brain neoplasm (intracranial neoplasm)
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Etiology
- primary brain tumor
- neuroepithelial neoplasm
- glioma
- astrocytoma (18%)
- oligodendroglioma (3%)
- glioblastoma (22%)
- ependymoma (2%)
- choroid plexus papilloma
- medulloblastoma
- pineal tumor
- dysembryoplastic neuroepithelial tumor[4]
- glioma
- lymphoma primary to CNS (4%)
- pituitary adenoma (10%)
- meningioma (27%)
- schwannoma (7%)
- craniopharyngioma
- cysts
- germ cell neoplasms
- chordoma
- hemangioblastoma
- malignant mesenchymal tumors of the meninges
- neuroepithelial neoplasm
- metastatic tumor
- genetic disorders associated with intracranial tumors
Epidemiology
- 2% of solid tumors in men
- 2nd most common tumor after leukemia in individuals < 15 years of age
- 3rd most common tumor in men, 4th most common in women age 15-34 years
- 4th most common tumor in men age 35-54 years
Pathology
- most commonly involve cerebral hemispheres[4]
Genetics
Clinical manifestations
- headache
- nausea/vomiting
- visual changes
- papilledema
- lateralized weakness, focal neurologic deficits, tremor
- ataxia
- seizures (most common presentation)[4]
- altered mental status, personality change
- aphasia
- nystagmus
- cranial nerve dysfunction
- upper motor neuron signs
- signs of brainstem compression
- decreased level of consciousness
- nonreactive or asymmetric pupils
- hypertension & bradycardia
- abnormal breathing pattern
- endocrine dysfunction
- vasomotor & autonomic changes
- signs & symptoms of primary metastatic cancer
Laboratory
- complete blood count (CBC)
- polycythemia may be associated with hemangioblastoma
- serum chemistries
- CSF examination
- AFTER neuroimaging
- presumptive diagnosis of intracranial tumor increases risk of fatal cerebellar-foramen magnum or temporal- tentorial herniation
- cell count & cytology
- medulloblastoma, ependymoma, choroid plexus papilloma & some embryonal pineal & suprasellar tumors may spread into the CSF
- glucose
- protein
- high protein & xanthochromia in the absence of RBC suggests obstruction of the subarachnoid space producing stasis of CSF in the lumbar sac
- seen with
- tumors at the base of the skull (acoustic neuroma)
- spinal cord tumors
- seen with
- high protein & xanthochromia in the absence of RBC suggests obstruction of the subarachnoid space producing stasis of CSF in the lumbar sac
- beta-hCG associated with trophoblastic tumor
- alpha-fetoprotein is associated with yolk sac tumor
- AFTER neuroimaging
- biopsy may have prognostic value
- intravenous bromodeoxyuridine (BUdR) administration prior to surgery facilitates obtaining a proliferation index in biopsied tumor tissue
- immunohistochemical staining for proliferating cell nuclear antigen PCNA
- monoclonal antibody staining for nuclear protein Ki67
- see ARUP consult[5]
Diagnostic procedures
- formal visual field testing
- visual evoked potentials may help distinguish multiple sclerosis from tumor[3]
Radiology
- magnetic resonance imaging (MRI) with gadolinium contrast
- multifocal ring-enhancing lesions at the gray-white junction suggest brain metastases[4]
- infiltrating white matter lesions suggest glioma
- contrast enhancement suggest higher grade neoplasm
- vague contast enhancement with honerycomb pattern suggests oligodentroglioma
- calcification seen best with CT
- periventricular homogeneous diffusely enhancing white matter lesions sugges primary CNS lymphoma
- posterior fossa suggests ependymoma vs medulloblastoma
- ependymoma:
- may also involve spinal cord
- contrast enhancement
- calcification
- +/- hydrocephalus
- medulloblastoma (cerebellum)
- ependymoma:
- cerebellar-pontine angle suggest schwannoma
- dural with diffusely-enhancing lightbulb sign suggests meningioma
- computed tomography (CT) of head
- emergency neuroimaging
- calcification may be best seen with CT
- chest X ray if metastatic lung cancer is possibility
Complications
- increased intracranial pressure
- obstructive hydrocephalus
- hemorrhage into a tumor
- fluid & electrolyte imbalance (especially hyponatremia)
- opportunistic infections
- complication of therapy
- radiation-induced complications
- early reactive peritumor edema or demyelination
- early-delayed corticosteroid-responsive encephalopathy
- radiation necrosis (3-13 months after radiation)
- vincristine neuropathy
- radiation-induced complications
- paraneoplastic syndromes
- meningeal carcinomatosis
- neoplastic angioendotheliosis
- venous thromboembolism: pulmonary embolism[4]
Differential diagnosis
- neoplasm
- primary tumor
- metastatic tumor
- infection
- hemorrhage
- miscellaneous lesions
- multiple sclerosis plaque
- acute infarction with swelling
- arachnoid cyst
- vascular malformation
- large aneurysm
Management
- metastatic workup, if indicated (10% of unknown primary)
- neurosurgery consultation
- biopsy
- resection
- ventricular drainage for hydrocephalus
- nothing by mouth (NPO) if neurosurgery is anticipated
