Questions To Ask Your Doctor About Cerebellar Astrocytoma

• Where is the tumor located in the brain?

·        What type is it?

·        What are the treatment options?

·        Is surgery indicated?

·        Will radiation therapy and chemotherapy be needed?

·        Is a recurrence likely?

·        What is the prognosis?

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Objective:

To study long-term effects on neurologic, neuropsychological, and behavioral functioning in children treated for cerebellar pilocytic astrocytoma (CPA) without additional radio- and chemotherapy.

Methods:

The authors assessed speech, language, nonverbal intelligence, attention, memory, executive skills, and visual (-spatial) functions in a consecutive series of 23 children. Neurologic and neuropsychological follow-up ranged from 1 year to 8 years and 10 months after resection.

Results:

 Long-term sequelae in the investigated domains were found in all children. Apraxia, motor neglect, and dysarthric features, as well as language, sustained attention, visual-spatial, executive, memory, and behavioral problems, were observed in various combinations and to different degrees. No clear pattern of neurocognitive disturbances could be discerned in this group. In addition, significant relationships were revealed between severity of preoperative hydrocephalus and visual-spatial skills. The high percentage of children who needed special education reflects the severity of the impairments.

Conclusion:

Despite the current opinion of a good quality of life after CPA treatment, careful long-term neurocognitive follow-up is needed in order to inform parents and teachers about the behavioral and cognitive sequelae and to contribute to timely social and educational intervention.

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Spiritual distress is unresolved religious or spiritual conflict and doubt. A serious illness like cancer may challenge a patient’s beliefs or religious values, resulting in high levels of spiritual distress. Some cancer patients may feel that cancer is a punishment by God or may suffer a loss of faith after being diagnosed.Other patients may experience mild spiritual distress when coping with cancer. For example, when prayer is used as a coping method, some patients may worry about how to pray or may doubt their prayers are being answered.

Spiritual and religious well-being may be associated with improved quality of life.It is not known for sure how spirituality is related to health. Some research shows that spiritual or religious beliefs and practices promote a positive mental attitude that may help a patient feel better. Spiritual and religious well-being may be associated with improved quality of life in the following ways:

• Reduced anxiety, depression, and discomfort.
• Reduced sense of isolation (feeling alone).
• Better adjustment to the effects of cancer and its treatment.
• Increased ability to enjoy life during cancer treatment.
• A feeling of personal growth as a result of living with cancer.
• Improved health outcomes.

Spiritual distress may contribute to poorer health outcomes. High levels of spiritual distress may interfere with the patient’s ability to cope with cancer and cancer treatment. This distress may contribute to poorer health outcomes and less satisfaction with life.

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1) Tumor stain was observed in only one case. A tumor was demonstrated as an avascular mass in the remaining 12 cases.

2) Demonstration of cerebellar astrocytoma as hypovascular or avascular masses was related to their low-grade malignancy in histology and cystic nature in gross appearance, as already pointed out. Furthermore, the present study suggested that mural nodules of cystic lesions should have certain weight and sizes so that they could be demonstrated as tumor stain.

3) Abnormal findings concerning tumor circulation were mostly limited to the cases with tumor stain. Early filling veins were not found in any case. Neither feeding artery nor draining vein was clearly identified in some cases. In addition, the abnormal vessels lacked hypertrophic and tortuous changes.

4) In the supratentorial region, five of the 12 low-grade astrocytoma exhibited abnormal tumor stain and tumor circulation by cerebral angiogram and we think that supratentorial and posterior fossa astrocytoma must usually exhibit different pathological tumor circulation by cerebral angiogram, since each group has distinctive clinical and biological characteristics.

5) CT was performed in 7 of 13 cases. It appeared to be more useful than cerebral angiography in the morphological diagnosis Especially in cystic tumors, CT produced minute information concerning peritumoral edema, enhancement of margin of cystic astrocytoma after intravenous contrast medium, and marginal enhancement with layering in the dependent part of the cyst.

6) Neuroradiological different diagnosis of cerebellar astrocytoma and cerebellar hemangioblastoma by CT was difficult in our cases of cystic tumors. However, both tumors were differentiated from each other with ease by tumor stain and tumor circulation in cerebral angiography, since cerebellar astrocytoma was lacking in abnormal vessels, whereas cerebellar hemangioblastoma was marked by many abnormal vessels. Thus, we concluded that cerebral angiography is superior to CT in differential diagnosis between cerebellar astrocytoma and cerebellar hemangioblastoma.

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Cushing probably was the first to report a large series of posterior fossa tumors. He published information about 61 patients with cerebellar medulloblastoma with mostly fatal outcome.

Advances in brain surgery for tumors primarily were due to discovery of anesthesia, asepsis, and neurological localization.

Problem: Tumors in the posterior fossa are considered critical brain lesions. This is, primarily, because of the limited space within the posterior fossa and the potential involvement of vital brain stem nuclei.

