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Being diagnosed with a brain tumor can be a terrifying and life-changing experience. If your doctor suspects you have a brain tumor, you should consult with other specialists who specialize in diagnosing and treating brain tumors. The brain is a complex and essential organ, and therapy frequently results in long-term alterations. It is critical to obtain the opinions of professionals as well as up-to-date medical information regarding treatment choices for the specific type of brain tumor.
BRAIN AND THE CENTRAL NERVOUS SYSTEM
The central nervous system (CNS) is made up of the brain and spinal column and controls all important activities. These functions include thinking, speaking, and moving one’s body. This means that when a tumor grows in the CNS, it can have an impact on a person’s mental processes, as well as the way they speak or move.
BRAIN ANATOMY
The cerebrum, cerebellum, and brain stem are the three primary components of the brain. The meninges, which surround the brain, are also thought to be a part of it.
1. The cerebrum: This is the brain’s biggest structure. It has two cerebral hemispheres, one on each side of the brain, that regulate the opposing side of the body. It is separated into four lobes, each of which performs a specific function:
- The frontal lobe is responsible for logic, emotions, problem solving, expressive communication, and movement.
- The parietal lobe regulates touch sensations such as pressure, discomfort, and warmth. It also regulates speech components, visual-spatial orientation, and arithmetic.
- Memory, particular senses such as hearing, and the ability to perceive spoken or written language are all controlled by the temporal lobe.
- The occipital lobe is in charge of seeing.
2. The cerebellum: The cerebellum is positioned in the back of the brain, just beneath the cerebrum. It is in charge of coordination and balance, as well as controlling functions on the same side of the body.
3. The brain stem: This is the area of the brain that links to the spinal cord and cerebellum. It regulates involuntary actions necessary for survival, such as heartbeat and breathing. Messages for functions controlled by the cerebrum and cerebellum pass to the body via the brain stem.
4. The meninges: These are the membranes that protect and surround the brain and spinal cord. The dura mater, arachnoid, and pia mater are the three meningeal layers. The cerebrospinal fluid (CSF) is produced in the lateral ventricles, which are located in the center of the brain. CSF circulates between the arachnoid and pia layers of the brain and spinal cord.
PRIMARY BRAIN TUMORS
A primary brain tumor is one that begins in the brain. A primary brain tumor is frequently classified as either “low grade” or “high grade.” A low-grade tumor grows slowly, although it might progress to a high-grade tumor. A high-grade tumor is more likely to spread quickly.
Secondary brain tumors, also known as brain metastases, are far more common in adults than initial tumors.
SECONDARY BRAIN TUMORS
A secondary brain tumor is a malignant tumor that began in another part of the body, such as the breast, lung, or colon, before spreading to the brain. Secondary brain tumors are frequently referred to as metastatic cancer or brain metastasis.
Leptomeningeal metastases or neoplastic meningitis occur when cancer spreads to the meninges and cerebrospinal fluid (CSF). People with leukemia, lymphoma, melanoma, breast cancer, or lung cancer are more likely to develop this illness.
The remainder of this guide focuses on primary brain tumors, with some information on brain metastasis thrown in for good measure.
PRIMARY BRAIN TUMOR TYPES
Primary brain tumors come in a variety of forms. Some cannot be assigned an accurate kind because the tumor’s location renders thorough testing impossible.
The following are descriptions of the most common brain tumor kinds in adults, split into glioma and non-glioma tumor forms.
Gliomas
Gliomas are among the most frequent forms of brain tumors. While the precise cause of gliomas is uncertain, they are assumed to develop from glial cells or glial precursor cells. A glial cell is a type of brain support cell. Astrocytes, oligodendrocytes, and ependymal cells are the three primary types of supporting cells in the brain. Astrocytoma, oligodendroglioma, and ependymoma are the three types of gliomas. Gliomas are graded, which indicates how aggressive the tumor is anticipated to be. A higher grade is typically more aggressive and likely to expand rapidly. Current research, however, is assisting clinicians in moving toward using tumor genetics to better define gliomas.
Gliomas are currently classified as follows:
1. Astrocytoma: The most prevalent kind of glioma is astrocytoma. Astrocytoma cells resemble glial cells known as astrocytes, which are present in the cerebrum and cerebellum. Astrocytoma in youngsters is more common than adult astrocytoma. Astrocytoma is classified into four grades.
- Grade I astrocytoma, also known as pilocytic astrocytoma, is a slow-growing tumor that is usually benign and only rarely spreads into adjacent tissue. The term “benign” refers to a tumor that can develop but does not spread to other sections of the body.
- Grade II or low-grade diffuse astrocytoma is a slow-growing malignant tumor that frequently spreads into adjacent tissue and can progress to a higher grade. Malignant indicates that it is malignant and has the potential to spread to other places of the body.
- Anaplastic astrocytoma, also known as Grade III astrocytoma, is a malignant tumor that can rapidly grow and spread to adjacent tissues.
- Glioblastoma, also known as grade IV astrocytoma, is a particularly malignant form of astrocytoma.
2. Oligodendroglioma: Oligodendroglioma is a tumor with cells that resemble glial cells known as oligodendrocytes. These cells are in charge of producing myelin. Myelin, which surrounds the neurons, is high in protein and fatty compounds known as lipids. They are classified as either oligodendroglioma, a low-grade tumor, or anaplastic oligodendroglioma, a high-grade tumor.
3. Brain stem glioma: A brain stem glioma begins in the brain stem’s glial cells.
4. Ependymoma: Ependymoma usually starts in the pathways in the brain where CSF is produced and stored. They are more common in adulthood and can also be of the myxopapillary subtype.
