外科学教学课件：Brain Tumors

Chapter3.BrainTumors

(intracranialtumors)NeurosurgeryNeurosurgeryDepartment,2ndHospital,CQMUPart1.GeneralintroductionofbraintumorsContentsPart2.CommonbraintumorsNeurosurgeryDepartment,2ndHospital,CQMUEtiology1Epidemiology2Clinicalmanifestations3Diagnosisanddifferentialdiagnosis4Part1.GeneralIntroductionofbraintumorsGeneralprinciplesoftherapy5NeurosurgeryDepartment,2ndHospital,CQMU1.EtiologyGeneticfactorsEnvironmentalfactorsOtherfactorsirradiationhasbeenidentifiedtoincreasetheincidenceofmeningiomasandthatofgliomas;

cellularphone,high-tensionwires,headtrauma,ordietarycompoundshavenotbeendemonstrated.

viralfactor

chemicalfactorhavenotbeendemonstratedNeurosurgeryDepartment,2ndHospital,CQMU2.Epidemiology

Overallincidence:12.7per100,000personyears

＃Histology:

neuroepithelialtumorswerethemostcommon(36%)；meningiomas(26%)；

pituitaryadenomas(15%)；nervesheathtumors(7%)；

Meanage:54yearsNeurosurgeryDepartment,2ndHospital,CQMU2.Epidemiology

Location:

Inadults,70%ofprimarybraintumorsariseinthesupratentorialcompartment,withtheremainderintheinfratentorialcompartment.Inchildrenthedistributionisreversed.NeurosurgeryDepartment,2ndHospital,CQMU3.ClinicalmanifestationsDependonthetype,locationandgrowthrateofthetumor3.1CommonSymptomandsign:

duetoincreasedICPrelatedtotumorgrowth,associatedcerebraledema,hydrocephalus,orintratumoralhemorrhage

increasedICPrelatedtotumorlocationincreasedICPrelatedtotumorgrowthortypeImage

Image

NeurosurgeryDepartment,2ndHospital,CQMUDisturbanceofconsciousness,comaSixthnervepalsy---inturningoftheinvolvedeyePersonalitychange,listlessness,mentalslowing,andproblemswithattentionandconcentrationHeadache,vomitingandpapilledema

----trilogyoftypicalICP

3.ClinicalmanifestationsNeurosurgeryDepartment,2ndHospital,CQMU3.2Focalsymptomandsign:relatedtotumorlocation3.ClinicalmanifestationsClinicalfeaturesvarywiththelocation.NeurosurgeryDepartment,2ndHospital,CQMU3.2.1thecerebralhemispherestumor

Frontallobetumorsalterationsinpersonality,behavior,motivation,mood,andmemory.expressivelanguagedifficulties(dominanthemisphere)focalseizure3.ClinicalmanifestationsNeurosurgeryDepartment,2ndHospital,CQMUParietallobetumorsreceptivelanguagedifficulties(dominanthemisphere)

＃difficultieswithnaming,calculating,reading,andleft-rightorientation---Gerstmann’ssyndrome

古茨曼综合征contralateralsensorydeficits3.Clinicalmanifestations~isacognitiveimpairmentthatresultsfromdamagetotheleftparietallobeintheregionoftheangulargyrusNeurosurgeryDepartment,2ndHospital,CQMUTemporallobetumorscontrolateralquadrantvisualspheredefect---opticradiationinjurycomplexpartial(psychomotor)seizures3.Clinicalmanifestationsauditoryhallucinations幻听memoryproblemsreceptivelanguagedifficulties(dominanthemisphere)NeurosurgeryDepartment,2ndHospital,CQMUavisualfielddefectOccipitallobetumors3.Clinicalmanifestationsvisualagnosia失认症NeurosurgeryDepartment,2ndHospital,CQMU＃

