intratumoral calcification

A better prognosis in all of these tumor types is associated with age younger than 40 years, high functional status, greater extent of surgical resection, lower histologic grade at the time of diagnosis, and the presence of specific molecular markers.

Seizures are the presenting symptom in approximately one third of patients with brain tumors, and 50–75% of patients develop seizures during the course of their illness.

No specific pattern leads to diagnosis of a brain tumor; most headaches in brain tumor patients are nonspecific and intermittent, progressively more intense, and longer in duration. Characteristics that raise suspicion of a brain tumor include headaches exacerbated by coughing, lying down, or sleep; headaches that wake the patient at night; new headaches that are different from prior patterns or are more severe; and headaches with associated nausea, vomiting, or neurologic deficits. The pain originates from pressure on the vasculature, dura, and some of the cranial nerves. Intense, episodic headaches occur when “spikes” of increased intracranial pressure are superimposed on already increased intracranial pressure.

Increased intracranial pressure can also cause a variety of other brainstem symptoms, such as dizziness, hearing loss, or tinnitus. Excessive intracranial pressure can lead to altered consciousness and the Cushing reflex of hypertension and bradycardia. Such symptoms are often associated with headache.

Headache, nausea and vomiting, seizures, and altered mental status are commonly seen with most types of brain tumors. Particular symptoms, such as focal neurologic deficits that are related to the site of the tumor, can localize the disease to a discrete area of the brain. These symptoms are typically the same across tumor types. The size and rate of growth of the tumor are also important factors in presentation given the brain’s confinement within a fixed volume. A slowly growing tumor can be quite large when diagnosed, because the brain can accommodate to a decreasing volume over an extended period of time. In contrast, a fast-growing, small tumor with a significant amount of peritumoral edema may have a more dramatic presentation.

|Download (.pdf) Table 12–4. Physical examination findings associated with cerebral tumors.

Sellar region Microadenoma and macroadenoma Meningioma Craniopharyngioma Glioma (pilocytic optic nerve glioma) Aneurysm

Patients whose tumors are in the pleura survive twice as long as those with peritoneal tumors;

The U.S. Food and Drug Administration has approved combination treatment with pemetrexed and cisplatin for malignant pleural mesothelioma that is not surgically resectable.

Subtotal pleurectomy with decortication is the accepted procedure. More radical surgeries such as pleuropneumonectomy (extrapleural pneumonectomy) may be appropriate for selected patients.

metastatic adenocarcinoma

In advanced disease, there may be obvious enlargement of the affected hemithorax, with bulging of the intercostal spaces and displacement of the trachea and mediastinum to the unaffected side. After removal of pleural fluid, a pericardial or pleuropericardial rub may be heard. Advanced signs also may include mediastinal lymph node enlargement, subcutaneous nodules in the chest wall, and clubbing. Encroachment on the mediastinal structures may lead to neuropathic signs such as vocal cord paralysis or Horner syndrome. Congestion and edema may develop in the upper trunk or lower limbs secondary to compression of the superior or inferior vena cava.

a persistent gnawing chest pain on the involved side, which may radiate to the shoulder and arm. In most patients, pain becomes the most incapacitating symptom. Dyspnea on exertion, dry cough (occasionally hemoptysis), and increasing weight loss are frequent accompanying symptoms. Some patients have low-grade fever, which can result in an incorrect diagnosis of chronic infection. The symptoms of peritoneal mesothelioma are nonspecific but may include increased abdominal girth, pain, and weight loss.

Fibers remain accumulated in the lower lung, adjacent to the pleura. The pathogenesis of peritoneal mesothelioma is thought to be similar to that of pleural tumors. Fibers of asbestos are transported in lymphatics to the abdomen, and asbestos is also transported across the mucosa of the gut after ingestion.

Erionite is what is known as a natural fibrous zeolite, found in volcanic ash. Although erionite is structurally similar to asbestos, it has different chemical and physical properties. Nonoccupational exposure to erionite has been documented in the Cappadocia region of Turkey where extremely high rates of pleural and peritoneal mesothelioma were linked to high erionite levels in the surrounding environment. Occupational exposure has decreased since the 1980s when the use of erionite for industrial applications made way for synthetic substitutes. However, workers involved in the mining, production, and use of other zeolites can be at risk for erionite exposure.

despite the known dose-response relationship

Asbestos is the dominant cause of human malignant mesothelioma and is responsible for at least 85–90% of pleural malignant mesothelioma among men.

atients with mesothelioma present with chest pain and shortness of breath. The chest radiograph reveals a pleural effusion, generalized pleural thickening, and a shrunken hemithorax.

The frequency of carcinoma developing in choledochal cysts is > 14% at 20 years, and thus early surgical excision is recommended

Photodynamic therapy

Immunotherapy Pembrolizumab has benefit in the 1–2% of cholangiocarcinomas with a mismatch-repair deficiency Pemigatinib has benefit in patients with advanced refractory cholangiocarcinoma harboring an FGFR2 fusion or rearrangement Larotrectinib and entrectinib for patients with an NTRK gene fusion

Diagnostic Procedures ++ Most helpful diagnostic studies before surgery

There are usually concomitant elevations of the serum alkaline phosphatase and cholesterol