Hello and welcome to the Physician Assistant Exam Review Podcast. This is Season 2, Episode 132, where we’re going to be finishing up neuro with neoplasms. My name is Brian Wallace. I’m the host and creator here at Physician Assistant Exam Review. And if you’re new to the show, when I say Season 2, all I’m referring to is the fact that I’ve been at this for a long time now, almost 15 years when I first started the podcast and we’ve been through the entire blueprint. This will be the second time where in fact, I think the only thing I have left to cover for the second time through is psych. And I love doing this.

I wasn’t sure when I first ended season one, what to do next. So I just restarted the blueprint. But what’s fun is I’ve grown a lot as a practitioner. I’ve learned a lot about test taking, about studying, about skills, about students. So each time I go through it, there’s more pieces to add, there’s more information, there’s easier ways to learn it. So I’m actually looking forward to starting again with season three and starting from the beginning all over again and making the material better, stronger, more accessible, all of those things. So that’s all we’re talking about.

So you’re not missing out if you’re wondering where season one is. There are ways to find it, but quite honestly, it’s only for humor purposes that it’s available because things are much, much worse and we get better as we go, right? So one thing I just want to touch on before we jump into today’s episode on neoplasms is that I am hosting, I hosted last night a Master Class on passing the PANCE, but really getting through PA school EORs and then how to approach the PANCE. We had a fantastic time last night. A ton of people showed up with amazing questions. Great work. It was really a lot of fun.

And we covered some ground I haven’t covered before. So there’s obviously a tight timeline on this, but I’m also going to be doing that tonight, 8pm Eastern time, just go to physicianassistantexamreview.com/masterclass. If you don’t want to miss out on stuff like that in the future, just go over to the website and sign up for the email community there and you will be notified when I do things like this 100% free, there’s nothing on that we’re selling or doing anything. I just had some free time thought I would fill it in with something. So fantastic.

Okay, so today we’re going to be covering neoplasms. We’re going to be working our way through malignant and benign neoplasms, comparing them, contrasting and talking about what we might need to know for the PANCE. This is a little bit of a tough subject for a few reasons. One is the blueprint just says, you know, neoplasms. It doesn’t really give you a whole lot to work from that standpoint. So you have to kind of think about what the most common things are, what’s most likely to be asked, and so on and so forth.

All right, so let’s keep moving.

Let’s start with our priming questions. What benign tumor commonly presents with unilateral hearing loss and balance issues? What benign tumor commonly presents with unilateral hearing loss and balance issues? Which benign brain tumor can cause bitemporal hemianopsia due to optic chiasm compression? If you don’t know these, it’s totally fine. I’m not really expecting you to know them off the top of your head unless you just finished covering neuro. I certainly don’t.

That’s not my expectation. The point here, though, is to think these through. Put some effort in. And what you’re doing is you’re priming your brain to receive the information as it comes. Multiple touches. Putting in some effort. That’s how we create strong neural networks and get retention.

So the next one is, what’s the most common and aggressive primary malignant brain tumor in adults? Basically, what’s the nastiest brain tumor there is? Which malignant pediatric tumor commonly causes obstructive hydrocephalus due to its posterior fossa location? How do metastatic brain lesions typically appear on MRI imaging? How do metastatic brain lesions typically appear on MRI imaging? And finally, what distinguishes benign brain tumors from malignant tumors clinically and on imaging? So where we start this discussion is comparing and contrasting malignant tumors to benign tumors.

So benign tumors are usually slow. I’m going to use the caveat of usually because, you know, I don’t want to say always for any of this stuff. This is and again, this is not my personal area of expertise. Benign tumors have slow growth. They have well-defined margins on imaging. Right. So this is normal for all cancers, minimal surrounding edema and gradual and less aggressive clinical courses.

Right. So that makes sense. Benign tumors have slow growth, well-defined margins on imaging, minimal edema around them, and gradual, less aggressive clinical courses. Malignant tumors, on the other hand, show rapid growth, rapid progression. They have infiltrative margins. That’s where you get those like spike lookings coming off of a central circle. They just look like they’re moving out.

They’re more aggressive. Significant surrounding edema and a poor clinical outcome. So again, this goes for all malignant versus benign tumors. It’s kind of what you’re looking for, right? Is that pattern of rapid growth, unclear margins, swelling and edema, and then they’ll have poor clinical outcomes.