3.2.2.SellarandparasellarregionsImage

anatomyrelativeImage

＃tumors3.ClinicalmanifestationsvisualpathwayandvisualfielddefectNeurosurgeryDepartment,2ndHospital,CQMUvisualpathwayvisualfielddefectNeurosurgeryDepartment,2ndHospital,CQMU＃

3.2.2.Sellarandparasellarregionsavisualfielddefectunilateralvisualloss---theopticnervebitemporalfielddefect---theopticnervechiasmautonomicdisturbancesandendocrinopathy---Hypothalamus

Obstructivehydrocephalus---thethirdventricle

cranialnervesⅢ,Ⅳ,Ⅴ,andⅥpalsyClinicalmanifestationsNeurosurgeryDepartment,2ndHospital,CQMU3.2.3.Posteriorfossamultiplecranialnervepalsies(Ⅶ-Ⅻ)atruncalataxiaoripsilaterallimbataxia躯干共济失调or同侧肢体共济失调obstructivehydrocephalus3.ClinicalmanifestationsNeurosurgeryDepartment,2ndHospital,CQMU3.2.4.Brainstem3.Clinicalmanifestationscrossedparalysis交叉瘫

disturbancesofvitalsignsNeurosurgeryDepartment,2ndHospital,CQMU4.Diagnosisanddifferentialdiagnosis4.1.Clinicaldiagnosisortentativediagnosis

progressivefocalneurologicaldeficit,eithermotororsensory,languagedifficultiesheadaches,analterationinpersonality,behaviorandmemory.focalorgeneralizedepilepticseizuresNeurosurgeryDepartment,2ndHospital,CQMU4.Diagnosisanddifferentialdiagnosis4.2.Imagingdiagnosiscomputedtomography(CT)scanningmagneticresonanceimaging(MRI)---themostimportantNeurosurgeryDepartment,2ndHospital,CQMU4.3.Definitivediagnosis

requireshistologicalassessmentoftumortissue4.4.DifferentialdiagnosisVascularmalformationsBrainabscessChronicSubduralhematoma4.DiagnosisanddifferentialdiagnosisNeurosurgeryDepartment,2ndHospital,CQMU5.Generalprinciplesoftherapy5.1.SymptomaticTreatment5.2.Surgery5.3.Radiotherapy5.4.Chemotherapy5.5.newtherapeuticstrategiesNeurosurgeryDepartment,2ndHospital,CQMU5.1.SymptomaticTreatmentvasogenicedemadexamethasonelowerincereasedICP---mannitol5.Generalprinciplesoftherapyanticonvulsant

NeurosurgeryDepartment,2ndHospital,CQMU5.2.SurgeryThemajorobjectivesofsurgicaltreatmenttoconfirmthepathologicdiagnosisinordertorecommendappropriatefurthertherapy;toremoveasmuchtumoraspossiblewithoutincreasingneurologicaldeficitsorcompromisingqualityoflife;

torelievesymptomsofincreasedICP;toimprovethefocalneurologicalsymptomsSurgeryrepresentsthesinglemostimportanttherapeuticmeasureformanybraintumors.NeurosurgeryDepartment,2ndHospital,CQMU1.Tumorsthatmaybecuredbysurgeryaloneinclude:meningiomasschwannomaspituitarytumorsNeurosurgeryDepartment,2ndHospital,CQMU2.Conversely,surgeryisnotcurativefordiffuseastrocytomas,craniopharyngiomasormalignantbraintumors.Soadjuvantradiotherapyandchemotherapyarerequiredtoimprovetheprognosisforthesepatients.NeurosurgeryDepartment,2ndHospital,CQMU3.Ventriculoperitonealshuntingtorelievehydrocephalus.NeurosurgeryDepartment,2ndHospital,CQMU5.3.RadiotherapyRadiotherapyisanessentialcomponentoftreatmentformostbraintumorsthatcannotberesectedintoto.Indicationofradiotherapy:diffuseastrocytomas

