Diagnostic Imaging Approach to a Supratentorial SOL in

Diagnostic Imaging Approach to a Supratentorial SOL in an Adult Antoinette Reinders Dept of Diagnostic and Interventional Radiology University of the Free State Aug 2012

Approach • Age • Location • Intra vs extra axial • Anatomical compartment • Midline crossing • Tumour spread • Characteristics on CT and MRI • Spectroscopy • Calcification/edema/mass effect • Enhancement • Differential diagnoses • “Tumor mimickers”

Brain Tumours Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http: //www. radiologyassistant. nl/en

Major Anatomical considerations Intra axial • • • Extra axial • Dural based • Bone tumours • Nasopharyngeal tumours Hemispheres (cerebrum/cerebellum) Brainstem Sellar/supraseller Pineal Ventricular

Approach • Location – Intra-axial vs Extra-axial Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http: //www. radiologyassistant. nl/en

Extra axial tumour • Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http: //www. radiologyassistant. nl/en

Intra vs Extra axial Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http: //www. radiologyassistant. nl/en

Approach • Location – Grey matter • Cortical/subcortical – White matter – Grey/white matter interface – Dural surface • Abut the meninges – Ventricles • Foramen of Monroe • Trigonum of the lateral ventricles – Pineal gland – Sella/suprasellar

Robert Wood Johnson University Hospital. Available from URL: http: //www. rwjuh. edu/gammaknife/gamma-knife-brain-tumor-treatment. aspx

Approach • Cross midline – Glioblastoma Multiforme, Radiation necrosis, Meningioma, Lymphoma, Epidermoid cyst, MS • Multifocal disease – Phacomatoses • NF 1: Optic gliomas, astrocytomas • NF 2: Meningiomas, Ependymomas, Schwannomas, Choroid plexus papillomas • TS: Subependymal tubers, Giant cell astrocytomas • VHL: Hemangioblastomas

Approach • Tumour spread – Subarachnoid seeding • • • PNET Ependymoma GBM Lymphoma Oligodendroglioma – WM Tracts • Astrocytoma – Pilocytic, Fibrillary, Gemistocytic, Protoplasmic – Foramina • Ependymoma

Tumour Spread Ependymoma of 4 th ventricle Pleomorphic xantoastrocytoma

Approach • Characteristics – MRI • • • – CT • • Edema Cystic Mass effect Fat containing Spectroscopy Calcifications Haemorrhage Homogenous or heterogenous appearance Periosteal reaction

Characteristics on CT

Haemorrhage Common haemorrhage Not common haemorrhage Glioblastoma multiforme Germ cell tumours Metastases • Choroid • Thyroid • Bronchus • Mamma/melanoma • Renal Medulloblastoma Craniopharyngioma Colloid cysts/central neurocytoma Oligodendrogliomas Ependymal Giant cell astrocytomas Chordoma Epidermoid/dermoid

Characteristics on MRI

Characteristics on MRI

Diffusion Weighted Imaging Abscesses, infarcts have ABNORMAL diffusion – restriction Tumours have NORMAL diffusion – no restriction

Approach • Enhancement – Destruction of BBB in order to enhance – Homogenous vs heterogenous enhancement – Enhancement of gliomas = higher grade of malignancy • NB in follow up – Diffusion weighted • Restricted diffusion in abscesses and not in tumours Smithuis R, Montanera W. Brain Tumor – systematic approach. Available from URL: http: //www. radiologyassistant. nl/en

Approach No Enhancement Patchy Enhancement Homogenous Enhancement Low grade astrocytomas Metastases Cystic non tumour lesions Oligodendroglioma Lymphoma • Dermoid GBM Germinoma and pineal tumours • Epidermoid Radiation necrosis Pituatary macroadenoma • Arachnoid cyst Pilocytic astrocytoma Hemangioblastoma Gangliocytoma Meningioma Schwannoma

Common things. . . Brain Tumours Breast Colon Lung Kidney Melanoma Meningioma Schwannoma Pituitary Pineal Lymphoma Metastases 20% Non Glial 40% Astrocytoma Oligodendroglioma

Approach • Differential diagnoses • Dural based – Meningioma, Dural metastases, Sarcoid, Haemangiopericytomas, pineoblastoma, lymphoma • Cortical based – Dural AV malformation, Herpes encephalitis • Multifocal disease – Septic emboli, Abscesses and Multiple Sclerosis • Sellar - Aneurysm

Take home points. . . • Age of patient • Location – Intra vs extra axial – Crossing midline – Multifocal disease • Tumour spread • Characteristics on CT/MRI – Calcifications – Haemorrhage – Spectroscopy • Enhancement pattern • Differential diagnoses

Cellphones? “Although our results overall do not indicate an increased risk of glioma in relation to mobile phone use, the possible risk in the most heavily exposed part of the brain with long-term use needs to be explored further before firm conclusions can be drawn. ” Int J Cancer. 2007 Apr 15; 120(8): 1769 -75. Mobile phone use and risk of glioma in 5 North European countries. Raised risks of glioma with mobile phone use, as reported by one (Swedish) study forming the basis of the IARC's re-evaluation of mobile phone exposure, are not consistent with observed incidence trends in US population data, although the US data could be consistent with the modest excess risks in the Interphone study. BMJ. 2012 Mar 8; 344: e 1147. doi: 10. 1136/bmj. e 1147. Mobile phone use and glioma risk: comparison of epidemiological study results with incidence trends in the United States. BMJ. 2012 May 1; 344: e 3083; author reply e 3088. doi: 10. 1136/bmj. e 3083. Association of mobile phone use with adult brain cancer remains plausible Davis DL, Miller AB, Philips A

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