indiacancer.org - Brain Tumor

Brain Tumor

		What is the Brain?
		What are the types of adult Brain tumor?
		How do Brain tumors present?
		How are Brain tumors detected?
		What are staging and grading?
		How are Brain tumors treated?
		What are the side effects of Brain tumor treatment?
		What is the importance of follow up?

What is the Brain?

The Brain is the headquarter for controlling memory and learning, the higher and lower senses and control of the parts of the body including muscles, organs and blood vessels. The higher senses include hearing, sight, smell, taste and touch.

On this particular web page we shall consider only primary Brain tumors and not Brain tumors which have originated from another site and have lodged in the Brain, in other words, secondary Brain tumor.

The Brain is housed in the skull and is surrounded by several layers or membranes covering it, which are known as the meninges and it is also surrounded by a lubricating and nourishing fluid called cerebrospinal fluid.

The Brain is continued inferiorly as the spinal cord.

The Brain and Spinal Cord

What are the types of adult Brain tumor?

The Brain (3-D View)

There are several types of adult Brain tumor and the various types can be classified as follows:

Astrocytomas, which are tumors starting in cells called astrocytes. There are different kinds of astrocytomas, which can be differentiated under the microscope. The various types of astrocytomas are as follows:

Noninfiltrating astrocytomas. These are tumors, that grow slowly and usually these do not grow into the surrounding tissue.

Well differentiated, mildly or moderately anaplastic astrocytomas. These are slow growing but more quickly growing than noninfiltrating astrocytomas. They do invade the surrounding tissues.

Anaplastic astrocytomas, which are cells, that are very different from normal cells, and show a pattern, which is almost fetal (akin to the young and immature cells seen in the fetus) in nature and grow much more rapidly.

Glioblastoma multiforme. These are tumors, which are extremely aggressive and cells which look very fetal in nature are a hallmark of gliobolastoma multiforme. They are like grade IV aggressive astrocytomas.

Brain stem glioma. These are tumors located in the bottom part of the Brain, which is connecting the Brain to the spinal cord. This part of the Brain is also known as the brain stem.

Ependymal tumors. Ependymal tumors begin in the ependyma, which is the lining of the ventricles of the Brain where the cerebrospinal fluid, the protective fluid around the Brain and the spinal cord is made and stored. There are several types of ependymal tumors and again these can be identified by the various cells seen under the microscope.

Well-differentiated ependymoma, which are cells which look pretty normal and grow slightly slowly.

Anaplastic ependymoma, which are cells that do not look like normal cells and show juvenile or fetal patterns and grow much more rapidly than well-differentiated ependymal tumors.

Ependymal blastomas are very rare cancers of the ependymal tissues that usually occur in children and grow extremely rapidly.

Cerebellar astrocytoma, which are astrocytomas occurring in the area of the brain called the cerebellum, which is just above the back of the neck. These are slow-growing tumors and usually do not spread to other parts of the brain or the body.

Oligodendroglial tumors. These are tumors that begin in Brain cells called oligodendrocytes, which are basically supportive and nourishing cells for those cells that carry forth nerve impulses. There are several types of oligodendroglial tumors, which are again defined by the look under the microscope.

Well-differentiated oligodendroglioma, which are slow growing tumors looking much like normal cells.

Anaplastic oligodendroglioma, which are rapidly growing invading cells with a cellular morphology which is almost fetal in nature.

Miscellaneous Brain tumors.

Mixed gliomas. These are tumors that occur in greater than one type of Brain cells and include ependymal cells, olingodendrocytes, and astrocytes.

Medulloblastomas, that begin in the lower part of the Brain and are almost always found in children or young adults. This may pass down from the Brain to the spinal chord.

Pineal parenchymal tumors. tumors are found in this tiny organ located near the center of the Brain, which is called the pineal gland. These tumors can be slow growing in which case they are known as pineocytomas or fast growing in which case they are known as penioblastomas. Astrocytomas can also start from the pineal gland.

Germ cell tumors. These are tumors arising from the sexual cells. There are many kinds of germ cell tumors including germinomas, dysgerminomas, embryonal cell carcinomas, choriocarcinomas, and teratomas.

