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Speaking generally, tumors of the central nervous system (CNS) constitute a bleak but vitally important chapter of neurologic medicine Their importance derives from the facts that they occur in great variety; produce numerous neurologic symptoms because of their size, location, and invasive qualities; usually destroy the tissues in which they are situated and displace those around them; are a frequent cause of increased intracranial pressure; and, most of all, are often lethal Slowly this dismal state of affairs is changing, as a result of advances in anesthesiology, stereotactic and microneurosurgical techniques, radiation therapy, and the use of chemotherapeutic agents For clinicians, it should be a matter of general knowledge that: 1 Many types of tumor, both primary and secondary, occur in the cranial cavity and spinal canal Certain ones are much more frequent than others and are prone to occur in particular age groups Some tumors such as craniopharyngioma, meningioma, and schwannoma have a disposition to grow consistently in particular parts of the cranial cavity, thereby producing highly characteristic neurologic syndromes The presence of certain diseases such as AIDS, inherited disorders such as neuro bromatosis, or some systemic cancers predisposes to the development of tumors of the nervous system The growth rates and invasiveness of tumors vary; some, like the glioblastoma, are highly malignant, invasive, and rapidly progressive and others, like the meningioma, are benign, slowly progressive, and compressive These pathologic peculiarities are important, for they have valuable clinical implications, frequently providing the explanation of slowly or rapidly evolving clinical states and determining a good or poor prognosis Systemic neoplasms, by poorly understood mechanisms, may have remote effects on the nervous system, quite apart from those due to their compressive, in ltrative, or metastatic actions Moreover, these remote effects, referred to as paraneoplastic, may constitute the initial or only clinical manifestation of the underlying neoplasm Metastatic neoplasms are a far more common cause than are primary tumors of brain and spinal cord, and certain cancers display this tendency more than others.

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Incidence of CNS Tumors and Their Types Currently, in each year there are an estimated 540,000 deaths from cancer in the United States Of these, the number of patients who died of primary tumors of the brain seems comparatively small (about 18,000, half of them malignant gliomas), but in roughly another 130,000 patients the brain is affected at the time of death by metastases Thus, in approximately 25 percent of all the patients with cancer, the brain and its coverings are involved by neoplasm at some time in the 546

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14 A user calls you with a question about Windows Several files that she knows should be hidden are showing up on the desktop What do you tell her A The hidden files will be listed but cannot be opened or modified B The hidden files can be truly hidden by selecting the appropriate option in the My Computer | View menu C The hidden files should be moved to the Recycle Bin D The user is incorrect because hidden files cannot be shown on the desktop 15 Which of the following statements is inaccurate A B C D The file s extension determines the type of icon used for that file The file s extension indicates the file s type You cannot change a file s extension You can make a file unusable by changing its extension

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course of the illness By comparison, there are about 200,000 new cases of breast cancer yearly Among causes of death from intracranial disease, tumor is exceeded in frequency only by stroke By contrast, in children, primary tumors of the brain constitute the most common solid tumor and represent 22 percent of all childhood neoplasms, second in frequency only to leukemia Viewed from another perspective, in the United States, the yearly incidence of all tumors that involve the brain is 46 per 100,000, and of primary brain tumors, 15 per 100,000 It is dif cult to obtain accurate statistics as to the types of intracranial tumors, for most of them have been obtained from university hospitals with specialized neurosurgical centers, which attract the more easily diagnosed and treatable forms For example, from the gures of Posner and Chernik, one can infer that secondary tumors of the brain greatly outnumber primary ones; yet in the large series reported in the past (those of Cushing, Olivecrona, Zulch, and Zimmerman), only 4 to 8 percent were of this type In the autopsy statistics of municipal hospitals, where one would expect a more natural selection of cases, the gures for metastatic tumors vary widely, from 20 to 42 percent (Russell and Rubinstein) Even these estimates probably err on the low side, since the brain is frequently not examined in cancer patients, and many of the patients with more benign tumors may have found their way to specialized neurosurgical services With these quali cations, the gures in Table 31-1 might be taken as representative In broad terms, most primary brain tumors are of glial-cell origin ie, gliomas a category that includes astrocytomas (which occur in several grades of malignancy), oligodendrogliomas, ependymomas (which may have characteristics of both glia and of epithelium), and a number of rarer types Other tumors arise from ectodermal structures related to the brain (meningioma); an increasingly important group arises from lymphocytes or their progenitor histiocytes, ie, reticulum cells (CNS lymphoma); a varied constellation is derived from precursor neuronal elements (neuroblastoma, medulloblastoma), germ cells (germinoma, craniopharyngioma, teratoma, etc), or endocrine elements (pituitary adenoma) A more recent and detailed tabulation is given in Table 31-2, compiled by the Central Brain Tumor Registry Notable in all series, and emphasized in the latter table, is the higher frequency of certain tumors during childhood The main change since the rst edition of this book (1977) is the increase in incidence of primary CNS lymphomas When Table 31-1 was rst composed, the incidence of this tumor, formerly called reticulum-cell sarcoma, was almost negligible In the last 25 years, the number in our hospitals has more than tripled; in specialized centers such as the Memorial Sloan-Kettering Cancer Center, the increase in incidence has been even more dramatic (DeAngelis) In most institutions, one in ve or six primary brain tumors is now of this type For the most part, this increase is attributable to the rise in number of immunosuppressed individuals, particularly of those with AIDS; but the incidence of this tumor.

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