Brain Tumor

Diagnosis, Imaging, Management

Dr. dr. Rr. Suzy Indharty, MKes Sp.BS

DEPARTEMEN ILMU BEDAH SARAF

FK USU/RSUP HAJI ADAM MALIK
 Epidemiology
• 9% of all primary tumors in ♂
• cause of death in 2% of all malignancy
• Incidence is 8-10/100.000/year,
21/ 100.000 (< 2 yo)
1/ 100.000 (teenager)
16/ 100.000 ≥40 yo
 Primary Brain Tumors
• Intra-axial / Intrinsic / Parenchymal Tumors
- Malignant, except Hemangioblastomas
- Infiltrative to the surrounding brain
- All types of Gliomas, adult: Glioblastoma Multiforme (GBM)

• Extra-axial/ Extrinsic tumors

- Benign, Capsulated
- Compresses the surrounding brain
- Meningiomas and Neurinomas
 Clinical Manifestations
• Common signs and symptoms of increased ICP
- Caused by the tumor and its surrounding perifocal edema
- Related to disturbances of venous return and CSF pathway

• Focal signs and symptoms

- Related to compression, dysfunction CNS dan perifocal edema
 Classification
 Neuroepitelial tumors 52%
- Glioma/ Astrocytoma ( 45 - 48% )
- Ependymoma ( 3% )
- Oligodendroglioma ( 2% )
- Medulloblastoma ( 3% )
 Meningioma 15%
 Acustic Neurinoma 8%
 Pituitary Adenoma 8%
 Metastatic tumors 15 -20%
 X-ray
CT scan
MRI
 Angiography / MRA-MRV
• Tumor’s blood supply: meningioma
(MMA=convexity,falcine,ethmoidalarteries=frontobasal tumors,
choroidal arteries =ventricular tumors)
• Intra-tumoral vascular network (capillary phase/ tumor staining/ tumor blush )
• Shift/ encasement of intracranial large vessel related tumor compression
MR-SPECTROSCOPY (90% accuracy)

Cholin : mitosis, Ch:Cr(perbandingan cholin-creatin)=neovascular,ganas

NAA : SSP=intraaxial↑,extraaxial↓
Lactat : metabolisme anaerob(anabolik)=infeksi,iskemi
Lipid : metastase
Alanin : extraaxial=meningioma
 MRI FUCTIONAL Tractografi
Pre ops Extrinsik Tumor= tractus bergeser Astrositoma=tumor melingkupi
kekanan-kiri,depan,blkg tumor tractus=defisit permanen

Post removal=tractus kembali posisi semula

Defisit membaik
 PET-SCAN ; Metabolisme (CMRO2,CMRGluc,etc)
MENINGIOMA ASTOCYTOMA
 INTRAOPERATIVE
NEUROMONITORING
 BRAIN NAVIGATION
MRA INTRAOPERATIVE
 Tumor Removal 
Always Microsurgery
NEUROENDOSCOPY
Before After
 Indication for Macroadenoma
Hipofise
• Decompression
• If only with minimal risk
• There were no response to medication
therapy
• Patient medication intolerance
• Progressive neurological deficit
Youssef, A.S, Agazzi, S., van Loveren, H.R. 2005. Transcranial Surgery for Pituitary Adenomas. Neurosurgery, 57(ONS
Suppl1), pp. ONS-168 – ONS-175.
McLanahan, C.S., Christy, J.H., Tindall, G.T. 1978. Anterior pituitary function before and after trans-sphenoidal
microsurgical resection of pituitary tumors. Neurosurgery, 3(2), 142-145.
Primeau, V., Raftopoulos, C., Maiter, D. 2012. Outcomes of transsphenoidal surgery in prolactinomas : Improvement of
hormonal control in dopamine agonist resistant patients. Eur J Endocrinol, 166(5), pp. 779-86.
Haddad, S.F., VanGilder, J.C., Menezes, A.H. 1991. Pediatric Pituitary Tumors. Neurosurgery, 29(4), pp. 509-514.
 Meningioma
• 15% of all primary intracranial tumor
• Peak incidence 45 yo (4-6 decade), children (1.5%)
• ♀:♂= 3: 2, spinal meningiomas 5 : 1 ( estrogen/progesteron recept)
• 90% supratentorial, dural attachment(only 15% no)
• Usually single, multiple meningiomas present in NF2
• Histologic types: Meningotheliomatous-Transitional
Fibrous-Angioblastic
Main location of meningiomas:
 Convexity 50%
 CPA 40%
 Falk - Parasagittal 25%
 Sphenoid ridge and convexity 20%
 Suprasellar 12%
 Tuberculum sellae, olfactory groove and Posterior Fossa 10%
 Ventricle 1.5%
KONVEKSITAS
Total removal with dural+bone
removal
PA : usually benign (WHO
grade 1)
 MENINGIOMA CPA

Vth,VIth,VIIth,VIIIth,IXth
Xth,XIth,XIIth nerve and
brainstem encased
tumor→difficult total
removal

Fibroblastic meningioma grade I WHO

 MENINGIOMA

FALX PARASAGITAL
Sinus
Sagitalis
Superior
encased
MENINGIOMA SPHENOID WING

Meningothelial meningioma, grade I WHO

 MENINGIOMA
OLFACTORY GROOVE

Post ops
 TUMOR SPINAL

Meningioma: total removal

Astrositoma : debulking

Motorik+sensorik evaluation pre-post,SSEP

intraoperatif,stabilisasi instrumentation

MRI T2 lesi intensitas

heterogen C1-2 menekan
medulla spinalis.
MENINGIOMA ORBITA
+ sekunder infeksi
 MENINGIOMA
TUBERCULUM SELLAE

