Brain tumour
A guide for patients and carers
Treatment of brain tumours
i) Surgery to remove the tumour
ii) Radiotherapy
iii) Chemotherapy
ii) Radiotherapy
iii) Chemotherapy
What sort of surgery is involved?
Surgery may be performed for two different reasons:
i) To make a diagnosis
ii) As a treatment
Pre-operative preparation
The scans may be repeated for technical reasons to do with planning surgery. Occasionally an angiogram is performed to show the blood supplies of the suspected tumour. This involves injecting dye through a catheter which is placed into the groin and fed up to the arteries in the neck. You have to be admitted to hospital to have this test and you may need to stay overnight.
Biopsy
This is where a small sample of the tumour is taken and sent for pathological analysis. It is an operation aimed at providing a diagnosis rather than treatment, although in some cases a larger amount of the tumour can be removed and this is one way in which some tumours can be treated. A preliminary diagnosis is often made during the surgery, though it may not be confirmed for several days.
Usually the procedure is carried out through a burr hole.This is an opening in the skull the size of a small coin. A needle is passed through this hole to the tumour.A sample of the tumour is then taken via the needle. The needle is frequently guided to the target with the use of a scan and a special frame which is placed on the head. This is known as a stereotactic biopsy. Recent advances allow this to be done without the frame in some cases, in which case it is known as frameless stereotaxis or image-guided surgery.
These biopsies are usually carried out under a general anaesthetic, but are sometimes done under a local anaesthetic.
Inevitably, as with any surgical procedure, there are risks. There is a risk that the symptoms may be worse after the biopsy or it may cause seizures. Your neurosurgeon will explain the risks to you. The risks are generally small.
Surgical treatment for the tumour
The aim here is to remove the tumour entirely, without damage to the surrounding brain tissue. Whilst this is often possible for benign tumours, it is rarely possible for malignant tumours as these invade the surrounding normal brain tissue, which must be left behind if serious disability is to be avoided. In these cases as much tumour as is judged safe is taken away.
Under anaesthetic, after shaving an area of the scalp, a cut is made to expose the bone of the skull. A piece of bone (bone flap) is cut out like a trapdoor to reveal the brain and the tumour. This process is called a craniotomy.
The surgeon then removes as much as possible of the tumour and sends part of it to the pathologist to establish what sort of tumour it is. The operation therefore serves two functions - first to obtain material to establish what kind of tumour is involved (i.e. a biopsy), and second to provide treatment by removing as much tumour tissue as is safe.
The risks are the same as those associated with a biopsy, but they are slightly greater as it is a bigger procedure.
Sometimes other surgical procedures are required. These may include the insertion of devices to drain the fluid from within the brain (a shunt) or to remove fluid from within the tumour cyst. Again, you will need to discuss these with your surgeon.
Radiotherapy
Radiotherapy is often used following surgery, most commonly for the treatment of malignant tumours, though occasionally it is also used to treat benign tumours.
This treatment is given by a radiotherapist who will also be an oncologist (expert in cancer). It is likely that your radiation oncologist will have a specific interest in tumours of the nervous system and will work closely with the neurosurgeon involved in your treatment. They will explain your radiotherapy, and if appropriate, your chemotherapy treatment to you, and talk through any anxieties you may have. Radiotherapy will not always be available at the hospital where you have had your surgery, but there is always a close link with a hospital that gives this treatment.
Radiotherapy uses x-rays or gamma rays to damage or destroy the tumour. The effect on the tumour is to slow its growth and lengthen the time before re-growth. In some circumstances, it may cure the tumour. The treatment is painless and involves lying on a specially designed table for a few minutes.
A typical pattern is to receive between four and six weeks of daily radiotherapy, possibly as an outpatient.
Common side effects are a temporary worsening of the neurological complaints and inflammation of the skin, which may lead to temporary hair loss. The hair grows back over the following months, although it may well not be as strong as before. Until adequate covering of hair has grown back strong sunlight should be avoided or a hat should be worn. Occasionally the hair loss is permanent, but this is unusual.
Most people feel tired towards the end of their course of treatment. The level of tiredness varies and may depend on the area of the brain being treated. Some people may manage all their normal activities with only mild tiredness. Others may experience quite severe problems. It is important that people don’t expect too much of themselves during this period and don’t get frustrated by their tiredness.