Non-glioma tumors
Non-glioma tumors are tumors that develop from non-glial cells in the brain. Non-glioma tumors include the following:
1. Meningioma: The most frequent type of primary brain tumor is meningioma. It usually starts in the meninges and is not malignant. Meningioma can be dangerous if it expands and presses on the brain or spinal cord, or if it grows into brain tissue.
2. Primary CNS lymphoma: This cancer is a type of lymphoma. Lymphoma is a type of cancer that develops in the lymphatic system. Primary CNS lymphoma begins in the brain and spreads to the spinal fluid and the eyes.
3. Medulloblastoma: Medulloblastoma is hypothesized to begin in the cerebellum from a specific type of cell. Cerebellar granule progenitor cells are the name given to these cells. It is more frequent in youngsters and is usually malignant, spreading throughout the central nervous system.
4. Craniopharyngioma: Craniopharyngioma is a benign tumor that develops near the pituitary gland at the base of the brain. These tumors are quite uncommon.
5. Pineal gland and pituitary gland tumors: These are tumors that develop in the pineal and pituitary glands.
6. Schwannoma: Schwannoma is a rare tumor that develops in the nerve sheath, or nerve lining. It frequently occurs in the vestibular nerve, which is a nerve in the inner ear that aids with balance control. It is usually not malignant.
SYMPTOMS AND SIGNS OF BRAIN CANCER
The following symptoms or indicators may be experienced by those who have a brain tumor. A symptom, such as weariness, nausea, or discomfort, is something that only the person experiencing it can identify and explain. A symptom is something that others can recognize and quantify, such as a fever, rash, or an increased pulse. Signs and symptoms, when combined, can assist describe a medical situation. Some persons with brain tumors do not exhibit any of the signs and symptoms listed below. Alternatively, the origin of a symptom or sign could be a medical disease other than a brain tumor.
Brain tumor symptoms might be generic or specialized. The pressure of the tumor on the brain or spinal cord causes a general symptom. Certain symptoms occur when a specific area of the brain is not functioning properly due to the tumor. Many persons with brain tumors were detected after going to the doctor with a symptom, such as a headache or other changes.
Among the general signs are:
- Headaches that can be severe and intensify with exercise or in the early hours of the morning
- Changes in personality or memory
- Vomiting or nausea.
- Fatigue.
- Drowsiness.
- Sleep issues.
- Memory issues
- Changes in the ability to walk or carry out daily tasks.
- Seizures. Seizures can occur in a variety of forms. Certain medications can help to prevent or control them. Motor seizures, often known as convulsions, are sudden involuntary muscle movements. The following are the many forms of seizures and how they appear:
1. Myoclonic: twitches, jerks, and spasms of a single or several muscles
2. Tonic-Clonic (Grand Mal):
- Consciousness and bodily tone are lost, followed by twitching and relaxing muscles, which are referred to as contractions.
- Control of body functions, such as bladder control, is lost.
- A person’s skin may turn a shade of blue, purple, gray, white, or green after a brief 30-second interval of not breathing.
- A person may feel sleepy and have a headache, confusion, weakness, numbness, and sore muscles after having this sort of seizure.
3. Sensory: Changes in sensation, vision, smell, and/or hearing that do not result in loss of consciousness
4. Complex partial:
- It is possible to experience a loss of awareness or a partial or entire loss of consciousness.
- Twitching, for example, may be connected with recurrent, involuntary movements.
Symptoms that may be particular to the tumor’s location include:
- A tumor in the frontal or parietal lobe of the cerebrum is associated with altered perception of touch or pressure, arm or leg weakness on one side of the body, or confusion between the left and right sides of the body.
- A pineal gland tumor might cause inability to see upward.
- A pituitary tumor has been connected to lactation, which is the release of breast milk, as well as irregular menstrual periods and adult hand and foot growth.
- A brain stem tumor might cause difficulty swallowing, facial paralysis or numbness, or double vision.
- A tumor in the temporal lobe, occipital lobe, or brain stem can cause vision alterations such as loss of vision or double vision.
- Near the tumor, there may be pressure or a headache.
- A cerebellar tumor is connected to loss of balance and trouble with fine motor skills.
- A tumor in the frontal lobe of the cerebrum is related with changes in judgment, such as loss of initiative, sluggishness, and muscle weakness or paralysis.
- A tumor in the cerebrum’s occipital or temporal lobe causes partial or full vision loss.
Please consult your doctor if you are concerned about any changes you are experiencing. In addition to other questions, your doctor will inquire as to how long and how frequently you have been experiencing the symptom(s). This is done to assist in determining the cause of the condition, which is referred to as a diagnostic.
If you are diagnosed with a brain tumor, symptom relief is a crucial element of your care and therapy. This is known as “palliative care” or “supporting care.” It is frequently initiated shortly after diagnosis and continues throughout treatment. Make an appointment with your health care provider to discuss your symptoms, especially any new or changing symptoms.
BRAIN CANCER GRADES AND PROGNOSTIC FACTORS
A staging system is used to indicate where a tumor is located, if it has spread, and if it is impacting other regions of the body for most other types of tumors in other sections of the body. However, because most primary brain tumors do not extend beyond the central nervous system, there is no suggested systemic staging scheme for adult brain tumors. Because the unique qualities of a brain tumor indicate how cancerous it is and how likely it is to grow, the grading system outlined below is always utilized instead.
Prognostic factors
The type and grade of a brain tumor must be determined before deciding on the best treatment. Several factors assist doctors select the best brain tumor treatment plan and a patient’s prognosis:
Tumor histology: A sample of the tumor is taken for examination. Tumor histology entails determining the type of tumor, its grade, and other molecular traits that indicate how quickly the tumor will develop. These indicators, when considered together, will assist your doctor in predicting how the tumor will behave. These characteristics may also play a role in determining your treatment options.