Meningothelial meningioma
 Glioma / Astrocytoma
 Intrinsic tumors, no clear border with the surrounding brain
 There is a ‘continuum’ from the benign to the most malignant GBM
 Benign (children) and malignant (adult).
 Tend to dedifferentiate/ change toward higher grade
 Malignant : aggressive biological behavior and grave prognosis
 Low grade tumor relatively avascular and fibrous
 High grade = nuclear pleomorphism & anaplastic astro=mitosis,
and GBM=endothelial proliferation & central necrosis
 Invade the whole hemisphere, called Gliomatosis Cerebri
 Calcium deposit (15%)
 Distribution
WHO Grade II Grade III Grade IV

Astrocytoma Anaplastic GBM

AGE :
ADULT 74.0% 87.2% 93.9%
CHILDREN 26.0% 12.8% 6.1%

LOCATION :
Supratentorial 75.6% 90.0% 95.4%
Infratentorial 24.4% 10.0% 4.6%
 Survival rate
in supratentorial glioma

Low grade Malignant gliomas Glioblastoma

CT pattern 1Y 5Y 1Y 5Y 1Y 5Y
precontrast
lowdensity 16.8 7.8 3.4 0.2 0.8 0.2
Isodensity 14.2 8.4 5.1 2.1 1.4 4.3
High-densi 12.8 8.6 8.0 8.9 5.1 19.4
Mixed-den 18.8 19.3 14.4 17.8 14.1 25.8
others 17.0 20.5 19.6 26.7 26.3 23.5
 Histologic Classification Astrocytoma

KERNOHAN Grade 1 Grade 2 Grade 3 Grade 4

(1949)
Astrocytoma Anaplastic GBM
RUBINSTEIN
RINGERTZ
WHO Grade II Grade III Grade IV

According to cellularity, mitoses, nuclear pleomorphism, endothelial/

adventitial proliferation, and necrosis
WHO grade I is only for Pilocytic Astrocytoma, which is biologically
distinct from the above diffuse astrocytoma
 PILOCYSTIC
ASTROCYTOMA
 Role of MRI
in delineating tumor margin Glioblastoma Multiforme
P-CT C-CT

Astocytoma
 AWAKE
SURGERY=malignant tumor in eloquent area

Aim = QOL (NOT Overall Survival (in years) )

 Management of Gliomas
• Aims of surgery: provides pathological diagnosis, decreased
ICP, cytoreductive (preparing for adjuvant therapy)
• Types of surgery: lobectomy for tumor in cerebral poles,
resection or biopsy if involves eloquent areas, stereotactic biopsy
(small and deeply located tumor)
• High grade tumor has 100 gr with 1011 cells at dx,
radical excision removes 90-95% (in low grade, 5Y survival >
50%, higher than partial/ subtotal removal, only < 20%)
• RDT kills another 90% of residual tumor (1010 cells)
• Chemothx kills the tumor cells left after RDT (recurrence
always at same location/ failure of local control)
Stereotactic Frame
biopsy of deep seated, small tumors
 Metastatic Brain Tumor
• 15% brain tumors (clinical series) and ≥ 30% of pathologist
• Most commonly originate: Lung (50%), breast (11%), stomach (5%), rectum (4%),
kidney (4%), uterus (4%), 15% unknown
• Most multiple, 1/3 solitary, 80% anterior circulation, mainly MCA
• Area:frontal-parietal(20%),cerebellum(10%),occipital&temporal(8%)
• Malignant melanoma (60% metastasize to the brain)
• Primary cancer→cerebral metastases: lung (5 months), a few month(malignant
melanoma) & breast Ca.
• H/A, vomite, focal signs (tumor location), seizures (25%)
• Cranial nerve abnormalities found in leptomeningeal metastases
• Images: isodense (CT-scan) contrast enhance peritumoral edema
• Contrast MRI demonstrate small metastases not visible on CT !!!
• Indication :
1. For internal decompression/ decreasing ICP:
- Solitary tumor in accessible location
- Multiple lesions with one large tumor
• Provide histological diagnosis:
- in uncertain or unknown primary tumor
- Other possibilities are suspected, such as granuloma
• Metastases without systemic spread
2.Radiotherapy : multiple metastases (≥45Gy) after removal of a single metastases
Craniotomy melintasi sinus sagitallis Total Tumor removal (tumor
superior padat, warna putih kekuningan)
 Radiotherapy:
Cobalt Linac Gamma Knife ABC
Perfection
for stereotactic radiation therapy of small and deeply located tumors
 CHEMOTHERAPY
Team Tumor Work (Depends on PA)
• TMZ (temozolamide)→DOC
• Nimotuzumab
• Cisplatin
• Vincristin
Prinsip Umum :
Membunuh sel agresive membelah
CANCER STEM CELLS ???

Trageting therapy
CD 133 (CD in Cancer Stem Cell of brain tumor)
Experimental Vaccine Targets Cancer Stem Cells in Brain Tumors

John Yu, vice chair of the Department of Neurosurgery, director of surgical neuro-oncology, medical
director of the Brain Tumor Center and neurosurgical director of the Gamma Knife Program at
Cedars-Sinai.
CHROMOSOMES ANALYSE
GENE THERAPY
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