Treatment for brain & spinal cord tumours

Thursday 1 May, 2014

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On this page: | Surgery | Radiotherapy | Stereotactic radiosurgery | Chemotherapy | Steroids | Seizures | Palliative treatment | Key points


The main treatments for brain or spinal cord tumours are surgery, radiotherapy and chemotherapy. These treatments may be used alone or in combination. Medication, such as steroids or anticonvulsants (anti-seizure medication), may also be given to reduce symptoms. Treatment offered to children is similar to adults.

There also may be new and experimental treatments, or improvements in existing treatments. These are given in clinical trials.

The aim of treatment, where possible, is to remove the tumour, slow its growth, or relieve symptoms by shrinking the tumour and swelling. Treatment cannot begin until the diagnosis is confirmed.

Your choice of treatment will depend on:

  • the type, size and location of the tumour
  • your age, medical history and general state of health
  • the types of symptoms and side effects you have. 

Surgery

Surgery in the central and peripheral nervous system is called neurosurgery. In many cases, removing all or part of the tumour may allow you to lead an active life for some time. However, you may also have other treatments.

Some tumours can be removed by neurosurgery. This type of operation is called a gross total resection. In other cases, the surgeon may only be able to remove part of the tumour. This is called a partial resection or debulking. Partial removal may be because the tumour is widespread, near major blood vessels, or cannot be removed without damaging other important parts of the brain or spinal cord. A partial resection may improve your symptoms by reducing the pressure on your brain.

Sometimes a tumour cannot be removed because it is too close to certain parts of the brain and would cause serious problems. This is called an inoperable or unresectable tumour. Your doctor will talk to you about other ways to try to ease the symptoms.

"My husband’s doctor said the tumour was inoperable. We decided to get a second opinion from another neurosurgeon to see if they agreed." – Judith 
Preparing for surgery

The types of scans used for diagnosing the tumour (e.g. CT, MRI or MRS scans) are often done again to plan surgery by precisely pinpointing the location of the tumour.

You may also have what is called a ‘functional MRI scan’ to help the doctors work out which areas of your brain control speech and movement. Brain mapping is another way to find these parts of the brain. A tiny electrode is placed on the outside layer of the brain and stimulated with a low dose of electrical current.

Identifying the brain’s sensitive areas can help the surgeon avoid causing damage during the operation.

One week before surgery, ask your doctor about what medication to take. Some medications interfere with the anaesthetic used during the operation, so you should temporarily stop taking them. You may also be advised to stop smoking before surgery. 

Surgery for a brain tumour

The surgeon will remove as much of the tumour as possible without damaging healthy parts of your brain. Surgery may be done as open surgery (a relatively large opening made in the skull) or a stereotactic biopsy (see below).

Biopsy

A small sample of tumour is removed using a needle and examined under a microscope. A biopsy can also be done at the same time as a craniotomy.

Craniotomy

The most common type of brain tumour operation. Some hair is shaved off and you are given a general anaesthetic. The surgeon cuts through the scalp and moves it aside, then removes a piece of skull above the tumour. The bone and scalp are put back once the tumour is taken out.

Awake craniotomy

This operation is done if the tumour is near parts of the brain that control speech or movement. All or part of the operation is done with the patient awake (conscious) but relaxed, so they can speak, move and respond. This is not painful because the brain itself does not feel pain, and local anaesthetic is used to numb surrounding tissues. During the operation, the surgeon asks the patient to speak or move parts of the body so they can identify and avoid certain parts of the brain. An electrode is also used to stimulate the brain with a small electrical current to identify the important areas.

Endoscopic transnasal brain surgery

This rarer type of surgery is used for tumours near the base of the brain (e.g. a pituitary gland tumour). The surgeon puts a long tube (endoscope) into the nose, then removes all or part of the tumour through the nostrils. This type of surgery may have a faster recovery time than a craniotomy.

