. Perimetry is the measurement of visual fields used when evaluating tumors near the optic chiasm. Electroencephalography (EEG) is used to monitor brain activity and detect seizures but has limited value during screening because EEG findings are often normal in clients with brain tumors. Lumbar puncture is used to analyze CSF, which is useful in the diagnosis and detection of dissemination of certain brain tumors. Audiometry and vestibular testing are useful for diagnosing tumors in the cerebellopontine angle. Endocrine testing is used to examine endocrine abnormalities with tumors in the pituitary gland and hypothalamus.
- 49. TREATMENT Medical &Surgical Management The ultimate goal of tumor management are to improve quality of life and extend survival, by improving body function & structures Treatment techniques are determined by histological type, location, grade, and size of tumor; age of onset; and medical history of the patient. Four Type of Treatment are discussed : 1. Traditional Surgery 2. Chemotherapy 3. Radiation Therapy 4. Stereotactic Radiosurgery
- 50. TRADITIONAL SURGERY: Primary Goal : Maximal tumor resection with the least amount of damage to neural or supporting structures. The purposes of surgery in the management of brain tumors include the following : 1. Biopsy to establish a diagnosis 2. Partial resection to decrease the tumor mass to be treated by other methods 3. Complete resection of the tumor 4. Provision of access for adjuvant treatment techniques
- 51. Biopsies areperformed through open, needle, and stereotactic needle techniques. ‒Open biopsies involve exposure of the tumor followed by removal of a sample through surgical excision. ‒Needle biopsies involve insertion a needle into the tumor through a hole in the skull and the excision of the tissue sample drawn through the needle. ‒Stereotactic needle biopsies use computers and MRI or CT scanning equipment to assisst in directing the needle into the tumor. Craniotomy Partial & Complete Resections are accomplished through craniotomy. –Craniotomy involves removal of a portion of the skull and seperation of the dura mater to expose the tumor. –Stereotactic craniotomy uses technologyto guide neurosurgeon duing the procedure. –Awake craniotomy allows for intra-op brain mapping.
- 52. CHEMOTHERAPY : Itcan be used independently or as an adjuvant to surgery or radiation. Chemotherapy can be administered in a number of different ways. Most agents are given intravenously through a peripheral intravenous line or through a catheter such as a peripherally inserted central catheter (PICC). Chemotherapy drugs impede cellular replication of the tumor cells, interfering with their ability to copy deoxyribonucleic acid (DNA) and reproduce. Methotrexate (Highly neuro-toxic) is admnistered with Leucovorin (Antidote) Temozolomide is orally available chemotherapeutic agent for the Rx of Gliomas. The antiangiogenesis monoclonal antibody Avastin (bevacizumab) improved the progression- free survival and the tumor images on MRIs of patients with glioblastoma. The drug targets vascular endothelial growth factor (VEGF) and is administered intravenously.
- 53. RADIATION THERAPY : It can be used alone or in conjunction with surgery or chemotherapy to treat malignant brain tumors. It is typically chosen as a treatment option for tumors that are too large or inaccessible for surgical resection and to eradicate residual neoplastic cells after a surgical debulking. Radiotherapy consists of the delivery of high-powered photons, with energies in a much greater range than that of standard x-rays, as an external beam directly at the tumor site.
- 54. Radiosurgery Radiosurgery involvesrelatively high-dose hypofractionated radiation beams directed at small tumor areas through the use of computer imaging. This type of treatment includes the Gamma Knife, linear accelerators, and the cyberknife.
- 55. HAVE A NICEDAY !! Thank you for your Attention …