Craniopharyngioma. These are tumors that occur near the pituitary gland, which is a small gland located just above the nose and controls many of the body's functions by storing many releasing hormones.

Meningioma. These are tumors that occur in the membranes covering the Brain and the spinal chord, which are known as the meninges as mentioned above. These are slow-growing tumors. A version of the meningioma, which is more aggressive, is known as malignant meningioma.

Choroid plexus tumors. These are located in the spaces in the Brain called the ventricles. The choroid plexus normally makes the cerebrospinal fluid that fills the ventricles and surrounds the Brain and spinal cord. tumors arising from the choroid plexus usually grow slowly and are known as choroid plexus papillomas. But they also may grow rapidly in which case they are known as anaplastic choroid plexus papilloma.

Recurrent adult Brain tumors are those in which the cancer has come back or recurred after the patient has undergone primary treatment. It may come back in the Brain or in any other part of the body.

How do Brain tumors present?

	The usual symptoms of brain tumor are as follows:
		Frequent headaches.
		Difficulty in speech.
		Difficulty in walking or abnormal gait.
		Vomiting, often projectile vomiting, which means that the vomit is thrown a great distance. If any or all of these symptoms are seen in a patient then a doctor, preferably a neurologist or a neurosurgeon, should be seen in a hurry.
		There also may be additional symptoms suggestive of an SOL or a space occupying lesion such as weakness along a side or half of the body, weakness of the muscles of the face, or tingling and numbness in certain nerve areas of the body.

How are Brain tumors detected?

The doctor may also order special tests including a CT scan of the brain or an MRI, which uses magnetic waves to make pictures of the Brain using a computer.

Many a times, surgery is the only option to determine if there is a Brain tumor and if there is so, what type of tumor it is. The patient may ultimately require some form of biopsy, which is removal of a piece of tissue, to identify the tumor. However, unlike other tissues, the biopsy of the Brain is extremely difficult and hazardous because there is very little margin for error in this vital region and many a times surgeons prefer to perform an open biopsy in which a formal craniotomy or opening of the skull is performed and the biopsy is taken under direct vision. Once the biopsy is taken, it is sent for review to the histopathologist to identify the type of Brain tumor and also the grade and the stage of the tumor.

Unfortunately enough, Brain tumors are the only peculiar variety of tumors in which benign tumors can prove to be as lethal as malignant tumors. The reason for this is that the Brain is housed in a closed, tight compartment and any SOL or space occupying lesion, whether benign or malignant, can cause life threatening complications just by the simple fact that it causes pressure on adjacent vital structures.

What are staging and grading?

These are terms with which you must become familiar, if you are dealing with any form of cancer.

When we stage a cancer, we try to establish carefully degree of spread of the cancer and if indeed there is spread, to what extent and involving which organs.

The grading of a cancer is a microscopic issue, in which the pathologist lets you know how aggressive this particular type of cancer is; well differentiated means less aggressive, moderately differentiated intermediately aggressive and poorly differentiated more aggressive.

Both grading and staging help your clinician to establish the prognosis or how serious your disease is and what is going to be the likely outcome.

Staging may require additional imaging tests such as CT Scan, MRI, Sonography of the abdomen, Bone scan or chest X-ray.

	How are Brain tumors treated?