The term “grade” refers to characteristics of the tumor that are associated with specific outcomes. Doctors may assess whether the tumor cells are growing out of control or whether there are a lot of dead cells, for example. Tumors with characteristics associated with faster growth are assigned a higher grade. The lower the grade of most tumors, the better the prognosis.
The grade of glial tumors is defined by its features as viewed under a microscope, using the following criteria:
- Grade I: These tumors grow slowly and are unlikely to spread. They are frequently curable by surgery.
- Grade II: These tumors are less likely to grow and spread, but they are more likely to recur following treatment.
- Grade III: These tumors have a higher likelihood of quickly proliferating cells but no dead cells. They have a rapid growth rate.
- Grade IV: The cells in a grade IV tumor are actively dividing. Furthermore, the tumor contains aberrant blood vessel growth as well as patches of dead tissue. These tumors have a high rate of growth and dissemination.
Age: When a person is diagnosed with a disease, one of the best ways to estimate a patient’s prognosis is to consider their age and degree of functioning, which is referred to as functional status. A younger adult has a better outlook in general.
Symptoms: The severity of a patient’s symptoms and how long they last may also influence prognosis. Seizures, for example, and having symptoms for an extended period of time are associated with a better prognosis.
Extent of tumor residual: Resection is the surgical removal of a tumor. The amount of tumor that remains in the body after surgery is referred to as residual. When all of the tumor can be surgically removed, the patient’s prognosis improves. There are four types of classifications:
- Gross total: The visible tumor was completely eliminated. Microscopic cells, on the other hand, may survive.
- Subtotal: A significant chunk of the tumor was excised.
- Partial: Only a small portion of the tumor was removed.
- Biopsy only: Only a little amount was taken and used for diagnostic purposes.
Tumor location: Tumors can develop in any area of the brain. Some tumor sites inflict more damage than others, and some cancers are more difficult to treat due to their location.
Molecular features: Certain genetic alterations discovered in the tumor may aid in determining prognosis. IDH1, IDH2, MGMT, and a 1p/19q co-deletion are among them. The presence of any of these mutations in a tumor can sometimes determine the type of brain tumor that is detected.
Functional neurologic status: The doctor will use a functional evaluation scale, such as the Karnofsky Performance Scale (KPS), to determine how well a patient can function and carry out daily tasks. A higher score suggests that you are in better functioning condition. Someone who is able to walk and care for himself usually has a better prognosis.
- 100: Normal, no complaints, no disease evidence
- 90: Capable of doing out usual activities; little illness signs
- 80: Normal activity with effort; some illness signs
- 70: Takes care of oneself; unable to engage in usual activity or active labor.
- 60: Requires assistance on occasion but is capable of caring for herself.
- 50: Requires a lot of help and frequent medical attention.
- 40: Disabled and in need of special care and support
- 30: Severe disability; hospitalization is recommended, but death is not imminent
- 20: Severe illness necessitates hospitalization; aggressive treatment is required.
- 10: Moribund, deadly processes that are rapidly advancing
Metastatic spread: Spread of metastatic disease. Even if a tumor begins in the brain or spinal cord, it seldom travels to other areas of the body in adults, but it may grow inside the CNS. As a result, with rare exceptions, tests examining other organs of the body are usually unnecessary. A tumor that spreads to other areas of the brain or spinal cord has a worse prognosis.
Recurrent tumor: Tumor that reappears. A recurrent tumor is one that has returned following treatment. If the tumor returns, more tests will be performed to determine the amount of the recurrence. These tests and scans are frequently identical to those performed at the time of the first diagnosis.
Currently, the aforementioned criteria are the best predictors of a patient’s prognosis. Researchers are now seeking for biomarkers in tumor tissue that could make a brain tumor easier to diagnose and allow for the staging of an adult brain tumor in the future, as detailed in Diagnosis. Other genetic tests that may indicate a patient’s prognosis are also being investigated by researchers. These techniques may one day assist clinicians in predicting the likelihood of a brain tumor growing, developing more effective treatments, and more accurately predicting prognosis.
DIAGNOSIS FOR BRAIN TUMOR
Doctors utilize a variety of tests to locate or diagnose a brain tumor and determine the type of brain tumor. They also run tests to see if it has spread to other parts of the body from where it began. This is known as metastasis, and it is uncommon in the case of a primary brain tumor. Doctors may also conduct tests to determine which treatments are most likely to be effective.
Taking a sample of the probable tumor is the only definite way for the doctor to know if an area of the body has a tumor for most types of tumors. This can be accomplished through a biopsy process or by surgically removing part or all of the tumor. During a biopsy, the doctor extracts a small sample of tissue for laboratory testing. If this is not possible, the doctor may recommend further tests to aid in the diagnosis.
How is a brain tumor diagnosed?
Imaging studies can assist doctors in determining if the tumor is a primary brain tumor or cancer that has spread to the brain from elsewhere in the body. Images of the inside of the body are produced via imaging tests. When selecting a diagnostic test, your doctor may take the following variables into account:
- The tumor type suspected
- Your symptoms and signs
- Your age and general well-being
- The outcomes of previous medical tests
The majority of brain tumors are discovered after symptoms begin. An internist or neurologist is often the first to diagnose a brain tumor. An internist is a doctor who specializes in adult medicine. A neurologist is a doctor who specializes in brain and central nervous system disorders.