primarycerebrallymphomametastaticbraintumorglioblastomasgermcelltumorsmedulloblastomasependymomasSideeffectNeurosurgeryDepartment,2ndHospital,CQMU5.4.ChemotherapyChemotherapymaybeadministeredasasecond-linetherapyorasapostsurgical"neoadjuvant"treatmentaftersurgeryandradiotherapyhavefailed,commonlycombinedwithradiotherapy.oligodendroglialtumorsIndicationofchemotherapy:glioblastomasgermcelltumorsmedulloblastomasprimarycerebrallymphomaeffectivecontroversialNeurosurgeryDepartment,2ndHospital,CQMUThetherapeuticefficacyofchemotherapy

againstprimaryormetastaticbraintumorshasbeendisappointing.---blood-brainbarrier(BBB)thatinhibitsthetransportofchemotherapeuticdrugstotheinterstitiumofthebrain---theendothelialcellshaveahighconcentrationofP-glycoprotein,whichactivelytransportsmanychemotherapeuticagentsoutofthebrain.NeurosurgeryDepartment,2ndHospital,CQMU5.5.newtherapeuticstrategiesmonoclonalantibodiesrecombinanttoxinsgenetransfertherapyNeurosurgeryDepartment,2ndHospital,CQMUAstrocytomas1Oligodendrogliomas2Meningiomas3Part2.CommonbraintumorsSchwannoma4Tumorsofthesellarregion5NeurosurgeryDepartment,2ndHospital,CQMU1.Astrocytomas星形细胞瘤＃

1.1.ClinicalAspectsPilocyticastrocytoma毛细胞型(I)Diffuseastrocytomas(II)Anaplasticastrocytomas(III)Glioblastomas(IV)malignantgliomas

WHOGradeNeurosurgeryDepartment,2ndHospital,CQMUmostlyencounteredinchildhood;

largecystsonCTandMRI;maybecuredbyresectionaloneA.Pilocyticastrocytoma(WHOgradeI)NeurosurgeryDepartment,2ndHospital,CQMUB.Diffuseastrocytomas(WHOgradeII)infiltrativegrowth,typicallylocalizedinthewhitematterofthecerebralhemispheres;

Epilepsyisthemostcommonclinicalmanifestation;CT:anareaoflowormixeddensitywithlittlemasseffect.TwothirdsdemonstratemoderateedemaNeurosurgeryDepartment,2ndHospital,CQMUC.Anaplasticastrocytomas(WHOgradeIII)D.Glioblastomas(WHOgradeIV)ariseanywhereinthebrain,butthefrontalandtemporallobesaremostcommonlyaffected.ashorthistoryoflessthan6months,NeurosurgeryDepartment,2ndHospital,CQMUclinicalpresentation：adevelopingfocalneurologicaldeficit,eithermotororsensory,headachesthatmaybeintermittentorconstant,focalorgeneralizedepilepticseizures,analterationinpersonalityNeurosurgeryDepartment,2ndHospital,CQMUAnaplasticastrocytomasCTorMRI:anmixeddensity/intensityareawithsurroundingvasogenicedemathatmaybeexcessiveevenwithsmalltumors.NeurosurgeryDepartment,2ndHospital,CQMUGlioblastomasNeurosurgeryDepartment,2ndHospital,CQMU1.2.PrinciplesofTherapyNeurosurgeryDepartment,2ndHospital,CQMU2.Oligodendrogliomas少突胶质细胞瘤＃2.1.ClinicalAspectsLocation:supratentorialcompartment.Morethan50%withinthefrontallobes.

