Number of primary CNS neoplasms estimated 9% of all primary tumor types. Intracranial neoplasms arising in an estimated 85% of cases. In general, primary brain tumor is a type of neuroglial., These tumors arise from the parenchyma and are generally derived from glioma. Approximately 6600 new cases of malignant glioma are reported each year. Meningioma is the second largest group of intracranial happens, roughly around 15%. The pituitary gland is the most frequently as the tumor growth, usually the type of adenoma. Roughly about 10% of all intracranial tumors. Neoplasm metastases are common. The incidence depends on age, and usually occurs after the fourth decade. An estimated 1/6 of brain tumor metastases will occur no symptoms. Treatment of tumors depends on tumor type, clinical condition, the need for therapy before surgery, and the handling time of surgery and post surgery. The most common glioma is a tumor.
Glioma is a tumor originating from the brain tissue. Glioma is a tumor that can invade penginflitrasi some parts of the brain. Malignant gliomas usually occur in many brain neoplasm whose number is about 45% of all brain tumors. Usually these tumors can not be removed completely, because the tumor spreads by infiltration into the surrounding nervous tissue and it is not considered to resect completely without causing damage to vital structures.
Gliomas are generally classified into 3 groups:
- Anaplastic astrositoma
- Glioblastoma multiform
Astrositoma showed relatively benign end of the spectrum of disease. In microscopic abnormalities in astrositoma difficult to distinguish from the normal form. Mitosis occurs rarely and does not appear to increase the number of cells. Mikrosistik changes sometimes appear and assist in determining the diagnosis. Cerebral changes often are not disturbed and the prognosis is generally good.
Anaplastic astrositoma indicate malignancy. This type often appear in middle age and usually occurs in cerebral hemisper. Lesions showed a clear place for the operation, and usually no real disorder limit. In microscopic cell density increases. Tues pleomorphic and mitosis appears to be happening.
Glioblastoma multiform showing the most malignant form of malignancy of gliomas. Tumors occur in general in the cerebral hemispheres but possibly up to the brainstem and in rare cases until well into the cerebellar hemispheres. At the time of surgery, made the contrast between the tumor and surrounding normal brain, because there are no clear boundaries. Often the area perdaraahan and necrosis, which is macroscopically showed symptoms of the disease. In microscopic diagnosis is confirmed by the identification of areas of high cellularity, pleomorphisme extreme, vascular proliferation and necrosis.
Glioblastoma is the most frequent primary tumor is found. Also known as malignant glioma and astrisitoma levels 3 and 4. more often arise in the frontal and temporal lobes. Growth is very rapid and the prognosis is always fatal. These tumors occur mainly at the age of 40-60 years. Bilateral lesions in the hemispheres of the shape of a butterfly lesion in the corpus callosum and basal ganglia may also concerning. Glioblastoma is a highly aggressive brain tumor type parenchym primer.52% of tumor cases and 20% of all intracranial tumors.
Criteria for Diagnosis
Complaints that arise can be a headache, nausea, decreased appetite, projectile vomiting, seizures, neurologic deficits (double vision, strabismus, disorders of balance, paralysis of limb motion, etc.), changes in personality, mood, mental, or cognitive impairment.
• Physical Examination
Generalist status examination and neurological status.
• Laboratory examination
Especially to see the patient's general condition and readiness for treatment that will be undertaken (surgical, radiation, or chemotherapy)
• radiological examination
• CT Scan
• MRI, MRS,
SPECT • CT
• PET CT
Importance of supporting examinations: Radiological examination is a standard CT scan and MRI with contrast. CT scan is useful to look at the initial step of tumor diagnosis and very good to see calcifications, lesions of erosion / destruction of the skull. MRI can look at the picture of soft tissues more clearly and very good for infratentorial tumors, but has limitations in terms of assessing calcification. MRS examinations such as functional MRI is excellent for determining the area of necrosis of the tumor is still viable, so
either used as a guide to biopsy as well as to rule out differential diagnosis, as well as DWI examination. Examination of single-photon emission computed tomography (SPECT) and positron emission tomography (PET) post-therapy may be useful to distinguish between recurrent tumor and radiation-induced tissue necrosis.
The clinical manifestations
The symptoms in patients with brain tumors depends on the location and rate of tumor growth. The combination of symptoms that are often found are:
A. increased intracranial pressure, increased pressure intrkranial Symptoms Caused by a gradual pressure on the brain caused by tumor growth. Symptoms that usually happens is a lot of headaches, vomiting, papilledema ("choken disc" or the optic nerve edema), personality changes and decreased the variation of focal motor, sensory and cranial nerve dysfunction.