In addition to obtaining a complete medical history from the patient and performing a physical examination, the doctor may recommend the tests listed below. These tests are used to determine the presence of a brain tumor, as well as its type or grade.
In general, magnetic resonance imaging is used to diagnose a brain tumor (MRI). When an MRI reveals that there is a tumor in the brain, the most frequent technique to detect the type of brain tumor is to examine the results of a tissue sample obtained during a biopsy or surgery. These tests and methods are discussed in greater detail below.
- Magnetic resonance imaging: An MRI produces detailed images of the body by using magnetic fields rather than x-rays. The tumor’s size can be determined via an MRI. To provide a crisper image, a special dye known as a contrast medium is administered before to the scan. This dye can be injected into a patient’s vein or given to them in the form of a pill or liquid to consume. MRIs produce more detailed images than CT scans (see below) and are the primary method for detecting a brain tumor. MRIs of the brain, spinal cord, or both may be performed, depending on the type of tumor detected and the likelihood that it would spread to the CNS. There are various forms of MRI. The outcome of a neuro-examination performed by an internist or neurologist aids in determining which sort of MRI to utilize.
1. In most cases, intravenous (IV) gadolinium-enhanced MRI is utilized to help provide a sharper picture of a brain tumor. This is when a patient initially undergoes a standard MRI and then receives a particular form of contrast material called gadolinium via IV. The dye is then used in a second MRI to obtain another series of images.2. An MRI method known as “diffusion weighted imaging” aids in revealing the cellular structure of the brain. Another approach known as “perfusion imaging” determines how much blood reaches the tumor. These techniques may aid doctors in predicting how well a treatment will work.3. Magnetic resonance spectroscopy (MRS) is a test that uses an MRI to determine the chemical composition of the brain. It can assist in distinguishing between dead tissue induced by prior radiation treatments and new tumor cells in the brain.4. A spinal MRI can be used to detect tumors on or near the spine.5. A functional MRI (fMRI) determines the location of certain areas of the brain that control muscle movement and speech. During the fMRI examination, the patient is prompted to do tasks that generate changes in the brain that are visible on the fMRI image. This test is used to help plan surgery so that the surgeon does not damage the brain’s working areas while removing the tumor.
- Tissues sampling/biopsy/surgical removal of a tumor: To make a final diagnosis, a sample of the tumor’s tissue is usually required. A biopsy is the removal of a small piece of tissue for examination under a microscope and is the only sure technique to diagnose a brain tumor. The material is next examined by a pathologist (s). A pathologist is a medical professional who specializes in interpreting laboratory tests and assessing cells, tissues, and organs to identify disease. A biopsy can be performed as part of a surgical procedure to remove the entire tumor. If completely eliminating the tumor is not possible due to its location or the patient’s health, surgery may be performed as a separate treatment.
Other tests may be recommended by your health care provider to assist in making a diagnosis or determining how well treatment is working. Not all of the tests outlined here will be utilized on every individual.
- Positron emission tomography (PET) or PET-CT scan: Initially, a PET scan is used to learn more about a tumor while a patient is undergoing treatment. It may also be utilized if the tumor returns following treatment. A PET scan is frequently coupled with a CT scan to form a PET-CT scan. However, your doctor may refer to this technique simply as a PET scan. A PET scan is a technique for creating images of organs and tissues within the body by employing various chemicals such as sugars or proteins. A radioactive chemical is put into the patient’s body in a modest amount. This chemical is taken in by actively dividing cells. Tumor cells absorb more radioactive stuff because they are more likely to be actively proliferating. The amount of radiation in the material, however, is too low to be dangerous. The material is then detected by a scanner, which produces images of the inside of the body.
- CT scan: A CT scan uses x-rays captured from various angles to create images of the inside of the body. A computer combines these images to create a detailed, three-dimensional image that identifies any anomalies or malignancies. A CT scan can aid in the detection of bleeding and expansion of the fluid-filled areas in the brain known as ventricles. A CT scan can also detect changes in bone in the skull and be used to estimate the size of a tumor. If the patient is unable to have an MRI, such as if they have a pacemaker for their heart, a CT scan may be performed instead. A contrast medium is sometimes administered before the scan to provide more detail on the image. This dye can be injected into a patient’s vein or given to them in the form of a pill or liquid to consume.
- Myelogram: A myelogram may be recommended by the doctor to determine whether the tumor has spread to the spinal fluid, other areas of the brain, or the spinal cord. A dye is injected into the CSF that surrounds the spinal cord during a myelogram. The dye is visible on x-rays and can be used to highlight the spinal cord to aid the doctor’s search for a tumor. This test is only performed on rare occasions; a lumbar puncture is more prevalent.
- Cerebral arteriogram, also known as a cerebral arteriogram: A cerebral arteriogram is an x-ray of the head, or sequence of x-rays, that depicts the arteries in the brain. After a specific dye called a contrast medium is injected into the patient’s main arteries, X-rays are taken.
- Lumbar puncture or spinal tap: A lumbar puncture is a procedure that uses a needle to collect a sample of cerebrospinal fluid (CSF) to examine for tumor cells, blood, or tumor markers. Tumor indicators, also known as biomarkers, are compounds discovered in higher-than-normal concentrations in the blood, urine, spinal fluid, plasma, or other body fluids of persons who have specific types of tumors. Before the procedure, a local anesthetic is usually used to numb the patient’s lower back.
- Neurological, vision, and hearing tests: These tests can help establish whether a tumor is interfering with brain function. A routine eye exam can reveal abnormalities in the optic nerve as well as alterations in a person’s field of vision.
