أسئلة العاشرة جراحة رابعة دمياط نيورو

Surgery Overview

• Brain tumors are addressed through surgery, specifically neurosurgery.
• The cost of surgery is marked at 5 LE
• The material covers L10: Brain Tumors

Brain Tumors

• Primary brain tumor incidence in Europe and the United States is age-related, ranging from 1-10 cases per 100,000 persons.
• Increased incidence in childhood (0-4 years) and elderly (65-79 years)
• In individuals older than 20, gliomas account for over 90% of primary intracranial tumors.
• Approximately 25% of gliomas are low-grade astrocytomas.
• Most low-grade astrocytomas are not fully resectable. Radiotherapy is the most effective non-surgical therapy.
• Many low-grade gliomas can turn to high-grade over time.
• There are over 120 types of brain tumors, which makes treatment planning difficult.
• Tumor names indicate the presumed cell of origin, such as astrocytoma, oligodendroglioma, and meningioma.
• Brain tumors consist of cells showing uncontrolled growth in the brain.
• Tumors can be benign (non-spreading) or malignant (primary or secondary).
• Common types include Gliomas, Metastases, and Meningiomas.

Site of Tumors

• Tumors location are either supratentorial or infratentorial.
• In adults, 80-85% of tumors are supratentorial and 15-20% are infratentorial.
• In children, 40% of tumors are supratentorial and 60% are infratentorial.

Risk Factors for Brain Tumors

• Primary brain cancer risk factors include radiation exposure and immune system dysfunction.
• Hereditary brain tumors are linked to genetic mutations.
• Specific hereditary conditions includes Neurofibromatosis type 1 (skin neurofibroma), Neurofibromatosis type II (acoustic schwannomas), Tuberous sclerosis (tubers in the face, SEGA), Von Hippel-Lindau syndrome (hemangioblastomas), and Turcot syndrome (glioblastoma or medulloblastoma).
• Metastatic brain cancer can result from any cancer that spreads to the brain.
• Common cancers that may spread to the brain include lung cancer, breast cancer, malignant melanomas, gastrointestinal tract cancer, and genital or urinary tract cancer.

WHO Classification of CNS Tumors

• Includes tumors of neuro-epithelial tissue (gliomas), cranial and spinal nerves, meninges, the sellar region, hematopoietic neoplasm, germ cell tumors, cyst and tumor-like lesions, local extensions from regional tumors, and metastatic tumors.

Types of Tumors

• Astrocytes: Low grade (Pilocytic & Fibrillary) and High grade (Anaplastic) astrocytoma
• Oligodendrocytes: Oligodendroglioma
• Ependymal cells & Choroid plexus: Ependymoma, Choroid plexus papilloma
• Poorly Differentiated Cells: Glioblastoma multiforme, Medulloblastoma
• Pineal cells: Pineocytoma, Pineoblastoma
• Meninges: Meningioma, Minigiosarcoma
• Nerve sheet cells: Neuroma (schwannoma), Neurofibroma
• Blood vessels: Haemangioblastoma
• Germ cells: Germinoma, Teratoma
• Maldeveloped tumors (Congenital tumors): Craniopharyngioma Remnant of rathkis pouch, Epidermoid & Dermoid cysts
• Pituitary cells: Pituitary Adenoma
• Metastatic (Secondary): Arises from any primary body tumor, commonly from Bronchus or Breast, and occurs in 25% of patients with disseminated cancer.

Grading of Brain Tumors (WHO)

• Lists tumor types by origin and grade, from I (lowest) to IV (highest).
• Different grades may be assigned based on the aggressiveness and characteristics of the specific tumor.

Clinical Features of Brain Tumors

• Raised ICP: Headache, Papilloedema
• Brain Compression: Vomiting and Pupillary dilatation, Deterioration of conscious level
• Epilepsy: Generalized or Partial
• The following are considered brain tumors until ruled out: change in headache pattern, headaches in childhood, or new-onset epilepsy in adults.

Localizing Signs

• False: Headache (diffuse, continuous, progressive), Nausea/vomiting (mainly morning), Disturbances of consciousness, Cushing phenomenon, Bilateral edema of the optic disc, Diplopia, Epilepsy
• True (lobes syndromes): Frontal lobe, Temporal lobe, Occipital lobe, Parietal lobe, Hypothalamus/Pituitary, Posterior Fossa, Psychiatric manifestation

Investigations

• Chest X-ray & ESR: Mandatory; any lesion may raise suspicion of IC tumor.
• Radiological Invesitgations: Anatomical imaging or Functional imaging or Anatomical + functional imaging.

Role of Radiological Investigations

• Skull X-ray: Calcification, Osteolytic lesions, Signs of Raised ICT, Pineal Shift.
• MRI: detailed information about the lesion, site, mass effect, and multiplicity, with superior clarity and anatomical relationships.
• CAT scan: Indicates the lesion's site and its impact on adjacent bone and mass effect, useful for single and multiple lesions and contrast enhancement.
• Cerebral angiography: Studies the tumor's vascularity and its relationship with important vascular structures.
• SPECT & PET scan: Identify high-grade activity within a tumor, and useful for excluding if proposing conservative management or in planning stereotactic biopsy.

Laboratory Testing

• Routine Investigations: Hormonal profile (Prolactin, GH, TSH, T3, T4, Cortisone, ACTH, LH), and Tumor markers (important with germ cell tumors e.g. α-fetoprotein).

Other Investigations

• Bone Scan, Visual assessment (Visual acuity - Field of vision) and Auditory assessment (Hearing acuity - Balance assessment).

Differential Diagnosis

• Vascular, Infection and Cysts

Management of Brain Tumors

• Treatment strategy depends on tumor type, location, size, grade, and overall patient health.
• Lines of treatment include observation, medical treatment, surgical treatment, endoscopic biopsy/excision, stereotactic biopsy, radiotherapy, chemotherapy, and gene therapy/nanotechnology.
• Observation is indicated for small, benign tumors not causing symptoms, like small meningiomas.
• Medical treatments: Steroid Therapy (Dramatically reduces edema and prolonged action) and Mannitol (brain dehydrating agent decreases ICT and surgical debulking is rapidly indicated).
• Surgical treatment: Most patients with brain tumors require surgery to remove the tumor without affecting surrounding structures. Approaches includes Craniotomy, Craniectomy, Transsphenoidal, Burr hole or Transoral routes.
• Other lines inclide: Endoscopic brain surgery and Stereotactic brain surgery and Brain Navigation system.
• *Radiotherapy: Conventional (Megavoltage X-rays and Gamma rays) and Recent (Stereotactic radiosurgery and Brachytherapy)
• Complications of radiotherapy: edema and radio-necrosis and Chemo and current research

Prognosis

• Fast-growing tumors are more likely to recur than slow-growing tumors.
• Patients surviving the first 2 years after diagnosis have at least a 70% chance of surviving for at least 5 years.
• Depends on Type & grade of tumor cells, Location & size, Age of the patient, Neurological condition of the patient at the time of diagnosis and Treatment options and techniques.