All right, let’s talk about benign neurologic neoplasms. We’re going to start with the meningioma. This is the most common benign intracranial tumor, and it originates from the meninges. Makes sense, right? In arachnoid cells. Slow growing, frequently calcified. On clinical presentation, this is often asymptomatic or presents with gradual onset of headaches, maybe seizures.

And it just all depends on the tumor location. Labs and studies for a lot of this, right, it’s going to be an MRI and a CT. That’s how we’re going to kind of get started here. The MRI here will show a well-defined extra-axial lesion with dural attachments. You get what’s called a dural tail sign. You might want to pull up an image of that. A dural tail sign.

And on CAT scan, you may see calcifications here. Treatment, surgical resection if symptomatic, and observation and serial imaging if incidental findings. So if you just stumble across this, it may not need a whole lot, right? It’s slow growing, it’s non-aggressive, might not need to do a whole lot. So you may find treatments for these are going to be fairly easy to remember. This is one of the reasons why I talk about learning treatments as groups as can be helpful. Schwannoma is next, also known as an acoustic neuroma.

This is a tumor originating from Schwann cells typically at the cerebellopontine angle involving cranial nerve eight. This is a progressive unilateral hearing loss, tinnitus, dizziness, balance difficulties. You can get facial numbness or weakness depending on which cranial nerves are involved. Like if you get involvement of cranial nerve 5 or 7. What do you think our lab studies and physical exam finds are going to be here? Well, we can do a hearing test, of course, but really it’s going to be the MRI. This is going to be a well-defined lesion at the cerebellar pontine angle, enhancing on contrast imaging.

Now, what do you think our treatment’s going to be? Surgical resection or observation in small asymptomatic tumors.

Next, we’re going to cover a pituitary adenoma. This is common benign tumor of the anterior pituitary gland classified by hormone secretion. So that’s the main thing here. And you’ve learned about these for sure when you’re covering endocrine, right? Pituitary adenomas. So this is a double hit because you might get it under neoplasms here, but you might get it more likely under endocrine. So here we have, you can get a prolactinoma with amenorrhea or galactorrhea.

You can get acromegaly, depending on which hormones are being secreted, right? That would be if growth hormones being secreted. What if ACTH is being secreted? What do you wind up with? Here’s a tough one, one no one wants me to ask. If ACTH is being secreted by this pituitary adenoma, what disease state does that create? Cushing’s, right?

Cushing’s disease. Visual field defects, bitemporal hemianopsia from optic chiasm compression. So that may be something that is useful. The rest of that presentation and the rest of the exam findings are going to be based on which hormones are being secreted. But the visual field defects is what’s going to come directly from the mass effect of the tumor. So lab studies and physical exam findings. Again, here, this isn’t something you have to memorize necessarily, right?

So what labs and studies are you going to get if you suspect a pituitary adenoma, right? I don’t know what would make you initially suspect a pituitary adenoma. It’s not something that would be on top of my list frequently. I guess it would depend on the symptoms they’re complaining of and maybe that visual field defect. But if I was looking for it, what would I test? What would I want? Well, obviously, I’m going to want hormone levels, right?

I’m going to get a prolactin level, growth hormone, ACTH, cortisol, TSH, all these things. And then, of course, we’re going to get imaging, right? Treatment here. So you can treat, if it’s a prolactinoma, you can treat it with dopamine, or we’re going to do surgical resection, especially if there are visual symptoms, then we may have to do a surgical resection.

All right, next we have malignant neurologic neoplasms. And the first one is a glioblastoma multiforme. This is the most common and aggressive primary CNS malignancy. This is the most common and aggressive. It has a rapid onset progression of headaches, seizures, focal deficits, cognitive changes, increased intracranial pressure with nausea, vomiting, and papilledema. This thing is nasty. Lab studies and physical exam findings.

The MRI will show irregular infiltrative lesions with central necrosis. You get a butterfly glioma crossing corpus callosum and extensive edema. So again, it just looks nasty on the MRI. Treatment. Really, there’s a whole bunch of things that they are trying, but the prognosis here is awful. It’s a median survival of 12 to 15 months. You can do surgical debulking, radiation, chemotherapy, etc., but there’s not a lot that’s going to change the course of this.