	A lot depends on the patient's constitution, the grade of his disease and its staging. Patients are usually treated by a team of specialists which utilizes a multipronged approach. This includes an neurosurgeon, an oncosurgeon and a radiotherapist. The plan of treatment is tailored to fit a patient's requirements. If necessary, chemotherapy may become an add on. Treatment strategies. Surgery is the bastion of treatment for adult Brain tumors. If the doctor is able to successfully take out the cancer from the Brain, then the maximum chances of survival are reached. In order to take out the cancer, the doctor has to perform a procedure called a craniotomy, in which a certain part of the bone from the skull is cut to access the Brain. After the cancer is removed, the bone is either put back or a piece of fabric or metal is used to cover the opening in the skull. The alternative local therapy to surgery is radiation therapy. This involves the use of high energy, penetrative rays to destroy cancer cells. It affects cancer cells only in the zone treated. Radiation therapy is also employed for palliation i.e. control of symptoms alone in an advanced cancer. Radiation therapy can also be used in adjunct to surgery or chemotherapy, either before or after. Teletherapy or external radiation is given via a machine remote from the body while brachytherapy or internal radiation is given by implanting a radioactive source within the involved tissues. Patients may or may not require both modalities of radiation. Radiotherapy, after initial planning, usually takes just 5 to 10 minutes per day, 5 days a week for about 6 weeks. This time period is flexible depending upon the modality of radiation used. Besides local therapy, the best attempt to control cancer cells circulating in the body and lodged at places other than the Brain is by using systemic therapy (therapy which affects the entire systems of the body) which is in the form of injections or oral drugs. This form of treatment is called chemotherapy. This form of treatment is given in a cyclical manner (each set of drugs is repeated usually after every 3-4 weeks). Chemotherapy can also be used in combination with surgery, radiotherapy or both, either before or after. Brain tumor treatment also employs another form of treatment called biological therapy. Biological therapy employs Biological Response Modifiers (BRM's), which are substances that use the body's own immune system, either directly or indirectly, to fight cancer or to lessen the side effects of the anti cancer drugs. Some examples of BRM's are interferon-alfa and interleukin-2. Adult noninfiltrating astrocytoma:
		Surgery.
		Surgery followed by teletherapy.
	Adult well-differentiated, mildly and moderately anaplastic astrocytoma. Treatment may be any one of the following options:
		Surgery followed by teletherapy.
		Surgery alone.
		Surgery followed by radiation therapy and chemotherapy (clinical trials are in progress for this kind of treatment).
	Adult anaplastic astrocytoma. Treatment may be one of the following options:
		Surgery followed by teletherapy.
		Surgery followed by teletherapy plus chemotherapy.
		A clinical trial is on to find out new patterns of radiotherapy such as internal radiation or brachytherapy, radiation during surgery or intraoperative radiotherapy or radiation given with drugs to make the cancer cells more sensitive to radiation. These drugs are called radiosensitisers.
		Chemotherapy or biological therapy following radiation therapy.
		Chemotherapy drugs alone in multimodal combination which are placed in the body during surgery.
	Adult glioblastoma multiforme treatment options:
		Surgery followed by teletherapy and chemotherapy.
		Surgery followed by teletherapy alone.
		New forms of radiation such as brachytherapy or radiation during the surgery or radiosensitizers followed by radiation.
		Chemotherapy or biological therapy after radiotherapy.
		Chemotherapy drugs placed in the body during surgery.
	Adult brainstem glioma treatment options:
		Teletherapy.
		Chemotherapy or biological therapy (clinical trials are in progress).
	Adult well-differentiated ependymoma. Treatment may be one of the following options:
		Surgery to remove the lesion.
		Surgery to remove the lesion followed by teletherapy.
		Chemotherapy or biological therapy.
	Adult malignant ependymoma. Treatment may be one of the following options:
		Surgery to remove the cancer followed by teletherapy.
		Teletherapy plus chemotherapy.
		Chemotherapy or biological therapy.
	Adult well-differentiated oligodendroglioma. Treatment may be one of the following options:
		Surgery to remove the cancer followed by radiotherapy.
		Surgery alone or radiotherapy plus chemotherapy.
	Adult anaplastic oligodendroglioma. Treatment may be one of the followingoptions
		Surgery plus teletherapy.
		Surgery plus teletherapy plus chemotherapy.
		New forms of radiation such as brachytherapy or intraoperative radiation or radiosensitizer drugs followed by radiotherapy.
		Chemotherapy plus biological therapy following radiation therapy.
	Mixed gliomas. Treatment may be one of the following options:
		Surgery followed by teletherapy.
		Surgery followed by teletherapy plus chemotherapy.
		New forms of radiation such as brachytherapy or intraoperative radiotherapy or radiosensitizer drug installation followed by radiotherapy
	Adult medulloblastomas. Treatment may be one of the following options:
		Surgery plus teletherapy.
		Surgery plus teletherapy plus chemotherapy.
	Adult pineal parenchymal tumors. Treatment may be one of the following options
		Surgery plus teletherapy.
		Surgery plus teletherapy plus chemotherapy.
		Internal radiation or intraoperative radiotherapy or radiosensitizer drugs followed by radiotherapy (clinical trials are in progress).
		Chemotherapy or biological therapy following radiation.
	Adult central nervous system germ cell tumor. Treatment greatly depends on whether the cancer can be removed in a single operative sitting, also the type of cells, the location of the tumor and other factors including the general constitution of the patient.
	Adult craniopharyngioma. Treatment may be one of the following options:
		Surgery.
		Surgery followed by radiation.
	Adult meningiomas. Treatment usually consists of surgery. If all cells of tumor cannot be removed during surgery, then the patient may have to go for teletherapy after surgery.
	Adult malignant meningioma. Treatment may be one of the following options:
		External beam radiotherapy following surgery.
		New forms of radiation such as brachytherapy or radiation given during surgery or radiosensitizer drug given before radiation.
	Recurrent adult Brain tumors. Treatment may be one of the following options:
		Surgery.
		Surgery followed by chemotherapy.
		External beam radiation therapy alone if not used during previous treatments with or without chemotherapy.
		Internal radiation.
		Clinical trial of chemotherapy.
	Clinical trial of chemotherapy drugs placed in the body during surgery.