Occasionally, radiotherapy may be administered by needles implanted into the tumour. This is an uncommon treatment appropriate to only a small number of cases.Your consultant will discuss this treatment with you, should it be felt to be useful in your case.
Radiosurgery
Radiosurgery is a technique for treating brain tumours that is available in the UK in only a few specialised neurological centres.
The two main methods of carrying out radiosurgery are by gamma knife and by modified linear accelerator (linac). Both of these procedures use a high energy dose of radiation that can be focused on a very precise point within the brain.
The linac uses only one beam of high energy radiation which arcs around a single point treating that specific area but not the surrounding tissue. The gamma knife uses 201 energy sources that combine to form a high energy point at their focus, each source being too weak to damage the healthy brain tissue in the path or surrounding areas.
Radiotherapy may require a number of visits over weeks or months; however, radiosurgery is completed in one visit and usually does not require an overnight stay. People are able to return to their normal routine immediately following treatment without some of the side effects of radiotherapy or open surgery.
This approach may be suited to deep-seated tumours within the brain that may be difficult to reach by other methods without causing damage to the surrounding healthy brain tissue.
Not all conditions are suitable for treatment by radiosurgery and the best individual course of action should be discussed with your doctor.
Chemotherapy
Chemotherapy is the use of drugs to destroy tumour cells, in the same way that antibiotics kill bacteria. This treatment has mainly been of use in the treatment of malignant brain tumours in children. It is not used in all cases, but is often a powerful and helpful treatment. Quite often adults also receive chemotherapy at some point.
There are many different types of chemotherapy. Some are taken by mouth, but others are given via a drip into the veins. Chemotherapy is usually given by the radiation oncologist, who has expertise in both radiation and chemotherapy. In the case of children it may be given by a paediatric oncologist, sometimes together with a radiotherapist. The consultant in charge of giving this treatment will be happy to discuss it with you if you are referred to them for treatment by your neurosurgeon.
Side effects
Side effects caused by chemotherapy vary considerably depending on the drug used. Possible side effects are nausea, tiredness, hair loss and increased susceptibility to infection, and you should discuss these with the specialist providing the treatment. Some of the more recent drugs such as temozolomide produce lower levels of side effects and are often very well tolerated.
Research
Surgery and radiotherapy remain the main treatments for brain tumours, with chemotherapy usually being given at a later stage. However, their success is limited with several types of tumour, and there is a constant search for new treatments.
It is entirely normal to be concerned about the outcome of your treatment, and your medical team will always be ready to discuss this with you and tell you about some of the newer, more experimental treatments, and whether they may be worth considering in your case. It is important to realise that none of these can offer a miracle cure, but they may have something to offer in some cases.
Some people may be asked to take part in a trial. These trials are used to assess the effectiveness of different forms of treatment. If you are asked to enter a trial your medical team will explain what is involved, but don’t be afraid to ask any questions you may have. Saying no to participating in a trial will not affect your treatment in any way.
Steroids
Steroids are used to reduce the swelling around the tumour. This helps to relieve headaches and the amount of disability that a tumour may cause i.e. weakness or numbness. It also makes any surgery much safer and easier. Dexamethasone is the most commonly used steroid drug (the brand name may be Decadron, Maxidex or Oradexon).
Side effects of steroids
These occur after several weeks of treatment and may include weight gain, acne, stretch marks, muscle weakness, diabetes, sleep disturbance, elation and hunger. These tend to go once the steroids are stopped. Steroid tablets irritate the lining of the stomach and increase the likelihood of getting ulcers. The risk of this may be reduced by giving anti-ulcer drugs. An antacid preparation, either in liquid or tablet form, may also be prescribed.
Anti-convulsants
This is the name for drugs used to control epileptic seizures or fits. As well as being used for people who have seizures they are sometimes given to help prevent them in someone who is about to undergo surgery.
There are many different types of anti-convulsants. Among the most common are tablets such as phenytoin, sodium valproate and carbamazepine. These are the names given to the compounds, but the name on the packet may be that given to it by the manufacturer e.g. Epanutin, Epilim and Tegretol. Free prescriptions are available for anti-convulsants.
