Tumor Otak

Low-grade glioma
Low-grade primary brain tumors include those tumors arising from the brain parenchyma, such as astrocytomas,oligodendrogliomas, ependymomas, subependymomas,choroid plexus papillomas (CPPs), ganglion cell tumors, and neurocytomas.

Astrocytomas
Noninfiltrative astrocytomas include pilocytic astrocytomas, pleomorphic xanthoastrocytomas, subependymal giant cell astrocytomas (SGCAs), and desmoplastic cerebral astrocytoma of infancy. Infiltrative astrocytomas include anaplastic and welldifferentiated types

Well-Differentiated, Diffuse, Infiltrative Astrocytoma

They most frequently arise from the supratentorial brain and the brain stem. Brain stem involvement is more frequently seen with children. On imaging these tumors most often appear homogeneous and infiltrating. Focal, circumscribed astrocytomas can also occur. They can be difficult to detect on CT, may manifest with only a slight density difference, and usually do not enhance.

Brain stem astrocytoma Noncontrast CT shows a hypodense On postcontrast CT the lesion does not enhance lesion expanding the pons and compressing the IV ventricle

 Sudden change in contrast enhancement may be an indication of conversion to higher grade (Fig. 5.7) or radiation necrosis.

Anaplastic transformation of a low-grade astrocytoma. Sixty-one-year-old female patient who presented with aphasia was discovered to have a WHO grade II astrocytoma involving left temporal and parietal lobes.

The tumor is much less conspicuous on a contrast-enhanced CT of the head

There was some hypodensity noted on CT within the tumor bed

Three months later the tumor showed significant progression on CT

 These tumors comprise WHO classification type I tumors classically composed of compact and spongy tissue. Pilocytic astrocytomas usually present in the first two decades of life They often arise from the cerebellum, hypothalamus, optic nerve, optic chiasm, and brain stem, or less commonly in the cerebral hemispheres.

Noninfiltrative, Diffuse, or Circumscribed Astrocytomas Pilocytic Astrocytoma

Imaging
On cross-sectional imaging they are identified as well circumscribed tumors. Classically, they present as a cystic tumor with an enhancing mural nodule. Cystic components are identified in approximately 68% of cases and may develop on follow-up exam On CT the solid component of the tumor typically appears hypodense (43%) or isodense (51%) or, less commonly, hyperdense (6%) Calcifications have been reported in approximately 11% of tumors examined by CT

Pilocytic astrocytoma within the left cerebellar hemisphere of a boy who presented at age 9 with headaches and developed a cyst 1 year later.

The tumor is less conspicuous on CT

Pilocytic astrocytoma

Noncontrast CT shows a cystic lesion with an isodense nodule

Postcontrast CT shows enhancement of the nodule

Axial CT images of a pilocytic astrocytoma centered in the corpus callosum.Note the calcific focus which occasionally accompanies this tumor type (arrows). The well-circumscribed appearance is suggestive of low grade and may help distinguish it from the butterfly pattern seen with glioblastoma

Pilomyxoid Astrocytoma
Pilomyxoid astrocytoma (PMA) is a low-grade astrocytoma previously considered to be classified as a pilocytic astrocytoma. They tend to occur in early childhood but have been identified in adults These tumors tend to occur in the hypothalamic/chiasmatic region

Pilomyxoid astrocytoma; 15-year-old male with pilomyxoid astrocytoma. Noncontrast axial CT. Note calcifications

Pleomorphic Xanthoastrocytoma
Pleomorphic xanthoastrocytomas (PXA) are rare tumors of children and young adults comprising less than 1% of all gliomas. They are generally classified as WHO classification grade II neoplasms, but have been known to undergo malignant transformation. Like pilocytic astrocytomas, PXAs occur more frequently in the first two decades of life. Unlike pilocytic astrocytomas, they occur more commonly in the cerebral hemispheres with a predilection in the temporal lobes followed by the parietal, occipital, and frontal lobes.

Imaging
PXA presents either as a cyst with a mural nodule or, less commonly, as a completely solid tumor. The mural nodule is usually attached to the leptomeninges. On unenhanced CT, the mural nodule or the solid portion of the tumor appears hypo- or hyperdense. After the administration of contrast medium PXAs enhance markedly.

Pleomorphic xanthoastrocytoma

Unenhanced CT shows a hyperdense, left parietal lesion surrounded by hypodense edema

Postcontrast CT shows marked enhancement of the solid tumor

Subependymal Giant Cell Astrocytoma

Subependymal giant cell astrocytoma (SGCA) is a low-grade primary brain tumor assigned a WHO grade I classification. These tumors invariably occur in the setting of tuberous sclerosis and affect the region near the foramen of Monro eventually obstructing this structure and causing hydrocephalus.