- Neurocognitive assessment: This includes a thorough examination of all key brain processes, such as memory storage and retrieval, expressive and receptive language abilities, math, dexterity, and the patient’s overall well-being. A licensed clinical neuropsychologist performs these examinations. This specialist will prepare a formal report to be compared to future exams or will highlight particular concerns that can be addressed through treatment.
- Electroencephalography (EEG): An EEG is a noninvasive test that measures electrical activity in the brain by attaching electrodes to the exterior of a person’s head. It is used to keep an eye out for potential seizures.
- Evoked potentials: Evoked potentials use electrodes to evaluate the electrical activity of nerves and are frequently used to diagnose acoustic schwannoma, a noncancerous brain tumor. When removing a tumor that is growing around vital nerves, this test can be utilized as a guidance.
- Biomarker testing of the tumor: Your doctor may advise you to undertake laboratory testing on a tumor sample to identify specific genes, proteins, and other components that are unique to the tumor, such as tumor markers. This is also known as tumor molecular testing. Some biomarkers may aid doctors in determining a patient’s prognosis, or possibility of recovery. Researchers are looking into biomarkers to see if they can detect a brain tumor before symptoms appear. The results of these tests may help you decide on a treatment plan. The following are the most routinely examined markers for brain tumors:
1. The loss of the p-arm of chromosome 1 and the loss of the q-arm of chromosome 19 in oligodendroglioma. This is known as a 1p/19q co-deletion. It has been related to better treatment outcomes, particularly with chemotherapy. It can be utilized to aid in therapy planning, particularly for anaplastic oligodendroglioma.
2. A mutation in the isocitrate dehydrogenase (IDH) gene, which is seen in around 70% to 80% of adult low-grade gliomas. Higher-grade tumors can also include IDH gene alterations, implying that these tumors began as lower-grade tumors and progressed to a higher grade. In both low-grade and high-grade cancers, this mutation is associated with a better prognosis.
3. If a gene called methyl guanine methyl transferase (MGMT) is altered in glioblastoma, it can assist doctors understand a patient’s prognosis and how effectively treatment will work. Clinical investigations are being conducted to determine its function in determining the benefit of treatment.
TREATMENT OF BRAIN CANCER
Different types of specialists frequently collaborate in brain tumor care to develop a patient’s overall treatment plan, which involves various types of treatment. This is referred to as a multidisciplinary team. Other health care experts on your care team may include physician assistants, nurse practitioners, oncology nurses, social workers, pharmacists, counselors, nutritionists, rehabilitation specialists, and others. It is critical to have a care team that specializes in treating persons with brain tumors, which may entail consulting with medical professionals outside of your local area to assist with diagnosis and treatment planning.
The most frequent types of brain tumor therapies are outlined below. Treatment for symptoms and side effects may also be part of your care plan, which is an important element of your medical care.
Treatment options and recommendations are influenced by various factors, including:
- The tumor’s size, kind, and grade.
- Whether the tumor is exerting strain on key brain areas.
- If the cancer has spread to other sections of the CNS or the body.
- Side effects are possible.
- Preferences and general health of the patient
Some brain tumors develop quickly, while others grow slowly. Taking all of these aspects into account, your doctor will consult with you about how soon treatment should begin after diagnosis.
Treatment options include surgery, radiation therapy, chemotherapy, and targeted therapy, as discussed below.
Surgery may be the only option for a low-grade brain tumor, especially if the tumor can be completely removed. Radiation therapy and chemotherapy may be done if there is still visible tumor following surgery. Treatment for higher-grade cancers typically begins with surgery, followed by radiation therapy and chemotherapy. Your specific treatment plan will be designed in collaboration with your health care team.
It can be difficult to treat brain tumors successfully. Normally, the blood-brain barrier protects the brain and spinal cord from hazardous substances. However, this barrier also prevents several forms of chemotherapy from entering. If the tumor is close to a sensitive portion of the brain or spinal cord, surgery may be challenging. Even if the surgeon is able to completely remove the original tumor, bits of the tumor that are too tiny to view or remove during surgery may remain. Radiation therapy can potentially cause tissue damage in healthy tissues.
However, research over the last 20 years has substantially extended the lives and improved the quality of life of many patients with a brain tumor. More sophisticated operations, a better understanding of which types of cancers respond to chemotherapy and other medications, and more targeted radiation therapy administration are among these developments.
Take the time to read about all of your treatment options, and don’t be afraid to ask clarifying questions. Discuss the aims of each treatment with your doctor, as well as what you can expect during treatment. These discussions are known as “shared decision-making.” When you and your doctors collaborate to identify therapies that meet the goals of your care, this is referred to as shared decision-making. Because there are various treatment choices for a brain tumor, shared decision-making is very vital.
Surgery
During an operation, the tumor and some surrounding healthy tissue are removed. It is typically used as the first treatment for a brain tumor. It is frequently the only option for treating a low-grade brain tumor. Removing the tumor can help relieve neurological symptoms, provide tissue for diagnostic and genetic study, make other brain tumor therapies more effective, and, in many cases, improve a person’s prognosis.
A neurosurgeon is a doctor who specializes in brain and spinal column surgery. Surgery on the brain necessitates the removal of a portion of the skull, a technique known as a craniotomy. After the tumor has been removed, the patient’s own bone will be utilized to close the opening in the skull.
Rapid breakthroughs in brain tumor surgery have occurred, including the use of cortical mapping, improved imaging, and fluorescent dyes.
- Doctors can use cortical mapping to identify areas of the brain that regulate the senses, language, and motor skills.
- Surgeons now have additional tools to plan and perform surgery thanks to improved imaging technology. Computer-based approaches, such as image guided surgery (IGS), for example, assist surgeons in precisely mapping out the position of the tumor. This is, however, a very specialized technology that may not be readily available.
