INTRODUCTION BRAIN TUMOR INTRA KRANIAL, MED SPINALIS AND MENINGES TWO TYPE PRIMER AND SECUNDER PRIMER TUMOR ASTROCYTE, OLIGODENDROCYTE, EPENDEMOCYTE,

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1 BRAIN TUMOR YUNELDI ANWAR DEPARTMENT NEUROLOGY MEDICAL FACULTY UNIVERSITY OF NORTH SUMATERA

2 INTRODUCTION BRAIN TUMOR INTRA KRANIAL, MED SPINALIS AND MENINGES TWO TYPE PRIMER AND SECUNDER PRIMER TUMOR ASTROCYTE, OLIGODENDROCYTE, EPENDEMOCYTE, ARACHNOID, NEUROBLAST AND MEDULLUBLAST SEKUNDER TUMOR METASTATIK FROM LUNG, BREAST, COLON AND SKIN

3 ETIOLOGY GENETIC GENE DEVIATION CONGENGITAL TERATOMA, CHORDOMA AGE PINEALOMA, MEDULLOBLASTOMA (< 20 yr). MENINGIOMA (> 50yr) CARSINOGEN HYDROCARBON, NITROSAMIN HEAD INYURY, INFECTION, TOKSIN, RADIATION, VIRUS

4 Risk factors related to CNS tumor Definitive ionizing radiation immune supression (HIV infection) Possible Electromagnetic field (high tension wires, cellular telepon) Diets (N-nitroso compounds, Aspartame) Occupation (petroleum industry, agricultural pesticides) Household chemicals (hairdyes and sprays, household pesticides) Head injury Medication (vitamin) Infections (Cysticercosis, varicella zoster, SV 40

5 CONCEPT OF PATOGENESIS PRIMER TUMOR HISTOGENIC THEORY (Bayley &Cushing) EMBRIOLOGICAL OF NERVE CELL AND GLIA RECENT THEORY TUMOR ARISES FROM TRANSFORMATION OF ASTROCYTE, OLIGODENDROCYTE, MICROGLIOCYTE, EPENDYMOCYTE NEOPLASM CELL MULTIPLICATION AND DIFFRENTIATION

6 PATHOFISIOLOGY NORMAL CAVUM CRANII CONSIST OF Brain tissue ( 1400 gr ) Cerebro spinal fluid ( 75 cc ) Blood ( 75 cc ) these component any time stabil Brain tumor increase intracranial pressure Brain tumor cerebral edema cerebral herniation

7 NORMAL BRAIN

8 Cerebral herniation A. Subfacial/cingulate hern B. Uncal herniation C. Transtentorial/central hern D. External herniation E. Tonsillar herniation

9 CLASSIFICATION HISTOPATOLOGICAL PATTERN Primary brain tumor histological benign or malformative meningioma pituitary adenoma, acustic neuroma, craniopharyngioma, pilocytic astrocytoma hemangioblastoma histological malignant glioma (anaplas tic astrocytoma, glioblastoma multiform), ependymoma, oligodendroglioma, medulloblasto ma, pineal cell tumor, chroid plexus carcinoma

10 MENINGIOMA

11 GLIOBLASTOMA

12 CLASSIFICATION CONT METASTATIC BRAIN TUMORS BREAST LUNG GI TRACT PROSTAT SKIN

13 INTRA CRANIAL METASTASIS Brain parenchyma breast, lung, melanoma Pituitary gland breast, melanoma, germ cell Dural based lung, prostat, breast Leptomeningeal disease breast, lung

14 SKULL METASTASIS Skull base breast, prostat, osteosarcoma of skull, head and neck cancer Calvarium breast, prostat

15 SPINE METASTASIS Epidural lung, breast, prostat, neuroblastoma, lymphoma. Leukemia Leptomeningeal breast, lung Intramedullary breast, colon, lung, prostat Brachial plexus lung, breast, lymphoma Lumbosacral plexus pelvic tumor

16 CLASSIFICATION BASED ON TOPOGRAPHY (LOCATION) SUPRA TENTORIAL TUMORS Cerebral lobe and deep hemispheric glioma, meningioma, metastatic tumor Sella turcica tumor pituitary tumor, craniopharyngiomas INFRATENTORIAL TUMOR MEDULLASPINALIS TUMOR

17 INFRATENTORIAL TUMORS ADULTS Cerebellopontine angel acoustic schwannoma Others sites brainstem gliomas, metastase, hemangioblastoma, ependymoma CHILDRENS Midline tumors medulloblastomas Cerebellar lobes astrocytomas

18 MEDULLA SPINALIS TUMORS EKSTRA DURAL Metastatic tumor INTRA DURAL Ekstra medulla meningioma Intra medulla neurofibromas ependymoma astrositoma

19 SYMPTOMS AND SIGNS Generalized symptoms caused by raised intracranial pressure Focal symptoms caused by invasion, ischemia and compression False localizing symptoms caused by shifts of cerebral structures

20 GENERALIZED SYMPTOMS AND SIGNS HEADACHE VOMITING DROWSINESS ( VERTIGO AND DIZZINESS) VISUAL OBSCURATION PERSONALITY CHANGE CONFUSION PAPILEDEMA APATHY