One of the reasons why perhaps I’ve been putting off closing out neuro is because this is the condition that my older brother died of not too long ago. He was having these weird, weird, I want to call them hallucinations, where he would think that he was in a different place from old TV shows, and that he would be on the set of old TV shows, and it caught him very off guard, and it was so real for him. And what he found out later was that this was a type of seizure that he was having. This was seizure activity, It was the first activity that the first symptom that he had. He went on to have all the rest. And obviously it was devastating to get his diagnosis because I knew immediately what that meant for where he was heading. Thankfully, his children are all older.

I don’t know if that’s better or worse, but they’re all college age or older. So that makes things at least a little bit more functional. But yeah, this thing is just nasty and runs its course pretty much no matter what you do. They had the best possible care you could get literally flying around the country. But it we really had… It extended his life somewhat. Gave him some functionality longer.

But this is this one’s nasty.

All right. Moving on. Medulloblastoma. This is a malignant pediatric… Sorry to bring you down. It is tough. But I didn’t want to ignore it.

I didn’t want to not mention it. I didn’t think that would be right. It’s also, for you anyway, a story that helps you hold on to the diagnosis. I always talk about looking for these stories because we don’t remember data points. We don’t remember independent data points. We remember stories. So another reason why I wanted to share that with you is because now maybe it’s something that you can hold on to, something you can remember, something you can get right on your exam if it comes up.

All right, medulloblastoma. Malignant pediatric tumor located in the cerebellum, commonly in the posterior fossa. Clinical presentation here, symptoms due to obstructive hydrocephalus, headache, vomiting, ataxia, and gait instability. Increased intracranial pressure, papilledema, altered mental status. The MRI here shows an enhancing mass in the posterior fossa and obstructive hydrocephalus. So you’re getting this increased intracranial pressure. Treatments, again, we’re going to have surgical resection, radiation chemotherapy.

Prognosis isn’t as bad as glioblastoma. It depends on the subtype and how thoroughly it’s been resected. But you can see the difference in our treatments here. Treatments for our malignant cancers are basically go take out the tumor, radiation chemotherapy with mixed success. Versus what we’re doing for our benign tumors is usually we’re trying to watch them, right, if at all possible. And then we go in and surgically remove them, if not. We have two more things to cover here.

So CNS lymphoma, primary CNS lymphoma, this is an aggressive malignancy primarily affecting immunocompromised patients. So that’s an important thing to note, to mark down, is this is if you have an immunocompromised patient, HIV, AIDS, post-transplant, etc. You’re looking for the CNS lymphoma. Clinical presentation is rapid cognitive decline, focal neurological deficits, seizures, may present with constitutional or what we call B symptoms, fever, weight loss, night sweats, lab studies and physical exam findings, the MRIs, multifocal enhancing lesions, periventricular distribution common. Here you’re going to find you might do a cerebral spinal fluid and the cytology may confirm lymphoma cells. You’d obviously have to have this suspicion in order to do that. Treatment, high-dose IV methotrexate, and then radiation therapy.

Steroids used cautiously because they can also mask the diagnosis, but that’s how you’re going to treat it. Our last thing we want to talk about for today is metastatic brain tumors. So this is cancers that occur in other areas of the body that wind up in the brain, right? Because they’re malignant and they move. Most common intracranial malignancy in adults would be lung, breast, melanoma, and renal. Clinical presentation, rapid onset neurological deficits depending on tumor location, right? So all of this is very location dependent on what it’s pushing on.

The symptoms are often multifocal. You can get increased cranial pressure with all these, right? So that doesn’t help you all that much in defining it. But it does make you, if you see someone with headaches, nausea, vomiting, seizures, you probably want to get an MRI. That’s what it’s telling you. It’s not going to tell you which type of tumor you’re getting based on symptoms usually, but it will tell you we need to start looking in the brain. So here we can get multiple ring-enhancing lesions at gray-white junctions with vasogenic edema on our MRI.

Treatment, corticosteroids for some symptomatic edema, and then radiation and surgical resection, if possible. If it’s a single mass Mets. If it’s more than that, obviously, it starts to get tricky. And chemotherapy.

All right. Sorry, that was a little bit tough for me to get through, but I do appreciate it. You give me a little bit of space to do that. But again, I wanted to share with you just for the reasons I said already. Our study tip for today, let’s keep moving, is something I talked about yesterday on Instagram. If you haven’t started following my Instagram, I’ve been posting a lot more there that you may find helpful. I don’t know.

