ONCOLOGIC DISORDERS OF THE BRAIN

BRAIN TUMORS

A brain tumor is a localized intracranial lesion that occupies space within the skull. Usually grow as a spherical mass, but they can grow diffusely and infiltrate tissue.

PRIMARY BRAIN TUMORS

Originate from cells and structures within the brain.

SECONDARY, OR METASTATIC, BRAIN TUMORS

Develop from structures outside the brain.

CAUSE OF BRAIN TUMORS

Unknown The only known risk factor is exposure to ionizing radiation.

INCIDENCE

Have increased in the past few decades The highest incidence of brain tumors in adults occurs in the fifth, sixth, and seventh decades, with a slightly higher incidence in men. In adults, most brain tumors originate from glial cells (glial cells make up the structure and support system of the brain and spinal cord) and are supratentorial (located above the covering of the cerebellum). Neoplastic lesions in the brain ultimately cause death by impairing vital functions, such as respiration, or by increasing intracranial pressure (ICP).

PATHOPHYSIOLOGY

Brain tumors may be classified into several groups: Those arising from the coverings of the brain (eg, dural meningioma), those developing in or on the cranial nerves (eg, acoustic neuroma), those originating within brain tissue (eg, gliomas), and metastatic lesions originating elsewhere in the body. Tumors of the pituitary and pineal glands and of cerebral blood vessels are also types of brain tumors.

GLIOMAS

Glial tumors, the most common type of brain neoplasm, are divided into many categories. Astrocytomas are the most common type of glioma. Oligodendroglial tumors are another type of glial tumor, representing 20% of gliomas

MENINGIOMAS

Represent 20% of all primary brain tumors, are common benign encapsulated tumors of arachnoid cells on the meninges. They are slow-growing and occur most often in middle-aged adults (more often in women). Most often occur in areas proximal to the venous sinuses. Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue. Standard treatment is surgery with complete

ACOUSTIC NEUROMAS

Is a tumor of the eighth cranial nerve. It usually arises just within the internal auditory meatus, where it frequently expands before filling the cerebellopontine recess. May grow slowly and attain considerable size before it is correctly diagnosed. The patient usually experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait.

PITUITARY ADENOMAS

Represent about 8% to 12% of all brain tumors and cause symptoms as a result of pressure on adjacent structures or hormonal changes (hyperfunction or hypofunction of the pituitary).

Angiomas

Brain angiomas (masses composed largely of abnormal blood vessels) are found either in or on the surface of the brain. They occur in the cerebellum in 83% of cases. Some persist throughout life without causing symptoms; others cause symptoms of a brain tumor. Occasionally, the diagnosis is suggested by the presence of another angioma somewhere in the head or by a bruit (an abnormal sound) audible over the skull. Because the walls of the blood vessels in angiomas are thin, these patients are at risk for a cerebral vascular accident (stroke). In fact, cerebral hemorrhage in people younger than 40 years of age should suggest the possibility of an angioma.

CLINICAL MANIFESTATIONS

Brain tumors can produce either focal or generalized neurologic signs and symptoms. Generalized symptoms reflect increased ICP, and the most common focal or specific signs and symptoms result from tumors interfering with functions in specific brain regions.

INCREASING ICP
Enlarging Tumor Gradual compression of the brain

Disruption of the equilibrium that exists between the brain, the CSF, and the cerebral blood, all located within the skull As the tumor grows, compensatory adjustments may occur.

compression of intracranial

reduction of CSF volume (by increased absorption or decreased production a modest decrease of cerebral blood flow, and reduction of intracellular and extracellular brain tissue mass.

If compensatory mechanisms fail

Development of signs and symptoms 6th nerve palsy
Localize d Sympto ms

headach e

Nausea and vomiting

Headache

Not always present Most common in the early morning and is made worse by coughing, straining, or sudden movement. It is thought to be caused by the tumor invading, compressing, or distorting the pain-sensitive structures or by edema that accompanies the tumor. Headaches are usually described as deep or expanding or as dull but unrelenting. Frontal tumors usually produce a bilateral frontal headache; pituitary gland tumors produce pain radiating between the two temples (bitemporal); in cerebellar tumors, the headache may be located

Vomiting

Seldom related to food intake Usually due to irritation of the vagal centers in the medulla.

Visual Disturbances and Papilledema

Present in 70% to 75% of patients Is associated with visual disturbances such as decreased visual acuity, diplopia (double vision), and visual field deficits.

Localized Symptoms

The most common focal or localized symptoms are hemiparesis, seizures, and mental status changes When specific regions of the brain are affected, additional local signs and symptoms occur, such as sensory and motor abnormalities, visual alterations, alterations in cognition, and language disturbances such as aphasia.

A motor cortex tumor produces seizure-like movements localized on one side of the body, called Jacksonian seizures. An occipital lobe tumor produces visual manifestations: contralateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumor) and visual hallucinations. A cerebellar tumor causes dizziness, an ataxic or staggering gait with a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction.

A frontal lobe tumor frequently produces personality disorders, changes in emotional state and behavior, and an uninterested mental attitude. The patient often becomes extremely untidy and careless and may use obscene language. A cerebellopontine angle tumor usually originates in the sheath of the acoustic nerve and gives rise to a characteristic sequence of symptoms. Tinnitus and vertigo appear first, soon followed by progressive nerve deafness (eighth cranial nerve dysfunction). Numbness and tingling of the face and the tongue occur (due to involvement of the fifth cranial nerve). Later, weakness or paralysis of the face develops(seventh cranial nerve involvement). Finally, because the enlarging tumor presses on the cerebellum,

Assessment and Diagnostic Findings

Neurologic Examination

indicates the areas of the CNS involved

CT Scan

gives specific information concerning the number, size, and density of the lesions and the extent of secondary cerebral edema, CT scans can provide information about the ventricular system.

MRI

- The most helpful diagnostic tool for detecting brain tumors, particularly smaller lesions A, and tumors in the brain stem and pituitary regions, where bone interferes with CT.
- The appearance of a brain tumor on an MRI is so characteristic that a biopsy is unnecessary, especially when the tumor is located in a part of the brain that is difficult to biopsy.

Positron emission tomography (PET)

-It is used to supplement MRI. -On PET scans, low-grade tumors are associated with hypometabolism and high-grade tumors show hypermetabolism.

Computerassisted stereotactic (3dimensional) biopsy

- Used to diagnose deep-seated brain tumors and to provide a basis for treatment and prognosis.

Cerebral Angiography

- Provides visualization of cerebral blood vessels and can localize most cerebral tumors

Electroencephalogr am

- Can detect an abnormal brain wave in regions occupied by a tumor and is used to evaluate temporal lobe seizures and assist in ruling out other disorders.

Cytologic Studies of the CSF

- Detect malignant cells

Gerontologic Considerations
Produce personality changes, confusion, speech dysfunction, or disturbances of gait. The most frequent tumor types in the elderly are anaplastic astrocytoma, glioblastoma multiforme, and cerebral metastases from other sites. The incidence of primary brain tumors and the likelihood of malignancy increase with age.

Medical Management

Chemotherapy External-beam radiation therapy Surgical resection Intravenous (IV) autologous bone marrow transplantation Gene-transfer therapy Photodynamic therapy

CHEMOTHERAPY

Antineoplastic agents