What are the side effects of Brain tumor treatment?

	Unfortunately treatment for cancer does cause damage to the healthy tissues. Please ask the clinician about any possible side effects before any form of treatment commences. The effects of radiation depend upon the dose of radiation, the size of the area radiated, and the number and size of each fraction. The commonest side effect is extreme fatigue. Although bed rest is good, most radiotherapists advise the patient to be as mobile as possible. Another common problem is that of radiation dermatitis in which the skin covering the radiated area becomes red, dry, itchy, and may show signs of scaling off. This will slowly settle down after radiation ceases, but there may be a permanent 'bronzing' of the skin. It is important to note here that this skin problem is associated only with teletherapy or external radiation therapy. Radiation also may cause nausea and vomiting, diarrhea, urinary discomfort. There may also be a fall in the white blood cells, which are needed by humans to fight infection. Usually the radiotherapist can suggest the drugs and diet necessary to alleviate such problems. The various drugs in chemotherapy cause a varied spectrum of side effects. The severity and variability of these symptoms are very individualistic, changing from patient to patient. Some of the common side effects are:
		Skin rashes.
		Loss of hair.
		Diarrhea.
		Vomiting.
		Tingling and numbness in the fingers and toes.
		Hearing loss.
	Most are temporary and recede after therapy is over. Hair growth gradually starts after cessation of chemotherapy. The medical oncologist will usually be able to reduce the severity and spectrum of these side effects. The psychology of the patient is very important during therapy. Better psychologically prepared the patient is, better are his chances of having decreased side effects. The patient should drink large quantities of water while the therapy is in progress, and preferably avoid uncooked or raw food. Water should be filtered or boiled. Any relative or person who has any sort of infection such as common cold should be asked to desist from coming close to the patient. Biological therapy The side effects commonly encountered with this therapy are as follows:
		Low grade fever.
		Rashes and bruises.
		Nausea and vomiting (usually mild).
		All these problems disappear on cessation of therapy.

What is the importance of follow up?

The importance of followup cannot be overemphasized. It is a fatal fallacy to assume on the patient's part that once the primary or the first phase of treatment is over, then he or she is cured. It must be stressed here that cancer has a notorious proclivity of coming back again and again. The only way to fight this is to pick up any problem when it is still early, so that it can be nipped in the bud. And the only way to do this is to follow up when the doctor calls you for the next visit. Each such visit will include a detailed history, a physical examination (including an internal i.e. a rectal or vaginal examination), a chest x-ray, an ultrasonography or a CT scan, and various other blood studies as indicated.