It’s been fun for me. And it’s the thought that you may be one idea in a series of ideas away from massive success. You come to PA school, you work your way through PA school with so much knowledge, so many skills. You’ve been working for so long. You’ve been learning new ways to learn. You’ve been learning about test taking. You’ve been practicing all of these things for so long now.

You have so much. But the thought that if you’re struggling, or even if you’re doing well, that the next piece of the puzzle may be the one that unlocks everything for you. And it doesn’t have to be that good of an idea. And maybe you could find it anywhere. But it may just be the thing that clicks everything into place. I know that that’s happened for me so many times and I was thinking about it in relation to students that you don’t need to start from the beginning when we talk about study skills. They don’t have to start from the beginning when we talk about test-taking skills.

You’ve developed so much of these. But maybe there’s just one piece in a series of steps that will unlock that door and change everything. And I believe that to be true. And I think that’s why I’ve seen so many students, you know, one recently who went from a 280 on her PANCE to over 400 on the next attempt. I don’t think that there’s a million things I taught her. I think there was one or two that using everything else she had, those kind of locked everything into place. So the point of this is I want you to keep working.

I want you to keep thinking about how you study. I want you to keep thinking about how you take tests. I want you to keep thinking about how you show up to lectures. Don’t just let this stuff pass by. Don’t just say, here I am. I’m fixed in space. This is me.

This is what I do. Fight that battle every day. So continue to fight that battle. It gets harder as you get older to not be so set in your ways, but continue to have that growth mindset where you’re looking for that next piece of the puzzle. Not again, we’re not starting from ground zero. We’re not changing everything that you do, but keep an eye out for an idea that may just be that piece you need in a series of good ideas.

All right, let’s get our answers to our priming question. What benign tumor commonly presents with unilateral hearing loss and balance issues? This is a big one. You have to absolutely have to know this. If you’re going to walk out of here with only a couple things, this is on the list for sure. What benign tumor commonly presents with the unilateral hearing loss and balance issues? This is schwannoma or acoustic neuroma?

Not “or.” It means the same thing. Which benign brain tumor can cause bitemporal hemianopsia due to optic chiasm compression? Again, big one here. This was our pituitary adenoma, right? We had all those hormone symptoms, but the one that should set off alarm bells is that bitemporal hemianopsia. What’s the most common and aggressive primary malignant brain tumor in adults? You should all be able to nail this one now.

Glioblastoma multiforme. Which malignant pediatric brain tumor commonly causes obstructive hydrocephalus due to its posterior fossa location? This was the medulloblastoma. How do metastatic brain lesions typically appear on imaging? Again, this isn’t like a memorizing thing. I’m sorry. This was the metastatic one.

It’s not malignant. This is kind of a memorizing thing. Multiple ring enhancing lesions head to gray matter, gray-white matter junctions. What distinguishes benign brain tumors from malignant tumors clinically and on imaging? That’s the part that’s not really a memorizing thing, right? I don’t hold on to each of these pieces. What I do is I think, all right, benign is slow growing and a nasty picture on imaging.

I’m sorry. Benign is slow growing and kind of a nice image on imaging. Malignant is fast growing and nasty looking on imaging. So we get well-defined margins, minimal edema, well-contained. That’s all benign. Infiltrative margins. Significant edema, significant swelling, all that stuff points to malignancy.

Right? So that’s pretty easy to identify and think about. That’s something that you shouldn’t really struggle with from that point of view. You should have that picture in your head.

All right. Fantastic. So that’ll wrap, actually wraps up neuro for us completely. Very excited about that being done with that. We’re going to move on. I believe it’s psych is next. It’s the only thing left to cover.

One more time. I just want to remind you that tonight, 8pm, if you’re if you are listening to this on July 29 on Tuesday at 8pm, I’m going to be hosting another one of the Master Classes I held last night. It was a ton of fun. We got a ton out of it. I got a ton out of it. And I think I can pass along a lot of useful information to people getting ready for their PANCE. People are in didactic year all the way through.

That’s really the way that we do things. You just go to physicianassistantexamreview.com/masterclass to register for that for tonight.

All right. Fantastic. Thank you so much. And I appreciate it. See you soon.