Brain Masses

Background

• Neoplasm is the biggest concern

  • 90% of malignant brain masses are metastatic

    • Most commonly: lung, RCC, breast, melanoma

    • Highest bleeding risk: melanoma, thyroid, choriocarcinoma, RCC

  • Primary brain tumors

    • Gliomas: WHO Grade I-IV

      • Glioblastoma multiforme (GBM) – WHO Grade IV; large heterogenous masses with edema; heterogenous contrast enhancement; can cross the corpus callosum

      • Lower grade gliomas – include oligodendrogliomas and astrocytomas

    • Meningioma: usually low grade

      • Can be left alone and monitored with yearly MRI

      • If symptomatic, may need resection/radiation

    • Ependymoma: uncommon. Can cause CSF outflow obstruction

    • CNS lymphoma – diffuse WM involvement, with mass effect, restricts diffusion on MRI with prominent contrast enhancement. Can also cross the corpus callosum

      • Usually B-cell, initially responds significantly to steroids

Presentation

• A significant number of brain lesions are detected incidentally

• If a patient has a first-time seizure, brain mass needs to be ruled out

• HA (usually constant, severe), seizure, and focal neurologic deficits

Evaluation/Management

• Imaging: MRI w/ and w/o contrast provides the most information

  • Findings suggesting malignant lesions: marked edema, multifocal lesions, or presence at gray-white junctions

• LP may be indicated if herniation risk is low, particularly if concerned for infection

• Biopsy will ultimately be needed in most cases, which is done by NSGY

Management

• Work up for primary malignancy, CT C/A/P + PET

• Steroids are generally indicated for treatment of edema

  • Decadron 10 mg IV to start; then transition to 4mg IV q6h with SSI

  • If pt is clinically stable and there is a concern for CNS lymphoma, consider delaying steroids to increase yield of cytology and biopsy, unless edema/mass effect warrants emergent treatment

  • Symptomatic tumors need eval by NSGY for resection consideration and radiation oncology