Brain Cancer

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Treatment

Treatment for brain cancer depends on the age of the patient, the stage of the disease, the type and location of the tumor, and whether the cancer is a primary tumor or brain metastases. The treatment plan is developed by the oncology team and the patient.

Treatment involves any combination of surgery, radiation, and chemotherapy. Some tumors require several different surgical procedures, and some can be treated with radiation alone.

Surgery

Surgery is the treatment of choice for accessible primary brain tumors, when the patient is in good health. The goal of surgery is to remove as much of the tumor as possible without damaging nearby normal brain tissue. The prognosis improves when more than 90% of a tumor can be removed.

Removal is often complicated by the nature of the tumor (e.g., invasive, highly vascularized) and by its location. Partial removal (debulking) of the tumor can improve quality of life by alleviating symptoms and sometimes improve the effectiveness of radiation therapy or chemotherapy.

Before surgery, some important tests are performed. Patients over the age of 40 usually undergo an electrocardiogram (ECG or EKG) and a chest x-ray. Other tests are used to detect the presence of uncontrolled hypertension, diabetes, active coronary ischemia, or the presence of circulating anticoagulant (substance that inhibits normal blood clotting) in the blood. If any of these conditions are present, it may not be advisable to undergo craniotomy.

Craniotomy

Craniotomy is the treatment of choice and the goal is to remove as much of the tumor as possible. The procedure is performed under general anesthesia and involves opening the skull (cranium).

The neurosurgeon makes an incision into the scalp and several holes (called burr holes) are made in the skull. A bone saw is used to join the holes together to create a flap of bone.

The bone flap is then removed to expose the brain and remove as much of the tumor as possible. After the tumor has been partially or completely resected, the bone flap is replaced and secured using fine wire. Recovery from the procedure may take as long as 8 weeks.

Complications of craniotomy include bleeding (hemorrhage), swelling (edema), increased intracranial pressure (IICP), infection, and brain tissue damage.

In laser microsurgery, MRI is used to pinpoint the location of the tumor and a laser is used to destroy the tumor. This procedure may be used after craniotomy to remove remaining tumor tissue.

Brain-mapping is performed under local anesthesia and sedation. Electrodes stimulate nerves in the brain, measure responses, and allow communication with the patient. The surgeon removes as much of the tumor as possible without damaging vital areas of the brain, such as those that control motor function and speech.

In some cases, a chemotherapeutic agent called BCNU is used following surgery. In this treatment, the neurosurgeon places a wafer soaked with BCNU (Gliadel®, BiCNU®) into the surgical cavity after the tumor has been removed. By applying it directly to the diseased area of the brain, side effects are limited and the drug has a more beneficial effect.

Postoperative care includes drug therapy with corticosteroids, histamine inhibitors (block stomach acid), and antiepileptics. Corticosteroids (dexamethasone and Decadron®) help reduce swelling and can relieve various postoperative neurological effects.

An MRI scan, with and without contrast, is often obtained to determine the extent of residual disease following surgery. Sometimes, a plan for rehabilitation is needed.

External-beam radiation
External-beam radiation, the traditional form of radiation therapy, delivers radiation from outside the body. Therapy usually begins a couple of weeks after surgery and is typically repeated at regular intervals for several weeks.

Hyperfractionation is a modified form of external-beam radiation that involves applying less intense but more frequent doses of radiation. Some benign tumors are treated with external-beam radiation to prevent recurrence, even if the entire primary tumor has been surgically removed. They also may be treated with radiation at the time of recurrence.

Stereotactic radiosurgery
Stereotactic radiosurgery delivers radiation to the tumor in a single dose and does not involve surgery, as the term may imply. In this procedure, a head frame supporting a CT or MRI scanner may be attached to the skull. With the aid of computer imaging, the radiologist is able to pinpoint the exact location of the tumor and aim the beam of radiation directly at it.

Some tumors, however, cannot be treated with the intense local radiation of radiosurgery. For example, tumors near the optic nerves are better treated with several small doses, because the optic nerves are especially sensitive to radiation. These tumors may be treated using stereotactic radiotherapy. Stereotactic radiotherapy involves applying many small doses of radiation, using the same imaging techniques used in stereotactic radiosurgery.

Newer stereotactic techniques usually do not involve the use of the head frame. Radiation often is delivered from several different directions, hitting the tumor at various angles. The advantage of using localized radiation is that the surrounding, healthy tissue is left undestroyed. This treatment may be used in addition to external-beam radiation, especially in cases of malignant gliomas and mestastases that are in deep or sensitive areas of the brain. Types of machines that are used to perform stereotactic radiosurgery include the Gamma knife® and modified linear accelerators (LINAC; e.g., CyberKnife®).

The Gamma knife uses ioninzing beams of radiation (called gamma rays) that are sent from different angles and come together at a single point on the tumor. Each beam is low dosage; however, when they converge, the intensity and destructive power is high. This treatment is used to treat small tumors.

Linear accelerators (e.g., CyberKnife®) involve using small doses of radiation over multiple sessions (called fractionated stereotactic radiotherapy). In this treatment, which allows larger tumors to be treated, the patient is positioned on a bed that can be moved, providing flexible positioning. Linear accelerators produce positively-charged atoms (called protons) in patterns that are matched to the size and shape of the tumor and used to destroy cancer cells.

Brachytherapy
Brachytherapy involves implanting capsules containing radioactive substances into the tumor to deliver localized radiation. It is frequently applied to treat recurrent disease in an area previously treated by external-beam radiation.

Advantages of this type of radiation therapy include sparing vital structures close to the tumor and a shorter length of treatment (i.e., hours to days instead of weeks).

Radiation follow-up

Because loss of pituitary function can be a long-term side effect of radiation therapy, an endocrine evaluation is an important part of follow-up care for patients who have received radiation. Neuropsychological testing may also be done to evaluate whether a patient has incurred diminished intellectual activity resulting from brain tumor radiation.

Brain Cancer, Treatment reprinted with permission from oncologychannel.com
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