Correspondence Address : Dr. However, they constitute the second most common type of malignancy in children after leukemia and the leading cause of cancer-related morbidity and mortality in children and young adults worldwide. Globally, there is substantial variability with nearly five-fold difference in incidence between various parts of the world. Brain tumors are quite heterogeneous with regard to histology, biological behavior, and prognosis mandating multidisciplinary therapeutic decision-making.
This retrospective audit of all consecutive patients registered in a single calendar year in the neuro-oncology disease management group at Tata Memorial Centre is reflective of the ground reality and fair representation of outcomes in routine neuro-oncologic practice. Cancers of the brain and CNS: Global patterns and trends in incidence.
Neuro Oncol ; McNeill KA. Epidemiology of brain tumors. Neurol Clin ; Neuro Oncol ;v Global incidence of malignant brain and other central nervous system tumors by histology, Yeole BB. Trends in the brain cancer incidence in India. Asian Pac J Cancer Prev ; Jalali R, Datta D. Prospective analysis of incidence of central nervous tumors presenting in a tertiary cancer hospital from India. J Neurooncol ; Spectrum of pediatric brain tumors in India: A multi-institutional study.
Neurol India ; The World Health Organization classification of tumors of the central nervous system: A summary.
Acta Neuropathol ; See the image below. Presenting complaints of patients with an intracranial neoplasm tend to be similar for primary brain tumors and intracranial metastases.
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The onset of symptoms usually is insidious, but an acute episode may occur with bleeding into the tumor, or when an intraventricular tumor suddenly occludes the third ventricle. Usually nonspecific and resembles tension-type headaches [ 1 , 2 , 3 ]. The location of the headache reliably indicates the side of the head affected, but it does not indicate the precise site of the tumor. Although often described as characteristic of tumor headaches, the following clincial features are not commonly present:.
No physical finding or pattern of findings unmistakably identifies a patient with a CNS neoplasm. Based on their location, intracranial tumors may produce a focal or generalized deficit, but signs may be lacking especially if the tumor is confined to the frontal lobe or even falsely localizing. Findings may include the following:. Papilledema, which is more prevalent with pediatric brain tumors, reflects an increase in intracranial pressure ICP of several days or longer. Diplopia may result from displacement or compression of the sixth cranial nerve at the base of the brain.
Tumors of the occipital lobe specifically may produce homonymous hemianopia or partial visual field deficits. Brainstem and cerebellar tumors induce cranial nerve palsies, ataxia, incoordination, nystagmus, pyramidal signs, and sensory deficits on one or both sides of the body.
See Clinical Presentation for more detail. With clinical suspicion of cancer, obtain routine laboratory studies on admission, including the following:. Obtain neuroimaging studies in patients with symptoms suggestive of an intracranial neoplasm, such as the following:. Although some tumors exhibit a characteristic appearance, do not make an unequivocal diagnosis based solely on radiologic findings. Generally, computed tomography CT is the imaging modality of choice for the emergency department physician.
CT findings are as follows:. Metastases to the brain tend to be multiple, but certain tumors eg, renal cell carcinomas tend to produce solitary metastatic brain lesions. As magnetic resonance imaging MRI becomes increasingly available, it may supplant CT as the imaging procedure of choice. Features of MRI for imaging intracranial neoplasms are as follows:.
MRI is most helpful for identifying tumors in the posterior fossa including acoustic neuromas and hemorrhagic lesions.
Drawbacks to MRI include incompatibility with certain medical equipment, longer imaging times increased risk of motion artifact , and poor visualization of the subarachnoid space. Generally, care of patients with a brain tumor is multidisciplinary, requiring assistance from a neurosurgeon, an oncologist, a radiologist, and an expert in radiation therapy. Surgical treatment options may include tumor removal or debulking, installation of a ventricular shunt, and placement of radioactive implants.
See Treatment and Medication for more detail. Tumors of the brain produce neurologic manifestations through a number of mechanisms. Small, critically located tumors may damage specific neural pathways traversing the brain. Tumors can invade, infiltrate, or supplant normal parenchymal tissue, disrupting normal function. Because the brain dwells in the limited volume of the cranial vault, growth of intracranial tumors with accompanying edema may cause increased intracranial pressure.
Tumors adjacent to the third and fourth ventricles may impede the flow of cerebrospinal fluid, leading to obstructive hydrocephalus. In addition, tumors generate new blood vessels ie, angiogenesis , disrupting the normal blood-brain barrier and promoting edema. The cumulative effects of tumor invasion, edema, and hydrocephalus may elevate the intracranial pressure ICP and impair cerebral perfusion.
Intracranial compartmental rise in ICP may provoke shifting or herniation of tissue under the falx cerebri, through the tentorium cerebelli, or through the foramen magnum. Slow-growing tumors, particularly tumors expanding in the so-called silent areas of the brain, such as the frontal lobe, may be associated with a more insidious clinical course. These tumors tend to be larger at detection. Most primary brain tumors do not metastasize, but if they do metastasize, intracranial spread generally precedes distant dissemination.
Metastatic brain tumors from non-CNS primary tumors may be the first sign of malignancy, or they may herald a relapse. Nonetheless, the signs and symptoms of brain metastases simulate those of primary brain tumors. Although few factors are unequivocally associated with an increased risk of brain cancer, most CNS neoplasms are thought to arise from individual cell mutations.
A few inherited diseases, such as neurofibromatosis, tuberous sclerosis, multiple endocrine neoplasia type 1 , and retinoblastoma, increase the predilection to develop CNS tumors. A prior history of irradiation to the head for reasons other than treatment of the present tumor may increase the chance of primary brain tumor. The most common tumors originating from the cerebellopontine angle are acoustic neuroma and meningioma.
Metastatic tumors reach the brain via hematogenous dissemination through the arterial system. Tunkel and W. Kelly Nicholas, Rimas V. Del Brutto, Juan J. Figueroa, and Hector H. Heuer and Peter B. Mamelak, William W. Sutherling, and Gregory D. Vives, Andy J. Redmond, and Dennis D.
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