- measures to attenuate cerebral edema
- dexamethasone:
- generally begun prior to surgical decompression
- generally tapered 1 week after surgery
- use lowest dose that maintains comfort & function
- do not use if primary CNS lymphoma suspected[4]
- mannitol
- intubation & hyperventilation seldom indicated
- dexamethasone:
- anticonvulsants for seizure prophylaxis not routinely recommended[4][7]
- anticonvulsant may be used for 1 week immediately after surgical resection[4]
- if seizure occurs, anticonvulsive therapy is recommended[4]
- radiation therapy
- chemotherapy
- agents which cross the blood brain barrier have anti- tumor activity against parenchymal tumors
- BCNU, CCNU, PCNU, ACNU, procarbazine, temozolomide
- hydroxyurea often used during radiation
- lomustine, procarbazine & vincristine (PCV) is a combination chemotherapy often used after radiation
- agents which cross the blood brain barrier have anti- tumor activity against parenchymal tumors
- metastasis to the brain
- a single brain metastasis may be amenable to surgical resection
- multiple brain metastases are treated palliatively
- whole brain irradiation
- stereotactive radiosurgery
- prophylaxis for venous thromboembolism in hospitalized patients
- anticoagulation in combination with pneumatic compression after surgical resection[4]
- intravenous heparin for pulmonary embolism[4][10]
- patient education
- no driving
- risks & benefits of procedures
- prognosis
- astrocytoma: median survival
- 93 months for grade 1 or 2
- 12 months for grade 3 (anaplastic astrocytoma)
- 5 months for grade 4 (glioblastoma multiforme)
- 1 year with radiation plus chemotherapy
- 18 months with radiation plus brachytherapy
- oligodendroglioma
- ependymoma: 5 year survival is > 80%
- primary CNS lymphoma:
- meningiomas
- surgical excision often curative
- radiation therapy reduces recurrence to < 10%
- schwannomas are clinically benign
- astrocytoma: median survival
More general terms
More specific terms
- astrocytic neoplasm, WHO grade 1
- brainstem neoplasm
- cerebellar neoplasm
- craniopharyngioma
- ganglioglioma; dysembryonic neuroepithelial neoplasm
- hypothalamic neoplasm
- malignant brain tumor
- pineal neoplasm
- pituitary neoplasm
Additional terms
References
- ↑ Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1068-70
- ↑ Harrison's Principles of Internal Medicine, 14th ed. Fauci et al (eds), McGraw-Hill Inc. NY, 1998, pg 623, 2398
- ↑ 3.0 3.1 Levin et al, Neoplasms of the central nervous system, in: Cancer: Principles & Practice of Oncology, DeVita et al, eds, Lippincott, Williams & Wilkins, Philadelphia, 2001, pg 2100
- ↑ 4.00 4.01 4.02 4.03 4.04 4.05 4.06 4.07 4.08 4.09 4.10 4.11 Medical Knowledge Self Assessment Program (MKSAP) 15, 16, 17, 18, 19. American College of Physicians, Philadelphia 2009, 2012, 2015, 2018, 2021.
- ↑ 5.0 5.1 ARUP Consult: Central Nervous System Tumors - Brain Tumors The Physician's Guide to Laboratory Test Selection & Interpretation https://www.arupconsult.com/content/central-nervous-system-tumors
- ↑ Hoffman S, Propp JM, McCarthy BJ. Temporal trends in incidence of primary brain tumors in the United States, 1985-1999. Neuro Oncol. 2006 Jan;8(1):27-37. PMID: https://www.ncbi.nlm.nih.gov/pubmed/16443945
- ↑ 7.0 7.1 Glantz MJ, Cole BF, Forsyth PA et al Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology. 2000 May 23;54(10):1886-93. PMID: https://www.ncbi.nlm.nih.gov/pubmed/10822423
- ↑ Ricard D, Idbaih A, Ducray F et al Primary brain tumours in adults. Lancet. 2012 May 26;379(9830):1984-96. PMID: https://www.ncbi.nlm.nih.gov/pubmed/22510398
- ↑ Maschio M, Dinapoli L. Patients with brain tumor-related epilepsy. J Neurooncol. 2012 Aug;109(1):1-6 PMID: https://www.ncbi.nlm.nih.gov/pubmed/22528794
- ↑ 10.0 10.1 Jo JT, Schiff D, Perry JR. Thrombosis in brain tumors. Semin Thromb Hemost. 2014 Apr;40(3):325-31. Review. PMID: https://www.ncbi.nlm.nih.gov/pubmed/24599439
- ↑ Schaff LR, Mellinghoff IK Glioblastoma and Other Primary Brain Malignancies in Adults. A Review. JAMA. 2023;329(7):574-587 PMID: https://www.ncbi.nlm.nih.gov/pubmed/36809318 https://jamanetwork.com/journals/jama/fullarticle/2801673
- ↑ Perkins A, Liu G. Primary Brain Tumors in Adults: Diagnosis and Treatment. Am Fam Physician. 2016 Feb 1;93(3):211-7. PMID: https://www.ncbi.nlm.nih.gov/pubmed/26926614 Free article. Review.
- ↑ Adult Brain Tumors (PDQ): Treatment http://www.nci.nih.gov/cancerinfo/pdq/treatment/adultbrain/HealthProfessional/
Childhood Brain Tumors (PDQ): Treatment http://www.nci.nih.gov/cancerinfo/pdq/treatment/childbrain/HealthProfessional/ - ↑ What you need to know about Brain Tumors http://www.cancer.gov/templates/doc.aspx?viewid=b5500bd0-3da6-496a-8080-3052a630ba57
- ↑ National Cancer Institute Brain Tumors - Health Professional version https://www.cancer.gov/types/brain/hp
Adult Central Nervous System Tumors Treatment (PDQ) - Health Professional version https://www.cancer.gov/types/brain/hp/adult-brain-treatment-pdq