Some patients should undergo an emergency operation, especially if they present with acute symptoms of brain stem involvement or herniation.

Frequency:

• Posterior fossa tumors are more common in children than the adults.
• Between 54% and 70% of all childhood brain tumors originate in the posterior fossa.
• About 15-20% of brain tumors in adults occur in the posterior fossa.
• Certain types of posterior fossa tumors, such as medulloblastoma, pineoblastoma, ependymomas, primitive neuroectodermal tumors (PNETs), and astrocytomas of the cerebellum and brain stem, occur more frequently in children.
• Some glial tumors, such as mixed gliomas, are unique to children. They are located more frequently in the cerebellum (67%) and usually are benign.

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Approximately two-thirds of medulloblastomas in children are located in the vermis. They impinge on the roof of the fourth ventricle and cause partial or complete obstruction of flow of the cerebrospinal fluid. Invasion of the leptomeninges via dissemination along CSF pathways is frequent. Intracranially, when there is subarachnoid tumor spread, it is seen most prominent within the sylvian fissures, the suprasellar subarachnoid space, cisterns of the posterior fossa, or over the cerebral hemispheric convexities. Drop metastases to the spinal subarachnoid space and cauda equina are most commonly seen at the thoracic and lumbosacral levels.

The most frequent abnormality on skull radiography is sutural diastasis. On CT a medulloblastoma appears as a hyperdense or isodense mass, because it is composed of small, round cells with a high nuclear-to-cytoplasmic ratio. It arises in the vermis or cerebellar hemispheres and compresses and obstructs the fourth ventricle. Mild to moderate edema surrounds the tumor and there is hydrocephalus. The tumor usually enhances diffusely but sometimes patchily. Calcification is seen in 10-20% of cases of medulloblastoma and cystic or necrotic, nonenhancing regions are seen in close to 50%.

On MR, the appearance of medulloblastomas is variable and nonspecific. Tumor location and patient age are the most important factors in making the correct diagnosis. The most common appearance is that of a hypointense mass compared with normal brain on T1-weighted images. The tumors are most commonly situated within the inferior vermis and can sometimes be seen originating from the inferior medullary velum, which is seen best on sagittal projections. T2-weighted images typically reveal a heterogeneous hypo- or isointense mass (compared to gray matter). The etiology of the hypo intensity or isointensity on T2-weighted images is most likely the highly cellular nature of the tumor and its relatively low interstitial water content. The heterogeneity probably results from the cysts and calcification. Enhancement may be uniform or patchy. The necrotic portions do not enhance.

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Brainstem gliomas most commonly arise in the pons, followed in frequency by the midbrain, medulla, cerebral peduncles, and cervical cord. Focal midbrain, thalamic, and cervicomedullary tumors are usually of lower grade and have a better prognosis than pontine or diffuse brainstem gliomas. Pontine gliomas are usually poorly circumscribed and large. Hemorrhage or cysts are present in approximately 25% of brainstem tumors, more commonly in focal tumors and less commonly in diffuse pontine tumors.

Skull radiographs are usually normal. On CT, brainstem gliomas almost always appear as expanded areas of the medulla, pons, or midbrain that are hypodense to isodense. There is frequently compression of the prepontine cisterns. Expansion of the pons by the tumor results in sagittal expansion of the brainstem and posterior displacement of the fourth ventricle. In addition, the floor of the fourth ventricle may become flattened. When the tumor extends into the cerebellar peduncles, the lateral aspects of the fourth ventricle may be flattened. Exophytic extension of the tumor into the cerebellopontine angle can cause a paradoxical widening of the cerebellopontine angle cistern on the same side. Foci of hemorrhage are uncommon; when present they are seen as localized hyperdense areas. Contrast enhancement is extremely variable.

The use of MR greatly facilitates the diagnosis and exact localization of brainstem gliomas. The characteristic MR appearance is a mass expanding the brainstem. Most brainstem gliomas have a homogeneous appearance and are hypointense on T1-weighted and isointense to hyperintense on T2-weighted sequences. Gadolinium enhancement is variable and may be diffuse, nodular, or ring-like along the margins of a cyst or about an area of necrosis. Enhancement is common in exophytic portions of brainstem gliomas and after radiation therapy; it is less common in untreated brainstem gliomas. Diffuse pontine gliomas are almost always seen as engulfing the basilar artery anteriorly.

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The most common primary cancers metastasizing to the brain are lung cancer (50%), breast cancer (15%-20%), unknown primary cancer (10%-15%), melanoma (10%), and colon cancer (5%). Eighty percent of brain metastases occur in the cerebral hemispheres, 15% occur in the cerebellum, and 5% occur in the brain stem. Metastases to the brain are multiple in more than 70% of cases, but solitary metastases also occur. Brain involvement can occur with cancers of the nasopharyngeal region by direct extension along the cranial nerves or through the foramina at the base of the skull. Dural metastases may constitute as much as 9% of total CNS metastases.