Craniectomy

This is similar to a craniotomy, except the piece of skull removed is not replaced because the brain may swell. Bone (or a piece of plastic or mesh) may be replaced in the future when it won’t cause extra pressure. This procedure is very uncommon.

Stereotactic surgery

This is when surgery is done using a computer to guide the surgeon. The computer creates 3D images of the brain and tumour and monitors the surgical instruments during the operation, allowing the surgeon to operate precisely.

Stereotactic surgery may require the surgeon to use small markers called fiducial markers. These are taped or glued to the scalp before a scan. Less commonly, a lightweight frame is screwed to the scalp. The scan shows the brain and tumour in relation to the markers or frame.

Stereotactic surgery is safer, more accurate and requires a smaller cut in the skull than non-computer guided surgery. 

Surgery for a spinal cord tumour

The main surgery for a spinal cord tumour is called a laminectomy. In this procedure, the surgeon makes an opening through the skin, muscle and a vertebra in the spinal column to remove the tumour that is affecting the spinal cord. Afterwards, the removed part of the vertebra may be replaced. You will be given a general anaesthetic for this operation.

After your brain or spinal cord operation
  • For the first 12–24 hours after the operation, you will be closely monitored. Nurses will regularly check your breathing, pulse, blood pressure, temperature, pupil size, arm and leg strength and function, and how aware (conscious) you are. These are called neurological observations. They show how your brain and body are recovering from surgery.
  • Some people have a build-up of fluid in their brain. This is called hydrocephalus. The surgeon may place a long, thin, permanent or temporary tube called a shunt from your brain into your abdomen to drain the extra fluid. The fluid can then be safely absorbed into the bloodstream. A small valve is inserted just under the scalp to make sure the fluid flows away from the brain.
  • You may need to wear pressure stockings on your legs to prevent blood clots from forming while you are bedridden. Tell your doctor if you have pain or swelling in your legs or suddenly develop difficulty breathing.
  • If you are recovering from a craniotomy, your head will be bandaged. Your face and eyes may be swollen or bruised, but this is not usually painful and should ease within about a week.
  • You may have a headache or nausea after the operation. Both can be treated with medications.
  • If you have had an operation on your spinal cord, the nurses will regularly check the movement and sensation in your arms and legs. You may need to lie flat in bed for 2–5 days to allow the wound to heal. A physiotherapist will help you learn how to roll over and how to get out of bed safely so the wound is not damaged.
  • The length of your hospital stay, changes to your speech or movement, and any other side effects will depend on the extent of the operation. Your doctor will tell you when you can start regular activities again.
For more information, see rehabilitation.
"I had a craniotomy for a benign brain tumour but they couldn’t take all the tumour out. The risk of paralysis or a stroke was too high because the tumour was wrapped around my carotid artery. Later I had radiotherapy. Part of the tumour is still there, but it is stable, so I have been able to return to full-time work and I can now drive again." – Debbie

Radiotherapy

Radiotherapy (also called radiation therapy) is a type of treatment that uses high-energy x-ray beams to kill or damage cancer cells. The radiation is specifically targeted at the treatment site to reduce the risk of damage to healthy cells. The treatment is painless.

Before your radiotherapy begins, you will need to have an appointment to plan it. This is often called a simulation appointment, because you will be put in the exact position needed for your treatment.

A radiation therapist will take measurements of your body, as well as doing an x-ray or CT scan, to work out the precise area to be treated. For spinal cord tumours, some small tattoos may be marked on your skin to indicate the treatment area. For brain tumours, a face mask – also called a cast – is made to keep the head in position. It is a tight-fitting mesh, but you will only wear it for about 10 minutes at a time. However, let the radiation therapist know if wearing the mask makes you uncomfortable.

Radiotherapy treatment is usually given once daily, from Monday to Friday, for several weeks. However, the course of your treatment will depend on the size and type of the tumour.