- The morning before surgery, a fluorescent dye called 5-aminolevulinic acid can be taken orally. Tumor cells soak up this dye. Doctors can observe the cells that have taken up the dye during surgery using a special microscope and light. This allows surgeons to remove as much of the tumor as feasible while remaining safe.
When a tumor is located near the brain’s speech center, it is becoming more frequent to execute the operation while the patient is conscious for a portion of the procedure. Once the surface of the brain is exposed, the patient is usually woken. Then, using unique electrical stimulation techniques, the exact area of the brain that governs speech is located. This method can aid in avoiding injury when removing the tumor.
Aside from removing or shrinking the brain tumor, surgery might give a tissue sample for investigation via biopsy. For some tumor types, the biopsy results can help decide whether cancer drugs or radiation therapy will be beneficial. Even if a cancerous tumor cannot be healed, removing it can alleviate symptoms caused by the tumor pressing on the brain.
Sometimes surgery is not possible because the tumor is in an area that the surgeon cannot reach or is close to a vital structure. These tumors are referred to as inoperable or unresectable. If the tumor is inoperable, the doctor will propose other treatments, which may involve a biopsy or the excision of a section of the tumor.
Discuss the potential side effects of the specific surgery you will undergo with your health care provider prior to surgery.
Radiation therapy
The use of high-energy x-rays or other particles to eliminate tumor cells is known as radiation therapy. Radiation therapy may be used by doctors to slow or stop the growth of a brain tumor. It is usually administered following surgery and may be combined with chemotherapy. A radiation oncologist is a doctor who specializes in administering radiation treatment to treat tumors. External-beam radiation therapy, which delivers radiation from a machine outside the body, is the most prevalent method of radiation treatment. Internal radiation therapy, also known as brachytherapy, is a type of radiation therapy that uses implants to deliver radiation. A radiation therapy regimen, or schedule, typically consists of a predetermined number of treatments administered over a predetermined time period.
External-beam radiation therapy can be used to treat a brain tumor in a variety of methods, including:
Conventional radiation therapy: Anatomic landmarks and x-rays are used to determine the treatment location. This approach is appropriate in some instances, such as whole-brain radiation therapy for brain metastases. Different strategies are required for more precise targeting. The amount of radiation used is determined on the grade of the tumor.
3-dimensional conformal radiation therapy (3D-CRT): On a computer, a 3-dimensional model of the tumor and healthy tissue surrounding the tumor is produced using pictures from CT and MRI scans. This model can be used to guide radiation beams directly at the tumor, protecting healthy tissue from excessive doses of radiation therapy.
Proton therapy: Proton treatment is a type of external-beam radiation therapy in which protons are used instead of x-rays. Protons have the ability to destroy tumor cells at high energies. Proton beam therapy is commonly utilized for malignancies where less radiation is required due to their location. Tumors that have developed into adjacent bone, such as the base of the skull, as well as those near the optic nerve, fall into this category.
Intensity modulated radiation therapy (IMRT): IMRT is a form of 3D-CRT (see above) that can target a tumor more precisely. It can send higher doses of radiation to the tumor while delivering less to healthy tissue around it. The radiation beams are divided into smaller beams in IMRT, and the intensity of each of these smaller beams can be adjusted. This means that the more powerful beams, or beams that emit more radiation, can only be aimed towards the tumor.
Fractionated stereotactic radiation therapy: In contrast to 1-day radiosurgery, radiation therapy is delivered with stereotactic precision but divided into small daily doses termed fractions and provided over several days or weeks. This method is utilized to treat tumors that are close to sensitive structures such as the optic nerves or brain stem.
Stereotactic radiosurgery: Stereotactic radiosurgery is the application of a single, high dose of radiation to the tumor rather than healthy tissue. It is most effective for tumors that are limited to a single area of the brain and for certain noncancerous tumors. When a person has more than one metastatic brain tumor, it can also be used. Stereotactic radiosurgery equipment comes in a variety of forms, including:
1. A modified linear accelerator is a machine that generates high-energy radiation by forming a stream of fast-moving subatomic particles with electricity.
2. Another type of radiation therapy is Gamma Knife, which concentrates extremely focused beams of gamma radiation on the tumor.
3. A Cyber Knife is a robotic instrument used in radiation therapy to direct radiation to tumors, most notably those in the brain, head, and neck.
Doctors are attempting to be more accurate with these various approaches in order to decrease radiation exposure to the surrounding healthy brain tissue. The radiation oncologist may use any of the above radiation treatments depending on the size and location of the tumor. In some cases, a mix of strategies may be the most effective.
Radiation therapy may cause fatigue, moderate skin responses, hair loss, stomach distress, and neurologic symptoms such as memory impairments in the short term. The majority of negative effects fade quickly after treatment is completed. Furthermore, radiation therapy is usually not suggested for children under the age of five due to the substantial risk of brain damage to their developing brains. Long-term adverse effects of radiation therapy include memory and hormonal difficulties, as well as cognitive (thinking process) alterations such as trouble understanding and doing complex activities.
Chemotherapy
Chemotherapy is the use of medications to eliminate tumor cells, typically by preventing tumor cells from growing, dividing, and proliferating.
A chemotherapy regimen, or schedule, typically consists of a predetermined number of cycles administered over a predetermined time period. A patient may be administered one medicine at a time or a mixture of drugs at the same time. Chemotherapy can be used to remove tumor cells that remain after surgery, to decrease tumor development, or to alleviate symptoms.
As previously stated, chemotherapy for a brain tumor is normally administered after surgery and perhaps with or after radiation therapy, particularly if the tumor has returned following initial treatment.
