A 35-year-old woman comes to the physician because of right arm weakness. She began noticing some clumsiness several months ago that she attributed to excess yard work. However, it worsened recently, causing her to drop things while working in the kitchen. She also reports stumbling and almost falling several times over the last month. She denies headaches, vision problems, or vertigo. She suffered from acute lymphoblastic leukemia at age 7 and received combination chemotherapy, cranial irradiation, and intrathecal chemotherapy. She has no other medical problems. She does not smoke or use alcohol.
Her blood pressure is 111/68 mm Hg and pulse is 68/min. Her BMI is 23 kg/m². Physical examination does not reveal any lymph node enlargement, carotid bruits, or heart murmurs. The spleen is not palpable. There is pronator drift on the right side. Her deep tendon reflexes are symmetric. She is stable in the Romberg position with her eyes closed but has mild instability on tandem walking.
Brain imaging in this patient would most likely reveal which of the following?

Question

Quizplus · Accepted Answer

Intracranial radiation and intensive chemotherapy for childhood acute lymphoblastic leukemia (ALL) are the greatest risk factors for developing a secondary malignancy. Brain tumors and hematologic malignancies (e.g., acute myelogenous leukemia) are common secondary malignancies in these patients. The most common brain tumors are meningiomas and gliomas. Meningeal cells are the most susceptible to cranial radiation, and patients may develop multiple and recurrent meningiomas. However, meningiomas usually have a prolonged latency period of up to 20 years after treatment. Most meningiomas are slow growing with symptoms resulting from compression of the underlying brain parenchyma. (Choice A) Most intracranial aneurysms are asymptomatic (are found incidentally) unless they rupture and cause subarachnoid hemorrhage. Symptomatic patients usually present with headache, visual loss, cranial neuropathies, or facial pain. This patient's more gradual onset of symptoms, primarily arm weakness, makes this less likely. (Choice B) Intracranial radiation can increase the risk of high-grade gliomas (glioblastoma multiforme), which is highly aggressive and often associated with extensive vasogenic edema. Patients usually present with seizures and/or signs and symptoms of increased intracranial pressure (e.g., nausea, vomiting, headache, and confusion) with rapid neurologic decline. (Choice C) This patient's history and physical examination show no evidence of infection such as systemic symptoms (e.g., fever, chills, night sweats), tachycardia, or lymphadenopathy. (Choice E) This patient's symptoms have progressively worsened and do not follow the relapsing and remitting pattern of multiple sclerosis. She also has no visual symptoms, which makes the diagnosis of multiple sclerosis less likely. Educational objective: Patients who received intracranial irradiation (e.g., childhood ALL) are at an increased risk of developing brain tumors (primarily meningiomas) after a prolonged latency period. __________ References: Long-term cause-specific mortality among survivors of childhood cancer. (http://www.ncbi.nlm.nih.gov/pubmed/20628130) Population-based risks of CNS tumors in survivors of childhood cancer: the British Childhood Cancer Survivor Study. (http://www.ncbi.nlm.nih.gov/pubmed/21079138) Childhood ALL and second neoplasms. (http://www.ncbi.nlm.nih.gov/pubmed/17952026)

A 35-Year-Old Woman Comes to the Physician Because of Right