21 MECHANISM HEADACHE ASSOCIATED WITH BRAIN TUMOR 1.Traction on venous sinuses 2.Traction on meningeal arteries 3.Traction on large arteries at base of the brain 4.Pressure on cranial and cervical pain sensi tive structure 5.Dilatation of intracranial arteries 6.Inflamation of pain-sensitive structures

22 FOCAL SYMPTOMS AND SIGNS FRONTAL LOBE Generalized seizure Focal motor seizure (contra lateral) Expressive aphasia (dominant size) Behavioral changes Dementia Gait disorders, incotinence Hemiparese

23 Frontal lobe tumor

24 FOCAL SYMPTOMS & SIGNS BASAL GANGLIA Hemiparesis (contralateral) Movement disorders (rare) PARIETAL LOBE Receptive aphasia (dominant size) Spatial disorientation (non dominant) Cortical sensory dysfungtion (contralat) Agnosias

25 Metastase parietal lobe tumor

26 FOCAL SYMPTOMS & SIGNS OCCIPITAL LOBE Hemiparesis (contralateral) Visual disturbance TEMPORAL LOBE Complex partial (psychomotor) seizures Generalized seizures Behavioral changes Olfactory and complex seizures Visual auras Visual field defect

27 Occipital lobe tumor

28 Temporal lobe tumor

29 FOCAL SYMPTOMS & SIGNS CORPUS COLLOSUM Dementia (anterior) Behavioral changes Memory loss (posterior) Asymptomatic (mid) THALAMUS Sensory loss (contralateral) Behavioral changes (posterior) Languange disorders (dominant size)

30 FOCAL SYMPTOMS & SIGNS MIDBRAINS/PINEAL Paresis of vertical eyemovement Pupillary abnormalities Precocious puberity (boys) SELLA/OPTIC NERVE/PITUITARY Endocrinopathy Bitemporal hemianopia Monocular visual defect Opthalmoplegia (cavernous sinus)

31 Pineal tumor

32 Pituitary tumor

33 FOCAL SYMPYOMS & SIGNS PONS/MEDULLA Cranial nerve dysfungtion Ataxia, nystagmus, spasticity Weakness, sensory loss CERBELLO PONTINE ANGLE Deafness (ipsilateral) Loss of facial sensation (ipsilateral) Facial weakness (ipsilateral), ataxia CEREBELLUM Ataxia (ipsilateral) Nystagmus

34 Cerebellum tumor

35 FALSE LOCALIZING SIGNS CRANIAL NERVE Anosmia Diplopia, ptosis, anisocoria Face pain, numbness, and weakness Tnnitus, hearing loss

36 FALSE LOCALIZING SIGNS PARENCHYMAL SIGNS Ipsilateral hemiparesis Ipsilateral gaze palsy Visual field defect, cortical blindness Ataxia OTHER SIGNS Nuchal rigidity

37 SYMPTOM AND SIGN SPINAL INTRAMEDULLARY Sensory loss CORD TUMOR Early spinchter dysfungtion Pain + Decreased rectal tone spasticity upper motor neuron signs Common tumor -> Ependymoma, astrositoma

38 Symptom and signs spinal cord tumor Intradural and extramedullary Pain, metastase +++ Pain, primary tumor + Radicular or local sensory loss Radicular or segmental weakness and sensory loss Upper motor neuron signs Common tumors Meningioma

39 Symptom and sign spinal cord EPIDURAL Pain +++ tumor Radicular or local pain Common tumors Metastasis

40 DIAGNOSIS BRAIN TUMOR HISTORY GENERAL PHYSICAL EXAMINATION NEUROLOGIC EXAMINATION LABORATORY FINDING, ESPECIALLY IMAGING

41 Laboratory findings IMAGING CT Scan MRI Magnetic resonance spectroscopy (MRS) Fungtional MRI BIOPSY Defenitive diagnosis

42 DIFFRENTIAL DIAGNOSIS OF HEMATOMA ABCESS GRANULOMA BRAIN TUMORS PARASITIC INFECTION CYSTYCIRCOSIS VASCULAR MALFORMATION MULTIPLE SCLEROSIS CEREBRAL INFARCS

43 Therapy of Intra Cranial Tumors Definitive therapy Surgery Biopsi, resection Radiation External beam Streotactic radiosurgery Heavy particles Brachytherapy Chemotherapy Parentral, lokal Experimental modalities Supportive therapy

44 Experimental modalities Angiogenesis inhibitor Growth factor inhibitor Diffrentiating agents Immunotherapy Gene therapy Antisense oligonucleotide

45 Supportive Therapy Anticonvulsant Corticosteroids Anti-thrombosis thrombosis agent Psychotropic agents Physical therapy

46 Goals of Surgery Establish the diagnosis Cure the patient Decrease tumor burden Relieve symptoms Improve neurologic fungtion Extend duration and quality of live

47 Basic concepts in cancer chemotherapy Chemotherapeutic agent kill only a percentage of cancer cell Some drugs kill only dividing cells Multiple drugs with differing site of action are better than a single drugs High dosee are better than low doses

48 Brain tumors anticonvulsant Prophylaxis -- does not prevent first seizure -- probably useful in perioperative period Treatment -- efficacy unclear -- side effects more commons -- hard to control levels -- best drug unknown

49 Advantages and Disadvantages of corticosteroid Advantages -- control neurologic symptom by reduce edema -- decrease acute RT toxicity -- relieve emesis from chemotherapy -- oncolytic (lymphoma) Disadvantages -- side effects common -- decrease chemotherapy entry