Some medications are more effective at crossing the blood-brain barrier. These are the medications that are frequently used to treat a brain tumor.
- Gliadel wafers are a method of administering the medication carmustine (BiCNU). These wafers are implanted in the location of the tumor that was excised during surgery.
- The most recent standard of care for persons with glioblastoma and high-grade glioma is radiation therapy combined with daily low-dose temozolomide (Temodar). Following radiation therapy, patients will get monthly temozolomide doses for 6 months to a year.
- Along with radiation therapy, a combination of three medications, lomustine (Gleostine), procarbazine (Matulane), and vincristine (Vincasar), was utilized. When given before or right after radiation therapy, this method has helped extend the lives of patients with grade III oligodendroglioma with a 1p/19q co-deletion. It has also been proven to extend patients’ lives following radiation therapy for a low-grade tumor that could not be entirely removed with surgery. Chemotherapy is being tested in clinical trials to delay radiation therapy for people with low-grade glioma.
While on active treatment, patients are followed with a brain MRI every 2 to 3 months. The duration between MRI scans is then increased based on the tumor’s grade. Patients are frequently subjected to regular MRIs to check their health after therapy is completed and the tumor has not grown. If the tumor expands during treatment, further options for treatment will be investigated.
Chemotherapy side effects vary depending on the individual and the dose used, but they can include exhaustion, infection risk, nausea and vomiting, hair loss, loss of appetite, and diarrhea. These adverse effects normally fade away once the treatment is completed. Certain medicines, on rare occasions, may cause some hearing loss. Others may harm the kidneys. To preserve their kidneys, patients may be given extra fluid via IV.
Targeted therapy
Targeted therapy, in addition to traditional chemotherapy, is another method by which doctors employ drugs to treat cancer. Targeted therapy is a treatment that specifically targets the tumor’s genes, proteins, or the tissue environment that contributes to tumor growth and survival. This sort of treatment inhibits tumor cell growth and spread while limiting damage to healthy cells.
The targets of all cancers are not the same, and some tumors may have more than one target. Your doctor may order tests to determine the genes, proteins, and other variables in your tumor in order to find the most effective treatment. This enables clinicians to provide the most effective treatment to each patient whenever possible. Furthermore, research studies are continuing to learn more about specific molecular targets and new treatments aimed at them. Discover more about the fundamentals of tailored therapy.
There are two forms of targeted therapy that can be utilized to treat a brain tumor:
- Bevacizumab (Avastin, Mvasi) is an anti-angiogenesis medication that is used to treat glioblastoma multiforme after other treatments have failed. Anti-angiogenesis therapy aims to halt angiogenesis, or the process of forming new blood vessels. Because a tumor requires the nutrients given by blood vessels to develop and spread, anti-angiogenesis therapy attempts to “starve” the tumor. Bevacizumab is not recommended by ASCO for persons with newly diagnosed grade IV glioblastoma who do not have an IDH mutation.
- Larotrectinib (Vitrakvi) and entrectinib (Rozlytrek) are examples of targeted therapies that are not specific to a certain type of tumor but instead target a specific genetic alteration known as an NTRK fusion. This type of genetic alteration has been discovered in a variety of malignancies, including certain brain tumors. These medications are approved to treat certain types of brain tumors that have spread or that cannot be removed surgically and have deteriorated despite previous treatment.
In brain cancers with other specific genetic alterations, such as IDH mutations, BRAF mutations, and FGFR fusions, a range of other targeted therapies are being investigated. Discuss with your doctor the potential side effects of a certain medicine and how to manage them.
Alternating electric field therapy (tumor treating fields)
This method of treatment employs a noninvasive portable device that disrupts the sections of the cell required for tumor cells to develop and spread. It is administered by attaching electrodes that generate an electric field to the outside of a person’s head. Optune is the name of the accessible device.
Alternating electrical field therapy may be an option for those who have been diagnosed with glioblastoma for the first time or who have recurrent glioblastoma. Researchers discovered that patients with recurrent glioblastoma who used the gadget outlived those who got chemotherapy. They also have less adverse effects. Other research indicates that when this treatment was taken in conjunction with temozolomide following radiation therapy, patients newly diagnosed with glioblastoma lived longer and were less likely to have the condition progress. This method of treatment is currently regarded a recommended choice for glioblastoma.
TREATMENT BY BRAIN TUMOR TYPE
Oligodendroglioma: ASCO recommends radiation therapy in combination with the chemotherapeutic medicines lomustine (Gleostine), procarbazine (Matulane), and vincristine (Vincasar) for persons with grade II or grade III oligodendroglioma with a 1p/19q co-deletion and an IDH genetic mutation (see “Chemotherapy,” below). Chemoradiation is the simultaneous administration of radiation therapy and chemotherapy. Treatment may not begin for some persons with this sort of grade II tumor until the tumor develops symptoms or imaging tests show that the tumor is developing.
Astrocytoma: ASCO recommends that persons with grade II astrocytoma who have an IDH genetic mutation but no 1p/19q co-deletion get radiation therapy followed by chemotherapy with temozolomide (Temodar) or PCV. Some persons with this grade II tumor may be able to postpone treatment until the tumor creates symptoms or imaging tests show that it is growing. People with grade III astrocytoma who have an IDH genetic mutation and no 1p/19q co-deletion should be treated with radiation followed by temozolomide, or both therapies should be given at the same time. Similarly, persons with grade IV astrocytoma who have an IDH genetic mutation may be given radiation therapy followed by temozolomide, or both therapies at the same time. Some astrocytomas that do not have an IDH mutation may be treated similarly to grade 4 glioblastoma that does not have an IDH mutation.