Imaging
Intrinsic CT features include the presence of calcifications and a hyperdense appearance relative to cortex. Tumoral calcifications are thought to relate to small areas of hemorrhage.

Precontrast CT shows a partially calcified mass at the foramen of Monro (arrows)

Oligodendroglioma
Oligodendrogliomas are typically slowgrowing tumors with a propensity to involve the cortex. Imaging features associated with this tumor include calcifications, cyst formation, calvarial scalloping Contrast enhancement with foci over 5 mm was seen only with anaplastic grade tumors.

Imaging
These tumors are almost always supratentorial and distributed equally in all lobes on the basis of the size of the lobe, although they have been identified in the posterior fossa and within the ventricular system. These tumors have been found in patients 380 years of age, with a mild peak at the fourth and fifth decades and a slight male predilection CT typically demonstrates a peripherally located hypodense tumor. Hypodensity is observed in 5770% of cases however, intraventricular olidogendrogliomas have a tendency toward hyperdensity. Calcifications have been identified in 4090% of cases on CT, although pathologic series report calcifications in 45% of cases. Cysts have been identified in 20% of oligodendrogliomas on CT and 32% in pathologic series.The tumor is well-circumscribed in 4957% of CT examination and enhances on CT in 2466% of cases. Calvarial erosion indicative of long-standing tumor has been identified in 17% of CT examinations

Oligodendroglioma

CT demonstrating a hypodense, solid (arrowheads), and cystic (double arrow) component with clump-like calcifications (arrow) in anaplastic oligodendroglioma

A hypodense right frontal mass (arrowheads) with punctate calcifications (arrows) in intermediate-grade oligodendroglioma

Choroid Plexus Papilloma

CPPs are WHO classification grade I tumors and are considered benign. CPPs tend to occur in the first couple of decades of life, although they may develop at any age. Up to onehalf of all CPPs are found in the lateral ventricle.

Imaging
On imaging, CPPs acquire the imaging characteristics of the normal choroid plexus. On CT, they are hyperdense or isodense relative to cortex and frequently contain prominent calcifications and display intense contrast enhancement

An 8-month-old child with a biopsy-proven choroid plexus papilloma. CT imaging demonstrates a left sided intraventricular mass isodense to gray matter associated with ventriculomegaly.

Ependymoma
Ependymomas are WHO classification II neoplasms consisting of ependymal cells. WHO classification III ependymal neoplasms are referred to as anaplastic ependymomas. Although they may be found in any agegroup, brain ependymomas have a tendency to develop in the first couple of decades of life Ependymomas are usually found along the ependymal lining of the ventricular system. Approximately 58% are infratentorial and 42% are supratentorial, occurring most commonly in the fourth ventricle followed by the lateral ventricles and less commonly (8%) in the third ventricle.

Imaging
On unenhanced CT they appear hypodense or isodense. About 50% of them show dense, punctuate calcification. After the administration of contrast material, they demonstrate variable enhancement, which can be homogeneous, inhomogeneous, or ring enhancing

CT of infratentorial intraventricular ependymoma

Postcontrast CT shows mild homogeneous enhancement of the mass

Unenhanced CT shows a slightly hyperdense fourth ventricular mass with small calcifications (arrows)

Dysembryoplastic Neuroepithelial Tumor

DNT is a recently described cortically based tumor (WHO grade I) that is defined by a multinodular architecture which may include specific glioneuronal elements, a nodular component of glial cells, and cortical dysplasia Patients typically present in childhood, though the tumor has been found in patients up to age 61 [179] and there is a slight male predominance It is found the tumor in the temporal lobe in 62%, frontal lobe in 31%, and parietoccipital lobe in 9% of the cases

Imaging
CT typically demonstrates a well-circumscribed hypodense lesion giving a pseudocyst appearance A cystic appearance on CT has been noted in 28% of cases Focal contrast enhancement on CT was noted in 18% of patients Calvarial scalloping or temporal fossa erosion, signs of a slow growing neoplasm, are reported in 960% of patients with corticalbased tumors or larger-sized tumors

Subependymoma
Subependymomas are biologically benign, slowgrowing intraventricular tumors consisting of astrocytes and ependymal cells. They are usually seen in adults with a mean age of 50 years. They are most commonly found in the fourth ventricle (3060%), where they arise from the floor, and in the lateral ventricle (4075%), where they are attached to the septum pellucidum