2. Symptoms localized location-specific symptoms occur in accordance with disorders of the brain regions affected, causing the signs indicated local, such as the sensory and motor abnormalities, visual changes and seizures. Because the brain functions differently in each part is to identify the location of the tumor can be determined from the changes that occur, such as:
A. Motor cortex tumor manifests itself by causing the movement of such
seizures are located on one side of the body, called Jacksonian seizures.
2. Occipital lobe tumors cause visual manifestation, hemianopsia homonimus
contralateral (loss of vision in half the visual field, on the opposite side of the tumor) and visual hallucinations.
3. Tumor serebellum cause dizziness, ataxia (loss of balance) or a staggering gait with a tendency to fall to the side of the lesion, the muscles are not coordinated and nystagmus (involuntary rhythmic eye movement) usually indicates the horizontal movement.
4. Frontal lobe tumors often causes personality disorders, change in status
emotional and behavioral, mental and behavioral disintegration. Patients often become
extreme irregular and less care for themselves and using obscene language.
5. Serebopontin angle tumors usually begin in the acoustic nerve sheath and give
series of symptoms that occur with all the characteristic symptoms of brain tumor.
6. Intracranial tumors can result in personality disorders, confusion, impaired
speech and gait function, especially in elderly patients. Most tumor types
often is a meningioma, glioblastoma and cerebral metastases from other parts.
Development of signs and symptoms to determine whether the tumor is growing or
Classification of primary central nervous system lesions based on histological grading and type:
WHO grade I: tumors with low proliferative potential, post-resection kurabilitas pretty good.
WHO grade II: tumor is infiltrative, low mitotic activity, but often occur
recurrence. Certain types tend to be progressive to the degree
WHO grade III: clear picture of mitotic activity, high infiltration capacity, and there
WHO grade IV: active mitosis, tend to necrosis, is generally associated with
rapid disease progression in pre / post surgery.
Therapy in the central nervous system tumors include surgery, radoterapi, and chemotherapy.
A. Craniotomy (bone incision) to treat patients meningioma, acoustic neuroma, astrositoma cystic on the cerebellum, in the third ventricle colloid cyst, congenital tumors such as dermoid cyst and a granuloma. For malignant glioma patients, overall tumor removal and treatment is not possible. But such action may include the reduction of the ICT, raise necrotic tissue and reduce a large part of the tumor which in theory leaves little left or cells become resistant to radiation or chemotherapy.
2. Steroptaktik biopsy can be done at the location of the lesion. In the low-grade glioma tumor resection to the maximum with the main purpose of improvement of clinical symptoms. In patients with total resection and subtotal resection without symptoms that bother you, then simply do a follow up MRI every 3-6 months for 5 years and thereafter every year. If the operation still cause symptoms that can not be controlled with symptomatic medication, then radiotherapy and chemotherapy is the next option. At the higher the degree of glioma surgery followed by radiotherapy and chemotherapy.
3. The use of stereotactic approach to 3-dimensional framework that follows the highly precise tumor location, stereotactic frame and multiple imaging studies (x-ray, CT) is used to determine complete tumor location and check its position. Laser or radiation may be released to the stereotactic approach. Radioisotope (131I) can also be applied directly into the tumor to produce high doses of radiation to the tumor (brakhiterapi) while meminimilkan impact on the surrounding brain tissue.
4. The use of gamma knife radio surgery to Do on the inside, for tumors that can not be incorporated drug, the action is often done alone.
5. Chemotherapy and external beam radiation. Chemotherapy in brain tumor cases are now widely used because it is known to prolong the survival rate of patients, especially in cases of oligodendroglioma. Glioblastoma is a type that is kemoresisten, but the last 2 years developing research on the usefulness of temozolomide in glioblastoma. Chemotherapy in brain tumors is not curative, the main purpose of chemotherapy is to inhibit tumor growth and improve the quality of life (quality of life) of patients as long as possible. Chemotherapy is used in combination with surgery and / or radiotherapy. Agents are widely used include nitrosurea, platinumbased, temozolomide, procarbazine, and taxol.
- Bagian Bedah Staf Pengajar FKUI : Kumpulan Kuliah Ilmu Bedah, Cetakan Pertama, Penerbit Binarupa Aksara, Jakarta 1995
- R . Sjamsuhidajat , Wim de Jong, Buku – Ajar Ilmu Bedah, eds. 2, Jakarta: EGC, 2004.
- Panduan pelayanan Medis Departemen Ilmu Bedah RSCM. Jakarta. 2005
- National Cancer Institute. Childhood Cerebral Astrocytoma/Malignant Glioma Treatment. April 2008.