Analgesics
These are pain killers and are used mainly to control headaches. They may be combined with drugs (anti-emetics) to control sickness. Many different types of pain killer may be used and your doctors will try to determine the most effective one for you.
Physiotherapy, Speech and Occupational Therapy
Your tumour may have left you with some physical or mental problems. The aim of these therapies is to minimise the effects of the condition and its treatment and to maximise the speed and extent of your recovery. Although progress and recovery are not always guaranteed, it is often possible to improve the quality of life and gain relief from some of the symptoms of the condition.
Complementary treatments
There is still a great deal that is not known about tumours, and you may find that complementary therapies such as aromatherapy or reflexology can help you. Most doctors would only recommend that these are used alongside established treatments, rather than as a substitute for them.
Would earlier diagnosis have made a difference?
Modern scanners are sufficiently sensitive that changes can sometimes be seen on scans before they cause any trouble to the patient, or before they are detectable when people are examined by their doctor. However, in practice, people are unlikely to consult a doctor at this early stage. Delays in the diagnosis can prove harmful – for example, parts of the brain which lie next to the tumour could be compressed and permanently damaged. It is therefore desirable that if a brain tumour is suspected, the process of investigation and treatment is prompt, not least for everyone’s peace of mind. However, whilst this means not waiting for months, it does not mean everything must be done on the same day. It would be true to say that many tumours do get diagnosed late as the first symptoms are often rather vague or don’t specifically suggest a serious problem (eg, headaches). At the same time, significant delays occasionally occur.
What will happen if the tumour comes back?
If the tumour were to recur, the symptoms would most likely be the same as those you experienced first time round. The pattern is sometimes identical. You will have another scan, which will either show that the tumour has gone, stayed the same size or grown. In some cases, even if the tumour has grown, there may be a perfectly adequate treatment to stop any further growth. In malignant tumours, even if there is no growth or signs of recurrence, great caution should be used in interpreting the results. It may well be that the scans look favourable for a long time, but then the lesion returns. Obviously it depends entirely upon the particular type of tumour and you should discuss this with your doctor.
The treatment options available for a recurring tumour are essentially the same as those for the initial tumour: surgery, radiotherapy and chemotherapy. It will depend entirely upon the nature of the recurrence as to which is the most appropriate.
Surgery may be performed for two different reasons:
i) To make a diagnosis
ii) As a treatment
Pre-operative preparation
The scans may be repeated for technical reasons to do with planning surgery. Occasionally an angiogram is performed to show the blood supplies of the suspected tumour. This involves injecting dye through a catheter which is placed into the groin and fed up to the arteries in the neck. You have to be admitted to hospital to have this test and you may need to stay overnight.
Biopsy
This is where a small sample of the tumour is taken and sent for pathological analysis. It is an operation aimed at providing a diagnosis rather than treatment, although in some cases a larger amount of the tumour can be removed and this is one way in which some tumours can be treated. A preliminary diagnosis is often made during the surgery, though it may not be confirmed for several days.
Usually the procedure is carried out through a burr hole.This is an opening in the skull the size of a small coin. A needle is passed through this hole to the tumour.A sample of the tumour is then taken via the needle. The needle is frequently guided to the target with the use of a scan and a special frame which is placed on the head. This is known as a stereotactic biopsy. Recent advances allow this to be done without the frame in some cases, in which case it is known as frameless stereotaxis or image-guided surgery.
These biopsies are usually carried out under a general anaesthetic, but are sometimes done under a local anaesthetic.
Inevitably, as with any surgical procedure, there are risks. There is a risk that the symptoms may be worse after the biopsy or it may cause seizures. Your neurosurgeon will explain the risks to you. The risks are generally small.
Surgical treatment for the tumour
The aim here is to remove the tumour entirely, without damage to the surrounding brain tissue. Whilst this is often possible for benign tumours, it is rarely possible for malignant tumours as these invade the surrounding normal brain tissue, which must be left behind if serious disability is to be avoided. In these cases as much tumour as is judged safe is taken away.
Under anaesthetic, after shaving an area of the scalp, a cut is made to expose the bone of the skull. A piece of bone (bone flap) is cut out like a trapdoor to reveal the brain and the tumour. This process is called a craniotomy.
