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Treatment of brain tumours

Brain arteriovenous malformation before (left panel) after (right panel) gamma knife radiosurgery showing obliteration.
Brain arteriovenous malformation before (left panel) after (right panel) gamma knife radiosurgery showing obliteration.
 

Glioma

The treatment of gliomas is common to all three subtypes and depends more on grade than whether the disease is an astrocytoma, ependymoma or oligodendroglioma.

 

The first and best therapy is a surgical debulking of as much tumour as possible, without causing irrevocable neurological damage.

 

The problem of normal and critical surrounding functioning brain is the reason that, complete resection of gliomas is impossible. Before taking the patient to theatre the surgeon may well wish the patient to have an initial period on potent steroid therapy. This serves to reduce the oedema (‘water-logging’) that surrounds every glioma (more so in higher grade tumours) and renders the patient in better neurological condition to undergo operation. The patient must be off any form of blood thinning therapy such as aspirin or anticoagulants.

 

The extent of glioma surgery will depend on the situation of the growth. For example, in the non-dominant frontal lobe (the right frontal lobe in right handed people), it is often safe to perform a major debulking operation, whereas in the middle of the dominant hemisphere such a radical debulking procedure could render the patient paralysed down his dominant right side and to the loss of speech (aphasia). The surgeon aims to remove as much of the tumour as he safely can without major risks to the patient's recovery to status quo ante.

 

Following surgery the need for other therapy is discussed. In most gliomas this is a routine course of post-operative radiotherapy carefully delivered in small daily doses (as this is the kindest way to deliver radiation to high dose without harming the normal nervous system) over a period of six weeks. High grade gliomas are also treated with chemotherapy nowadays, usually by employing the orally active tablet temozolomide chemotherapy (for other chemotherapy, see further down this page).

 

At relapse, further surgical debulking has a selected place for patients with relatively superficially situated tumours that are causing pressure and in patients who are in good enough shape to withstand further surgery. At the time of such an operation, the surgeon may place some chemotherapy infiltrated wafers (Gliadel wafers) in the surgical cavity, specifically against the cavity walls. Subsequent chemotherapy is more complex and the drugs include BCNU/CCNU (carmustine/lomustine), irinotecan and bevacizumab (avastin).

 

Occasionally, low grade gliomas may be watched for a time before radiation therapy is recommended: at the time when the scan shows progression. Chemotherapy is not routinely recommended for low grade gliomas at first presentation but may have a role if later relapse occurs.

  

Brain scan showing acoustic neuroma before (left panel) and after (right panel) showing good response to gamma knife radiosurgery.
Brain scan showing acoustic neuroma before (left panel) and after (right panel) showing good response to gamma knife radiosurgery.
The outlook (prognosis) in gliomas is predictable to some extent. Younger patient in good clinical condition (i.e. no severe neurological damage due to the tumour) and lower grade tumours do well; conversely elderly patients presenting with high grade tumours and marked neurological deficit due to their disease do badly. Indeed, most grade 4 (glioblastoma multiforme) patients are dead by two years.

 

In younger patients of all grades, the effects of radiotherapy are more pronounced and there is a definite group of grade 3 patients who are long term survivors and an increasing proportion of the low grade patients.

 

In older patients, with higher grade tumours the decision for post-operative radiotherapy is taken in conjunction with the patient/family. Following radiotherapy, the patients lose some/a lot of hair and feel tired towards the end of the course.

 

Metastases to brain

Occasionally the surgeon will have a radical attempt to resect a known single brain metastasis, but will not risk much neurological damage to do so, as radiation therapy can take over where the surgery has stopped.

 

Nevertheless, where the patient is in good clinical condition (i.e. not about to succumb to cancer progression in the rest of the body) then the results of surgical removal of an ostensibly isolated brain metastasis followed by brain radiotherapy are better than radiotherapy alone. Stereotactic radiation boost *(e.g. by gamma knife) may be used if a metastasis survives the broad field radiotherapy and the patient's general condition remains otherwise good.

 

For the more usual situation of multiple metastases to the brain, then wide field brain radiotherapy is recommended and stands a reasonable chance of durable control of the brain - other methods such as focal stereotactic radiosurgery* being reserved for later relapses in one or two sites and only in patients in otherwise good condition.

 

 

Meningioma and pituitary tumour

Surgery is the therapy of choice for meningiomas and for pituitary tumours (the surgical access to the latter being often via the nasal cavity (the trans-sphenoidal route) with the intention of cure. However, once again here too the operation, particularly for deep seated and small tumours is often being replaced by the non-invasive focal radiation* methods such as the gamma knife (not a knife at all but a form of non-invasive focal radiation therapy).

 

Craniopharyngiooma

Similarly surgery is the first therapy for craniopharyngiomas but cure without post-operative radiotherapy is less readily achieved.

 

Acoustic neuroma

Surgery used to be recommended for acoustic neuromas with the intention of complete removal and cure, but in recent years the surgery has largely been replaced by focal stereotactic radiation therapy* (technique such as the gamma knife). Such focal radiation therapy has the ability to focus a high dose of radiation on the tumour, usually resulting in cessation of any further growth and sparing hearing, without the risks of surgery. Only where the tumour is very large do we now contemplate surgery.

 

Stereotactic radiation therapy/ radiosurgery*:

*In stereotactic focal radiation therapy/radiosurgery, the patient is immobilised in a frame which encircles the head as does an equator encircle the globe (the head in this case). The patient then has a scan and this allows three dimensional co-ordinates, longitudes and latitudes continuing the former analogy or x, y, z co-ordinates in stereotactic language, to be obtained and for the x or gamma ray beams to then be concentrated on the growth.

 

Such is the concentration of dose on the target region and the speed of dose ‘fall-off’ at the edge of the targeted tumour that it is possible to deliver obliteratively high single radiation doses to the tumour without over-irradiating the surrounding normal brain. The technique of stereotactic radiation therapy is becoming an increasingly important tool in the neuro-oncologist’s armamentarium.

  

Chemotherapy

Chemotherapy has a limited place in the treatment of most brain tumours. Following surgical debulking and radiotherapy, the two most powerful therapies have been given and the addition of chemotherapy may help somewhat but it is not as strong as radiotherapy.

 

Temozolomide has been shown to be active in high grade gliomas.

 

Irinotecan and bevacizumab/avastin is a couple of drugs showing promise, and are offered to some patients in relapse after first therapy.

 

Other drugs that are active against gliomas are: nitrosoureas (BCNU, CCNU and Methyl-CCNU), procarbazine and vincristine.


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