Glioblastoma: ASCO supports concurrent radiation therapy and temozolomide chemotherapy for most persons with newly diagnosed grade IV glioblastoma or grade II or III astrocytoma with no IDH genetic mutation. Following this medication, 6 months of temozolomide is advised. Alternating electric field therapy (tumor treating fields) may also be indicated for grade IV glioblastoma in the upper region of the brain (see “Alternating electric field therapy (tumor treating fields),” below). If the planned treatment regimen proves too difficult to complete, the doctor may suggest supportive care, hypofractionated radiation therapy, and/or temozolomide.
METASTATIC CANCER
Doctors refer to cancer that has migrated from its original site to another section of the body as metastatic cancer. If this occurs, it is advisable to consult with specialists who have treated similar cases in the past. Different doctors may have differing views on the optimal conventional treatment strategy. Clinical trials are another possibility. Learn more about getting a second opinion before beginning treatment so that you are confident in your treatment plan.
A diagnosis of metastatic cancer can be extremely stressful and traumatic for many people. You and your family are encouraged to express your feelings to doctors, nurses, social workers, and other members of the health care team. Talking with other patients, such as in a support group or other peer support program, may also be beneficial.
Your treatment strategy may involve a combination of surgery, radiation therapy, targeted therapy, and immunotherapy, a type of treatment that boosts the body’s natural defenses to fight the tumor.
BRAIN METASTASES TREATMENT
A brain metastasis, metastatic cancer, or secondary brain tumor occurs when cancer spreads to the brain from another region of the body. Traditionally, brain metastases have been treated with surgery or radiation therapy. Chemotherapy is rarely utilized since the blood-brain barrier prevents many medications from reaching the brain. Chemotherapy was previously used mostly when radiation therapy did not work. Other drugs, like as targeted therapy and immunotherapy, are available for some people. Current treatment options for brain metastases include:
- Surgery: Surgery is usually reserved for individuals who have one or two locations of brain cancer, especially if the tumors are big and producing symptoms. Patients with many locations of cancer in the brain who have a single big lesion generating symptoms may be considered for surgery on occasion. Radiation therapy is usually administered later, although it can sometimes be administered before.
- Radiation therapy: High-dose radiation therapy delivered using stereotactic techniques is preferred for patients with 1 to 4 tumors. Stereotactic radiosurgery directs radiation only at the tumor in the brain, which can reduce adverse effects. Whole-brain radiation therapy is radiation therapy that is administered to the entire brain and may be an option for some patients. If whole-brain radiation therapy is prescribed, your doctor may advise you to avoid exposing the hippocampus to radiation as much as possible, as well as to take a medicine called memantine (Namenda), which can help with cognitive problems.
- Immunotherapy: Some forms of immunotherapy have showed potential in treating lung cancer and melanoma brain metastases. Ipilimumab (Yervoy), nivolumab (Opdivo), and pembrolizumab are examples (Keytruda). Immunotherapy is another sort of medication-based therapy.
- Targeted therapy: Some types of targeted therapy can enter brain tumors and target specific genetic abnormalities in cancer that has spread to the brain from another location. These are some examples:
1. Osimertinib (Tagrisso) or icotinib for metastatic non-small cell lung cancer (NSCLC) with an EGFR gene mutation (icotinib has not been approved by the U.S. FDA).
2. Alectinib (Alecensa), brigatinib (Alunbrig), or ceritinib (Zykadia) for advanced NSCLC with an ALK gene mutation.
3. Tucatinib (Tukysa), trastuzumab (Herceptin), and capecitabine (Xeloda) are potential treatments for HER2-positive metastatic breast cancer.
4. For metastatic melanoma, dabrafenib (Tafinlar) was used with trametinib (Mekinist).
A comprehensive overview of when and how surgery and radiation therapy are utilized to treat brain metastases is provided below:
- Stereotactic radiosurgery is typically used for those with 1 to 3 brain metastases. If the brain metastases are big or producing symptoms due to pressure on the brain, and the patient is otherwise healthy, surgery is often followed with stereotactic radiosurgery.
- Stereotactic radiosurgery or whole brain radiation therapy may be used to treat persons in generally good health who have more than four tumors that cannot be removed surgically or more than two tumors that were removed surgically.
- If the disease outside the brain is not worsening, people who have metastatic cancer in other parts of the body usually continue their treatment program. If the disease worsens, the treatment strategy may be modified in accordance with the recommendations for that form of metastatic cancer.
Treatment of metastasis of the leptomeninges
Leptomeningeal metastases occur when cancer spreads to the meninges or CSF. Patients with leptomeningeal metastases may be given treatment directly into the brain’s CSF. Intrathecal chemotherapy is administered by a lumbar puncture. It can also be delivered through a catheter with a reservoir, known as an Ommaya reservoir. Radiation therapy is another possibility.
Managing Brain Metastases Symptoms and Side Effects
The symptoms of brain metastases vary depending on where the disease has spread in the brain, how much cancer is there, and how quickly it progresses.
The treatment of a person’s symptoms and side effects is an important element of cancer care. Treatment for symptoms can continue even if active treatment to cure or delay the cancer is discontinued. Make an appointment with your doctor if you notice any new or changing symptoms.
The following approaches are recommended by ASCO to assist reduce symptoms of brain metastases:
- Dexamethasone (a generic medication), is a type of drug corticosteroid, which is used to reduce swelling in the brain and help alleviate neurological symptoms produced by the tumor and swelling in healthy brain tissue.
- Anti-seizure drugs are only advised for persons who are experiencing seizures.