The surgeon then removes as much as possible of the tumour and sends part of it to the pathologist to establish what sort of tumour it is. The operation therefore serves two functions - first to obtain material to establish what kind of tumour is involved (i.e. a biopsy), and second to provide treatment by removing as much tumour tissue as is safe.
The risks are the same as those associated with a biopsy, but they are slightly greater as it is a bigger procedure.
Sometimes other surgical procedures are required. These may include the insertion of devices to drain the fluid from within the brain (a shunt) or to remove fluid from within the tumour cyst. Again, you will need to discuss these with your surgeon.
Radiotherapy
Radiotherapy is often used following surgery, most commonly for the treatment of malignant tumours, though occasionally it is also used to treat benign tumours.
This treatment is given by a radiotherapist who will also be an oncologist (expert in cancer). It is likely that your radiation oncologist will have a specific interest in tumours of the nervous system and will work closely with the neurosurgeon involved in your treatment. They will explain your radiotherapy, and if appropriate, your chemotherapy treatment to you, and talk through any anxieties you may have. Radiotherapy will not always be available at the hospital where you have had your surgery, but there is always a close link with a hospital that gives this treatment.
Radiotherapy uses x-rays or gamma rays to damage or destroy the tumour. The effect on the tumour is to slow its growth and lengthen the time before re-growth. In some circumstances, it may cure the tumour. The treatment is painless and involves lying on a specially designed table for a few minutes.
A typical pattern is to receive between four and six weeks of daily radiotherapy, possibly as an outpatient.
Common side effects are a temporary worsening of the neurological complaints and inflammation of the skin, which may lead to temporary hair loss. The hair grows back over the following months, although it may well not be as strong as before. Until adequate covering of hair has grown back strong sunlight should be avoided or a hat should be worn. Occasionally the hair loss is permanent, but this is unusual.
Most people feel tired towards the end of their course of treatment. The level of tiredness varies and may depend on the area of the brain being treated. Some people may manage all their normal activities with only mild tiredness. Others may experience quite severe problems. It is important that people don’t expect too much of themselves during this period and don’t get frustrated by their tiredness.
Occasionally, radiotherapy may be administered by needles implanted into the tumour. This is an uncommon treatment appropriate to only a small number of cases.Your consultant will discuss this treatment with you, should it be felt to be useful in your case.
Radiosurgery
Radiosurgery is a technique for treating brain tumours that is available in the UK in only a few specialised neurological centres.
The two main methods of carrying out radiosurgery are by gamma knife and by modified linear accelerator (linac). Both of these procedures use a high energy dose of radiation that can be focused on a very precise point within the brain.
The linac uses only one beam of high energy radiation which arcs around a single point treating that specific area but not the surrounding tissue. The gamma knife uses 201 energy sources that combine to form a high energy point at their focus, each source being too weak to damage the healthy brain tissue in the path or surrounding areas.
Radiotherapy may require a number of visits over weeks or months; however, radiosurgery is completed in one visit and usually does not require an overnight stay. People are able to return to their normal routine immediately following treatment without some of the side effects of radiotherapy or open surgery.
This approach may be suited to deep-seated tumours within the brain that may be difficult to reach by other methods without causing damage to the surrounding healthy brain tissue.
Not all conditions are suitable for treatment by radiosurgery and the best individual course of action should be discussed with your doctor.
Chemotherapy
Chemotherapy is the use of drugs to destroy tumour cells, in the same way that antibiotics kill bacteria. This treatment has mainly been of use in the treatment of malignant brain tumours in children. It is not used in all cases, but is often a powerful and helpful treatment. Quite often adults also receive chemotherapy at some point.
There are many different types of chemotherapy. Some are taken by mouth, but others are given via a drip into the veins. Chemotherapy is usually given by the radiation oncologist, who has expertise in both radiation and chemotherapy. In the case of children it may be given by a paediatric oncologist, sometimes together with a radiotherapist. The consultant in charge of giving this treatment will be happy to discuss it with you if you are referred to them for treatment by your neurosurgeon.
Side effects
Side effects caused by chemotherapy vary considerably depending on the drug used. Possible side effects are nausea, tiredness, hair loss and increased susceptibility to infection, and you should discuss these with the specialist providing the treatment. Some of the more recent drugs such as temozolomide produce lower levels of side effects and are often very well tolerated.
