00:02
At this point, the classification we’ll
take a look at is primary CNS lymphoma.
00:08
It’s the first time that we’re dealing
with a lymphoma in the brain.
00:12
The classification thus far
that we’ve walked through
have been primary CNS tumors
including our astrocytomas,
under the category of
neuroepithelial tumors.
00:23
And then after astrocytomas, we
walked through oligodendrogliomas,
ependymomas and so forth.
00:29
So here we have a lymphoma.
00:31
Accounts for 1% of
intracranial tumor.
00:33
1%.
00:35
Most common CNS in what
kind of individual?
Think about an HIV patient or in other
words, immunocompromised patient.
00:42
That’s extremely important.
00:44
In fact, we have perhaps even
diffuse large B cell lymphoma
that may be taking
place in your CNS.
00:52
And if you remember
from WBC pathology
that whenever you
talk about lymphomas,
you’re dividing this into
Hodgkin’s and non-Hodgkin’s.
01:00
And under non-Hodgkin’s,
if you remember,
those are the ones that love
to actually be extranodal.
01:06
You’ll have high-grade
B cell neoplasia.
01:09
Once again, diffuse
large B cell lymphoma
is something that could be found in
these immunocompromised patients.
01:17
Our topic here, ladies and
gentlemen, is a primary CNS tumor.
01:22
But this is of the
lymphoma variant,
a major clinical pearl here is,
think,
HIV or immunocompromised
patient, unfortunately.
01:35
The clinical features of your lymphoma:
Deep gray structure
and white matter.
01:39
Multifocal lesions are common.
01:41
Diffusely enhanced on MRI.
01:45
Diffusely enhanced.
01:47
The reason I say that is because on MRI,
you have another description that you want
to know in pathology called ring-enhancing.
01:54
But this is lymphoma, so therefore,
it’s diffusely enhancing.
01:58
Now, remember, there are
different routes of metastasis.
02:03
You could take your hematogenous route,
which are mostly likely sarcomas.
02:07
The carcinomas would take the lymphatics.
02:11
With the carcinomas, we’ve talked
about a bunch of exceptions.
02:15
And the third route of possible
metastasis would be seeding.
02:19
What does seeding mean to you?
It means that these
neoplastic cells are then
metastasizing to the
adjacent structure, right?
So seeding into the CSF
is once again common.
02:31
And we’ve talked about this
a few times with seeding.
02:34
For example,
I’ll bring this to your attention so
that your thoughts are organized.
02:38
The most common brain tumor, primary brain
tumor in a child is medulloblastoma.
02:44
There’s every possibility that these small
blue cells may then seed into the CSF.
02:50
And glioblastoma multiforme,
one of a common adult type of primary
CNS tumor may seed into the CSF.
02:59
Is that clear?
It can also spread to the eye,
this particular CNS lymphoma.
03:05
Well-defined, with
central necrosis.
03:08
Treatment is based on the patient's age, comorbidities and their wishes.
03:12
It may include chemo, radiation, stem cell transplants and in cases of palliation glucocorticoids.
03:19
Leave the brain behind and
now, we go into the sella.
03:23
Now, normally, what do
you have in your sella?
We have the pituitary.
03:28
So here, we’ll talk quickly
about some pituitary adenomas
without going into great detail
as to the endocrinology because
that has already been covered.
03:35
It may present with endocrine,
neurologic manifestation.
03:38
Think about the pituitary gland.
03:40
Think about what you
have superior to it.
03:43
And obviously, you are then
going to compress the chiasm.
03:46
It may result in bitemporal hemianopsia.
03:49
It may result in headaches, right?
May have visual issues, bitemporal issues.
03:54
Most endocrine presentation
might be hypopituitarism.
03:58
Be very careful with
an adenoma, please.
04:01
What do I mean by that?
Because as soon you
hear an adenoma,
do not think that it’s always
going to be functioning.
04:08
You can have an adenoma
that is non-functioning.
04:11
And in fact, with an adenoma, whether
it be micro or macroadenoma,
you really, really want to pay
attention to the clinical picture.