In some cases, the entire brain receives treatment – for example, this may be done for secondary tumours. Your medical team will tell you if this is recommended for you. 

Stereotactic radiosurgery

Stereotactic radiosurgery is a type of radiation therapy, not a type of surgery. It is a non-invasive treatment that uses high doses of precisely targeted radiation to treat a brain tumour in a single hospital visit. Treatment is so accurate that surrounding areas of healthy brain tissue are unlikely to be affected. The patient is usually able to return home the same day as treatment.

Radiosurgery may be offered when traditional surgery is not suitable. It is most commonly used for some meningiomas and pituitary tumours, and acoustic neuroma. It is also used for metastatic cancers that have spread from another part of the body. It is not usually used for gliomas, as they require a larger treatment area.

Stereotactic radiosurgery may also be used to deliver a long course of radiation, particularly for benign brain tumours. The same precise system is used, but several small treatments are given.

Radiotherapy for children

Radiotherapy is not often used for children under age 5 because high-dose therapy can affect intellectual development and slow hormone production and physical growth. Children may later need hormone therapy to help them grow and develop. Your child’s health care team will discuss treatment options and possible short- and long-term side effects with you before treatment. Young children may require a general anaesthetic for radiotherapy.

Side effects of radiotherapy

Radiotherapy causes many possible side effects. Most occur in the treatment area and are temporary, but some may be permanent or last for a few months or years.

The side effects vary depending on if you have a brain or spinal cord tumour. They may include:

  • nausea – often occurs during the course of treatment
  • headaches – often occur during the course of treatment
  • tiredness or fatigue – worse at the end of treatment for a brain or spinal cord tumour, and fades over time
  • red, sore, inflamed or flaky skin in the treatment area – usually happens at the end of treatment for brain tumours, but can worsen before improving
  • hair loss in the treatment area – for brain tumours
  • swallowing problems (dysphagia) – for spinal cord tumours
  • diarrhoea – for spinal cord tumours.

Some people experience similar side effects for several years after treatment. However, it is not always clear if these changes are caused by radiotherapy, the tumour or other treatment. You may benefit from rehabilitative therapy or medication, and your pituitary gland may be monitored.

Many side effects – short-term side effects in particular – can be treated effectively with medication. Talk to your doctor about how to manage side effects, call Cancer Council 13 11 20 or see our radiotherapy section.

Chemotherapy

Chemotherapy is the use of drugs to treat cancer. Generally, chemotherapy drugs travel through the bloodstream and damage or destroy rapidly dividing cells such as cancer cells, while causing the least possible damage to healthy cells. Healthy fast-growing cells, such as your bone marrow, may also be affected, causing side effects (see below).

However, it can be difficult to treat brain tumours with chemotherapy drugs because the body has a protection system called the blood-brain barrier. This guards the brain from substances circulating in the blood, such as germs or chemicals, that could harm it. Only certain drugs can get through this barrier.

You may be given chemotherapy by taking an oral capsule or through a drip inserted into your vein (intravenously). Each treatment session is usually followed by a rest period of a few weeks.

Some patients who have a craniotomy have small, dissolvable chemotherapy wafers inserted into their brain during surgery. The wafers release drugs into the brain over a couple of weeks. As the drug is placed directly at the tumour site, it doesn’t affect other areas of the body and so reduces the chance of side effects.

Chemotherapy is often combined with radiotherapy for the treatment of glioblastomas (grade 4 tumours). This combination improves outcomes, compared with radiotherapy alone.

Side effects of chemotherapy

The way your body reacts to chemotherapy will be monitored through regular blood tests. Your treatment schedule may change when your doctor sees how you are responding to the drugs.

There are many possible side effects of chemotherapy, depending on the type of drugs you are given. Side effects may include:

  • increased risk of infection
  • nausea, vomiting or loss of appetite
  • tiredness, fatigue and lack of energy
  • mouth sores and ulcers
  • diarrhoea or constipation
  • breathlessness due to low red blood cell levels (anaemia)
  • the feeling of pins and needles (nerve damage known as peripheral neuropathy).