Research
Surgery and radiotherapy remain the main treatments for brain tumours, with chemotherapy usually being given at a later stage. However, their success is limited with several types of tumour, and there is a constant search for new treatments.
It is entirely normal to be concerned about the outcome of your treatment, and your medical team will always be ready to discuss this with you and tell you about some of the newer, more experimental treatments, and whether they may be worth considering in your case. It is important to realise that none of these can offer a miracle cure, but they may have something to offer in some cases.
Some people may be asked to take part in a trial. These trials are used to assess the effectiveness of different forms of treatment. If you are asked to enter a trial your medical team will explain what is involved, but don’t be afraid to ask any questions you may have. Saying no to participating in a trial will not affect your treatment in any way.
Steroids
Steroids are used to reduce the swelling around the tumour. This helps to relieve headaches and the amount of disability that a tumour may cause i.e. weakness or numbness. It also makes any surgery much safer and easier. Dexamethasone is the most commonly used steroid drug (the brand name may be Decadron, Maxidex or Oradexon).
Side effects of steroids
These occur after several weeks of treatment and may include weight gain, acne, stretch marks, muscle weakness, diabetes, sleep disturbance, elation and hunger. These tend to go once the steroids are stopped. Steroid tablets irritate the lining of the stomach and increase the likelihood of getting ulcers. The risk of this may be reduced by giving anti-ulcer drugs. An antacid preparation, either in liquid or tablet form, may also be prescribed.
Anti-convulsants
This is the name for drugs used to control epileptic seizures or fits. As well as being used for people who have seizures they are sometimes given to help prevent them in someone who is about to undergo surgery.
There are many different types of anti-convulsants. Among the most common are tablets such as phenytoin, sodium valproate and carbamazepine. These are the names given to the compounds, but the name on the packet may be that given to it by the manufacturer e.g. Epanutin, Epilim and Tegretol. Free prescriptions are available for anti-convulsants.
Analgesics
These are pain killers and are used mainly to control headaches. They may be combined with drugs (anti-emetics) to control sickness. Many different types of pain killer may be used and your doctors will try to determine the most effective one for you.
Physiotherapy, Speech and Occupational Therapy
Your tumour may have left you with some physical or mental problems. The aim of these therapies is to minimise the effects of the condition and its treatment and to maximise the speed and extent of your recovery. Although progress and recovery are not always guaranteed, it is often possible to improve the quality of life and gain relief from some of the symptoms of the condition.
Complementary treatments
There is still a great deal that is not known about tumours, and you may find that complementary therapies such as aromatherapy or reflexology can help you. Most doctors would only recommend that these are used alongside established treatments, rather than as a substitute for them.
Would earlier diagnosis have made a difference?
Modern scanners are sufficiently sensitive that changes can sometimes be seen on scans before they cause any trouble to the patient, or before they are detectable when people are examined by their doctor. However, in practice, people are unlikely to consult a doctor at this early stage. Delays in the diagnosis can prove harmful – for example, parts of the brain which lie next to the tumour could be compressed and permanently damaged. It is therefore desirable that if a brain tumour is suspected, the process of investigation and treatment is prompt, not least for everyone’s peace of mind. However, whilst this means not waiting for months, it does not mean everything must be done on the same day. It would be true to say that many tumours do get diagnosed late as the first symptoms are often rather vague or don’t specifically suggest a serious problem (eg, headaches). At the same time, significant delays occasionally occur.
What will happen if the tumour comes back?
If the tumour were to recur, the symptoms would most likely be the same as those you experienced first time round. The pattern is sometimes identical. You will have another scan, which will either show that the tumour has gone, stayed the same size or grown. In some cases, even if the tumour has grown, there may be a perfectly adequate treatment to stop any further growth. In malignant tumours, even if there is no growth or signs of recurrence, great caution should be used in interpreting the results. It may well be that the scans look favourable for a long time, but then the lesion returns. Obviously it depends entirely upon the particular type of tumour and you should discuss this with your doctor.
The treatment options available for a recurring tumour are essentially the same as those for the initial tumour: surgery, radiotherapy and chemotherapy. It will depend entirely upon the nature of the recurrence as to which is the most appropriate.
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