04:20
And by that, I mean the following:
Microadenomas granted tend to be
functioning, that we talked about earlier.
04:26
In microadenoma, if we’re
talking about functioning,
prolactin might be the most common
hormone to then be secreted.
04:33
If it’s macroadenoma, these then
tend to be non-functioning.
04:36
And if it’s non-functioning, it
may result in hypopituitarism.
04:40
However, even with
macroadenomas,
you could have a secreting tumor such
as a growth hormone, macroadenoma.
04:47
Is that clear?
So we talked about this
earlier in endocrinology.
04:51
I’m bringing this to your
attention once again,
the first thing that you always ask
yourself is my adenoma functioning or not?
And as soon as you have something like
a macroadenoma that’s non-functioning,
every single hormone will be compromised
from the pituitary except prolactin.
05:10
Why?
Because this large adenoma
might then compress the stalk.
05:16
If you compress this stalk, you’re
not able to deliver the dopamine.
05:19
And thus, you’ve increased
your release of prolactin.
05:23
I’m not going to review that.
05:24
At this point, you should be well
versed with the effect of dopamine,
influence of dopamine
on prolactin.
05:30
Most common, hyperfunctioning presentation
will be excess prolactin as we talked about.
05:35
So therefore, this female,
if she has a functioning
prolactinoma,
she’s going to present with galactorrhea
and you know from feedback mechanism, your
prolactin inhibits your GNRH, doesn’t it?
And so therefore, your
prolactin inhibits GNRH.
05:51
She is then going to present with
amenorrhea and decreased libido.
05:58
Treatment, obviously surgical.
06:00
You get in there, and try
to remove the prolactinoma.
06:02
However, with the prolactinoma,
you know that you’re going to
use your dopamine agonist,
either it be bromocriptine
or cabergoline.
06:10
These are dopamine
agonist to then halt or
control the amount of
prolactin being secreted.
06:18
Here, we’ll take a look
at acoustic neuroma.
06:21
So what does an acoustic
neuroma mean to you?
As soon as you hear acoustics,
you’re thinking about what?
Oh, yeah, hearing.
06:28
And as soon as you hear about hearing,
then you should be thinking
about what cranial nerve?
Eighth, right?
Vestibulocochlear.
06:36
It’s not a primary brain tumor.
06:39
Schwannoma of the vestibular branches
of the eighth cranial nerve.
06:42
Stop there and make sure whenever you hear
the word or description acoustic neuroma,
you should be thinking about
the cerebellar pontine angle.
06:52
Cerebellar pontine angle and here,
you have your bilateral schwannomas.
06:58
And a bilateral schwannoma,
in general, would then come from
what’s known as a preceding event
and that’s called
neurofibromatosis type II.
07:08
We’ll talk a little bit more in a second.
07:09
At this point,
acoustic, automatically
cranial nerve VIII.
07:15
Automatically, thinking vestibular
branch of the eighth cranial nerve.
07:20
In terms of location, you’re at
the cerebellar pontine angle.
07:24
It’s the most common tumor of
the cerebellar pontine angle.
07:27
And here once again, in
meningioma perhaps number 2.
07:32
Benign tumors, surgical resection
is curative treatment.
07:35
Often presents with unilateral
tinnitus or hearing loss.
07:38
Symptoms could be unilateral if
you’re affecting the vestibular.
07:42
So look for hearing
issues or tinnitus.
07:46
In terms of an acoustic neuroma
and where it’s arising from,
how many ears do you have?
One,
two.
07:53
Okay.
07:54
So therefore, an acoustic neuroma would
arise from neurofibromatosis type 2.
08:02
A type 2 neurofibromatosis would
give rise to an acoustic neuroma,
a.k.a., a schwannoma.
08:10
Now, what I’m not going to describe
to you but you want to keep in mind
is that if at some point in time, you
hear about neurofibromatosis type 1,
then you’re thinking about giving
rise to your neurofibroma.
08:25
With neurofibromatosis type 2, this is
then referred to as being your Merlin.