A lesion in the brain should not be assumed to be a metastasis just because a patient has had a previous cancer; such an assumption could result in overlooking appropriate treatment of a curable tumor. Primary brain tumors rarely spread to other areas of the body, but they can spread to other parts of the brain and to the spinal axis.

The diagnosis of brain metastases in cancer patients is based on patient history, neurological examination, and diagnostic procedures. Patients may describe headaches, weakness, seizures, sensory defects, or gait problems. Often, family members or friends may notice lethargy, emotional liability, or personality change.

A physical examination may show objective neurological findings or only minor cognitive changes. The presence of multiple lesions and a high predilection of tumor may be sufficient to make the diagnosis of metastases. In the case of a solitary lesion or a questionable relationship to the primary tumor, a brain biopsy (usually a stereotactic biopsy) may be necessary. In one study, the diagnosis of single brain metastasis was changed in 6 of 54 patients after the lesion was biopsied. The 6 patients had primary brain tumors or infectious and inflammatory lesions. CT scans with contrast or MRIs with gadolinium are quite sensitive in diagnosing the presence of metastases. PET scanning and spectroscopic evaluation are new strategies to diagnose cerebral metastases and to differentiate the metastases from other intracranial lesions.

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• Not everything causes cancer.
• Cancer is not caused by an injury, such as a bump or bruise.
• Cancer is not contagious. Although being infected with certain viruses or bacteria may increase the risk of some types of cancer, no one can “catch” cancer from another person.
• Having one or more risk factors does not mean that you will get cancer. Most people who have risk factors never develop cancer.
• Some people are more sensitive than others to the known risk factors.

Risk factors are:

Growing Older

The most important risk factor for cancer is growing older. Most cancers occur in people over the age of 65. But people of all ages, including children, can get cancer, too.

Tobacco

Tobacco use is the most preventable cause of death. Each year, more than 180,000 Americans die from cancer that is related to tobacco use. Using tobacco products or regularly being around tobacco smoke (environmental or secondhand smoke) increases the risk of cancer. Smokers are more likely than nonsmokers to develop cancer.

Sunlight

Ultraviolet (UV) radiation comes from the sun, sunlamps, and tanning booths. It causes early aging of the skin and skin damage that can lead to skin cancer.

Ionizing Radiation

Ionizing radiation can cause cell damage that leads to cancer. This kind of radiation comes from rays that enter the Earth’s atmosphere from outer space, radioactive fallout, radon gas, x-rays, and other sources. Medical procedures are a common source of radiation:

• Doctors use radiation (low-dose x-rays) to take pictures of the inside of the body. These pictures help to diagnose broken bones and other problems.
• Doctors use radiation therapy (high-dose radiation from large machines or from radioactive substances) to treat cancer.

Certain Chemicals and Other Substances

People who have certain jobs (such as painters, construction workers, and those in the chemical industry) have an increased risk of cancer. Many studies have shown that exposure to asbestos, benzene, benzidine, cadmium, nickel, or vinyl chloride in the workplace can cause cancer.

Certain Hormones

Doctors may recommend hormones (estrogen alone or estrogen along with progestin) to help control problems (such as hot flashes, vaginal dryness, and thinning bones) that may occur during menopause. However, studies show that menopausal hormone therapy can cause serious side effects. Hormones may increase the risk of breast cancer, heart attack, stroke, or blood clots. A woman considering menopausal hormone therapy should discuss the possible risks and benefits with her doctor.  

Family History of Cancer

Most cancers develop because of changes (mutations) in genes. A normal cell may become a cancer cell after a series of gene changes occur. Tobacco use, certain viruses, or other factors in a person’s lifestyle or environment can cause such changes in certain types of cells. Some gene changes that increase the risk of cancer are passed from parent to child. These changes are present at birth in all cells of the body.

Poor Diet, Lack of Physical Activity, or Being Overweight

People who have a poor diet, do not have enough physical activity, or are overweight may be at increased risk of several types of cancer.

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Untreated Childhood Cerebellar Astrocytoma

Untreated childhood cerebellar astrocytoma is a tumor for which no treatment has been given. The child may have received drugs or treatment to relieve symptoms caused by the tumor.

Initial treatment for childhood cerebellar astrocytoma is usually surgery. When the tumor is completely removed by surgery, more treatment may not be needed and the child is closely observed for symptoms to appear or change. This is also called watchful waiting.

If cancercells remain after surgery, treatment depends on the location of the remaining cancer cells and the age of the child. Standard treatment may include the following:

• Watchful waiting.
• Another surgery to remove the tumor.
• Radiation therapy.
• Chemotherapy.

Recurrent Childhood Cerebellar Astrocytoma

Standard treatment of recurrent childhood cerebellar astrocytoma may include the following:

• Surgery.
• Radiation therapy.
• Chemotherapy.

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