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Brain Tumors

  • Brain tumors are 2nd MC malignancy in childhood and MC solid tumors in children.
  • MC intracranial tumor in adults : SECONDARIES
  • In children childhood secondaries are relatively rare.
  1. Cerebellar astrocytoma is MC posterior fossa tumor of childhood and has best prognosis
    Hence MC intracranial tumor in children = Cerebellar astrocytoma
    MC supratentorial brain tumor in children = Craniopharyngioma
    1. MC histological type = Glial cell tumors
    2. Relevant oncogenetics:

  1. MC symptom = Headache
  2. Alterations in personality are often Pt symptoms of a brain tumor irrespective of site.
  3. Tumors occupying fourth ventricle are often associated with pernicious vomiting
  4. Diplopia is common in posterior fossa tumors and so is Nystagmas and ataxia

  1. Cerebellar vermis tumors are characterized by truncal ataxia, anterior cerebellum involvement involves broad based gait. Cerebellar hemispheral involvement produce ipsilateral extremity ataxia and dysdiachokinesia.
  2. Frontal lobe tumors are usually larger and may have JACKSONIAN MARCH (tonic clonic seizures)


  1. CraniopharygiomaQ
    1. Age <20 yrs. usually
    2. Derived from Rathke s Pouch, arising near pituitary stalk and commonly extend into suprasellar cistern (SUPRATENTORIAL).
    3. Usually large, Cystic, locally invasive, benign.
    4. It is MC cause of suprasellar calcfi cation with raised intracranial tension in a child. Q
    5. Clinical features:
      1. Signs of increased ICP (Headache, vomiting, papilledema and hydrocephalus) are the usual presentation (H-2034)
      2. 50% children have growth retardation
      3. Associated symptoms —visual field abnormalities (bitemporal hemianopsia) personality changes, cognitive deterioration, cranial nerve damage, weight gain, sleep disturbances, diabetes insipidus and delayedpuberty (<10%).
        1. Investigations
          • 90% shows calcification on plain skull X-ray or CT.
          • Hypodense if cystic and hyperdense if solid on CT
        2. Pathology
          • It is MC cystic tumor containing fluid resembling Machinery oil.
        3. Treatment
          • Transcranial/Transsphenoidal surgical resection followed by postoperative radiation.
  2. Medulloblastoma & PNET
    1. Highly cellular malignant tumors
    2. MC PNET = Medulloblastoma
    3. MC malignant brain tumor in children = Medulloblastomas of posterior fossa (Harrison) MC posterior fossa tumor in children’s and MC tumor in children younger than 7 year (Ne1ôn 1859)
    4. Frequently disseminate via CSF.
    5. Site in adults in >50% is - Posterior fossa in adults in >50% is - midline (vermis of cerebellum)
    6. Expansile tumor; spreads to long bones and ribs (extracranial spread).
    7. Treatment
      In adults — surgical excision of PNET followed by chemotherapy and irradiation of entire neuraxis.
      In <3 year — surgery followed by chemotherapy only, withholding RT to later age.
      1. Investigation
        MRI is best. CT myelography is alternative.
      2. Prognosis
        Favourable, if not disseminated
  3. Meningiomas
    1. Derived from mesoderm, probably from cells giving rise to arachnoid granulations.
    2. Usually benign, may mvolve skull (rarely bram).
    3. MC site — along sagittal sinus, over cerebral convexities, CP angle and along dorsum of spinal cord. (MC foramen magnum tumor)
    4. More in women, peak incidence in middle age.
    5. C/F: Usually found incidentally on CT/MRI, may present with focal seizure, focal deficit or high ICP symptoms.
    6. Psammoma bodies seen in its pathology.
    7. Investigations : CT/MRI
    8. Radiological image of a dural based, extra axial mass with dense, uniform contrast enhancement is essentially diagnostic.
    9. Treatment:
      1. Total surgical resection of benign meningiomas is curative.
      2. Local external beam RT may reduce recurrence.
      3. For surgically inaccessible, targeted radiosurgery with gamma knife or heavy particle radiation.
  4. Oligodendroglioma
    1. Site  frontal lobe (not seen in posterior fossa).
    2. Disseminates by CSF.
    3. Spontaneous intracerebral hemorrhage may occur.
    4. Fried egg appearance seen.
    5. May calcify.
  5. Secondaries In Brain
    1. MC intracranial tumors in adults.
    2. MC mode of spread = HEMATOGENOUS.
    3. Anatomical predilections:
      1. In general — Gray matter-white matter junction and border zone between middle and posterior cerebral artery.
      2. Breast Cancer — Cerebellum and posterior pituitary (SEED and SOIL hypothesis).
    4. MC Primary — Lung cancer (Multiple metastasis)
    5. Other common primaries —
      1. Breast - Germ cell tumours
      2. GIT- Thyroid
      3. Melanoma (multiple brain metastasis)
    6. Rare in:
      1. Hodgkin’s disease
      2. Ovary cancer
      3. Prostatic cancer
      4. Breast cancer which metastasize to bone
    7. Investigations
      1. Choice : contrast enhanced MRI
      2. CECT is less sensitive than MRI
      3. CSF examination is not indicated
    8. Treatment
      1. Palliative therapy mainly
      2. Mainstay of initial treatment — corticosteroids (exp. Dexamethasone) to reduce edema around tumor. Chemotherapy not effective alone.
      3. TOC of solitary, surgically assessible metastasis is surgical excision followed by cranial irradiation.
      4. In surgical inaccessible metastasis — STEREOTACTIC Radiosurgery using ‘gamma Knife’ gives best result.
      5. RADIATION is primary treatment for brain metastasis (Harrison)
      6. Usual dose of radiation = 30-37.5 Gy in 10-15 fractions.
  • Radioresistants metastasis: 
    1. - Melanoma
    2. - Renal cell CA
    3. - Sarcoma
    4. - CA Colon
  • Prognosis:
  1. Leptomeningeal Metastases
    1. Primaries from:
      1. CA Breast 41% (MC)
      2. Lung
      3. Melanoma
      4. G1T tumors
    2. Clinical features: Encephalopa thy is frequent
      1. Cranial neuropathy, Spinal radiculopathy from nodular nerve root compression is characteristic
    3. Diagnosis
      1. CSF finding — Lymphocytic pleocytosis, elevated protein levels and N to low glucose
      2. Meningeal biopsy
    4. Treatment
      1. Mainstay — Intrathecal chemotherapy (Methotrexate/ara-C, thiotepa)
        Focal external beam RT
    5. Prognosis of poor

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