Imaging
The imaging appearance of subependymomas has been noted to vary based on location. CT of fourth ventricular subependymomas demonstrates variable density compared to gray matter with calcifications in 50100% of cases and enhancement in 6292%. Lateral ventricle subependymomas, on the other hand, vary in density, but are moreoften hypodense, usually do not enhance, and calcifications are seen in less than 10%

Subependymoma

The tumor displays contrast enhancement as well as the calcific deposits identified on the CT image (arrowheads). These features make the fourth ventricular location different than the lateral ventricular location of this tumor. The relative lack of invasion of the brain parenchyma suggest lowgrade tumor

High-grade glioma
Gliomas are the most common primary brain tumors in adults and account for 4050% of all intracranial tumors. They may manifest at any age, but preferentially affect adults. Their peak incidence is in the fifth and sixth decade of life. They are slightly more common in men than women (1.5:1 ratio), and significantly more common in white than black people. Gliomas can affect any part of the CNS, but they usually occur more supratentorially in adults and infratentorially in children

Anaplastic Astrocytoma
Almost all AAs originate as a benign tumor and have a tendency for malignant progression to glioblastoma multiforme Although some arise as new primaries, 75% result from differentiation of low-grade gliomas (LGGs). AAs correspond histologically to WHO grade III tumors. AAs generally appear in a slightly higher age group than low-grade astrocytomas. Their peak incidence is in the fourth and fifth decades of life.

Imaging
On CT AA presents as an ill-defined inhomogeneous lesion. Calcification is rarely encountered and only in cases of preexisting LGGs with malignant transformation. Peritumoral edema may be present as a hypodense area. After the administration of contrast material they show moderate or significant heterogeneous enhancement

Anaplastic astrocytoma in a 68-year-old patient.

Postcontrast CT shows an inhomogeneous left parietal mass with moderate enhancement (arrow), and white matter edema.

Glioblastoma Multiforme
GBM is the most common primary intracranial CNS tumor accounting for more than half of all glial tumors and 15 20% of all intracranial tumors Glioblastoma and its variants correspond to WHO grade IV tumors and is the most aggressive and least differentiated type of gliomas GBM may occur at any age with a peak incidence between 45 and 70 years. As with gliomas in general, these lesions show a male predominance of approximately 3:2. GBMs are most often found in cerebral hemispheres, particularly in frontal, parietal, and temporal lobes, although they can be situated in any lobe.

Imaging
On unenhanced CT GBM appears as a central low-density mass located usually in the centrum semiovale. Calcification is rare in GBMs. They are heterogeneous due to the reflecting sites of necrosis, hemorrhage, and increased cellularity. Necrosis is the imaging hallmark of GBMs Besides necrosis and hemorrhage, another characteristic radiologic feature is the presence of edema, which surrounds the tumor, extends along the adjacent white matter tracts, and usually produces significant mass effect. After the administration of contrast material, they usually show marked heterogeneous rim enhancement with thick, shaggy, irregular, and nodular wall

Unenhanced CT shows a low density, right temporoparietal mass with ill defined borders.

Postenhanced CT shows an irregular ring-like enhancement of the mass with central necrosis

Gliosarcoma
In a small percentage of GBM, not more than 2%, a sarcomatous component is apparent, making, macroscopically, a relatively discreet appearance. They are peripherally located and involve the temporal, parietal, and occipital lobes Most patients with gliosarcoma are in their fifth to seventh decade. Gliosarcomas correspond histologically to WHO grade IV

Imaging
On plain CT, most tumors appear as slightly hyperdense lesions because of their high vascularity and cellularity. After the contrast administration, gliosarcomas show marked enhancement and may mimic a meningioma, when the tumor is located near the skull or falx. Gliosarcomas, however, are less homogenously hyperdense than meningiomas, do not have a large base in contact with the skull, and are virtually always associated with peritumoral edema. In other cases, the CT appearance is that of an intracerebral mass with irregular and peripheral enhancement and large necrotic areas, similar to malignant astrocytomas or glioblastomas

Gliomatosis Cerebri
GC describes a diffuse overgrowth of the neuraxis by neoplastic glial cells with relative preservation of the underlying cytoarchitecture where no grossly discernible mass is recognizable Although the cerebellum, brain stem, and spinal cord may be involved, the cerebral hemispheres are primarily affected GC can affect all age groups, but the peak incidence is in the second to fourth decade. Men and women are affected with equal frequency

Imaging
GC appears on CT as a diffuse, poorly defined, iso- to hypodense area with more or less diffuse mass effect, which is usually not enhanced Contrast enhancement is encountered only in some cases in the late stage of the disease. The pattern of enhancement varies from local to linear

Gliomatosis cerebri in a 50-year-old patient.

Postcontrast CT shows a hypodense, slightly enhanced lesion involving the left temporal lobe.

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