Epilepsyisthemostcommonclinicalpresentation;CT:acommonradiologicalfeatureiscalcificationNeurosurgeryDepartment,2ndHospital,CQMU2.2.PrinciplesofTherapyThereisnodefinedstandardtreatmentforoligodendroglioma.surgeryradiotherapychemotherapyNeurosurgeryDepartment,2ndHospital,CQMU3.Meningiomas脑膜瘤3.1.ClinicalAspects

＃

Meningiomas

areusuallybenign,accountfor26%ofallprimarybraintumorsandarisefromarachnoidcapcellsLocation:commonlyoccuralongthefalx,parasagittal,sphenoidwing,andconvexitydura.Clinicalpresentations:epilepsy,

afocalneurologicaldeficit，

headaches,NeurosurgeryDepartment,2ndHospital,CQMUparasagittalmeningiomaconvexitydurameningiomaparafalxmeningiomacommonmeningiomasNeurosurgeryDepartment,2ndHospital,CQMUsellarregionmeningiomasphenoidwingmeningiomaNeurosurgeryDepartment,2ndHospital,CQMUparafalcinetentorialmeningiomaNeurosurgeryDepartment,2ndHospital,CQMUSurgery:completeresectionistheoptimalstrategyofchoiceRadiotherapyismostoftenusedforthelocalcontrolofinoperablemeningiomas(e.g.,ofthecavernoussinusorthesphenoidridge).＃3.2.PrinciplesofTherapyNeurosurgeryDepartment,2ndHospital,CQMU4.Schwannoma(neurilemmomas)神经鞘瘤or施旺氏细胞瘤Schwannomasarebenigntumors,arisingfromtheneuroectodermalSchwanncellsoftheperipheral(mostlyvestibular)nerves＃

4.1.ClinicalAspects

Vestibularschwannomas前庭神经鞘瘤

orAcousticneuroma听神经鞘瘤accoutfor70%-80%ofallschwannomasinthecerebellopontineangleNeurosurgeryDepartment,2ndHospital,CQMU

Themostcommonclinicalpresentation:

progressiveunilateralhearingloss,progressionwillcontinuetodeafness,withtinnitusanddizzyLaterfeatures:facialnerveparesistrigeminalneuralgiacerebellarsigns---limbataxia

hydrocephalusIX~XIIcranialnervedysfunctionNeurosurgeryDepartment,2ndHospital,CQMUCTScanMRIContrastexaminationNeurosurgeryDepartment,2ndHospital,CQMU4.2.PrinciplesofTherapy

Surgery:completeresection

Fractionatedstereotacticradiotherapy:tumorslessthan2.0cmofdiameterPre-Post-NeurosurgeryDepartment,2ndHospital,CQMU5.Tumorsofthesellarregion鞍区肿瘤5.1PituitaryTumors垂体腺瘤NeurosurgeryDepartment,2ndHospital,CQMU＃

ClinicalAspects

Mostpituitarytumorsarebenignadenomas.

Classification:dependingonwhethertheadenomasecretesahormoneresultinginahypersecretorysyndromeNeurosurgeryDepartment,2ndHospital,CQMUClassificationsecretesahormoneclinicalpresentationsomatotropicadenomasGHacromegaly(orgigantisminchildren)corticotropicadenomasACTHCushing’sdiseasethyrotropicadenomasthyroidhormonehyperthyroidismhyperprolactinemiaPRLgalactorrheaandamenorrheainwomenGonadotropicadenomasFSHorLH-----endocrine–inactiveadenomas----------NeurosurgeryDepartment,2ndHospital,CQMUprogressivepituitarydysfunctionbitemporalfielddefect---theopticchiasma

headacheclinicalpresentation:NeurosurgeryDepartment,2ndHospital,CQMUPreoperativepreparation:athoroughvisualassessmentendocrinologicalprofileexaminationhormonaldeficienciesreplacementNeurosurgeryDepartment,2ndHospital,CQMUSurgery:completeresectionistheoptimalstrategyofchoiceRadiotherapy:tumorrecurrenceorfortumorsincurablebysurgeryalone＃

PrinciplesofTherapyNeurosurgeryDepartment,2ndHospital,CQMUPost-MRIPre-MRIFemal，35years-old，am