Hair loss is rare with the drugs commonly used to treat brain and spinal cord tumours.

Ask your doctor what side effects to expect and how to control them. You may be prescribed medication to make you feel better. You can also read our chemotherapy section or call Cancer Council 13 11 20.

The Sydney Neuro-Oncology Group produces useful fact sheets for patients with brain tumours and their carers. See the Patient & Carer Kit.

Steroids

"Steroids cause severe mood swings for me. You could tell me I won the lottery and I’d feel like I hated life. I get irritated and cry easily. It’s not rational of course, but I’m aware of how they make me feel and I wait out the feelings." – Kate

Steroids are made naturally in the body, but they can also be produced artificially and used as drugs. Steroids may help to reduce swelling in the brain, and can be given during radiotherapy or before, during or after surgery. Dexamethasone is the most commonly prescribed steroid.

You must eat some food before taking steroids. This decreases the likelihood of the steroids irritating your stomach.

The side effects you experience depend on the dose and the length of treatment. Steroids given for a short time may cause increased appetite, weight gain, insomnia, restlessness and mood swings. If taken for several months, steroids can cause puffy skin (fluid retention or oedema) in the feet, hands or face; high blood pressure; unstable blood sugar levels; diabetes; or muscle weakness. You will also be more likely to get infections.

Most side effects are temporary and will fade if your medical team reduces your dose. Short-term side effects can be managed with medication and counselling (if you have mood swings or behavioural changes). If you or your family members are worried about side effects, talk to your doctor or a counsellor. 

Seizures

A tumour may cause seizures, which are disruptions to the normal patterns of electrical impulses in the brain.

Seizures are sometimes called fits or convulsions. They can often be prevented with anti-convulsant medication (also called antiepileptic or anti-seizure medication).

Generalised seizures

These types of seizures typically affect the whole body. The most common type is called a tonic-clonic seizure (previously known as a grand mal seizure). A seizure often starts with a sudden cry, followed by the person falling down and losing consciousness. The person’s muscles may twitch violently and their breathing may be shallow for up to two minutes. They may lose control of their bladder or bowel and bite their tongue.

Partial seizures

These affect one part of the body, such as an arm or a leg. Symptoms include twitching; jerking; tingling or numbness; altered sensations (hallucinations), such as changed vision or hearing, sensing strange tastes or smells, or a feeling of déjà vu. Partial seizures may cause a brief loss of consciousness. 

Anti-convulsant medications

There are many types of anti-convulsant drugs, which are used to prevent seizures. You may require blood tests while you are taking anti-convulsants. This is to check whether the dose is effective and how your liver is coping with the medication. 

Grapefruit, Seville oranges and certain herbal medicines may change the way some anti-convulsants work. You should also limit your alcohol intake. Talk to your doctor about these risks.

Side effects of anti-convulsant drugs vary and may include tiredness, weight changes, gum problems, tremors, nausea, vomiting and depression. If you are allergic to the medication, you may get a rash. Tell your medical team if you have any skin changes or other side effects.

Your doctor can adjust your dose to reduce any side effects, or can give you another type to try. It is important not to stop taking the medicine or change the dose without your doctor’s advice.

Ways to help someone having a seizure
  • Remain calm and stay with the person, but do not restrain them or put anything in their mouth.
  • Time how long the seizure lasts.
  • Protect the person from injury (e.g. by moving hazards or placing a soft pillow under their head and shoulders).
  • Lie the person on their side as soon as possible, or right away if they have vomited. This is important if they are unconscious or have food or fluid in their mouth.
  • Talk to the person and explain what has occurred. In many cases, people are confused after a seizure.
  • Observe the person until they have recovered or the ambulance arrives.
  • If the seizure occurs while a person is in a wheelchair or car, support their head and leave them safely strapped in their seat until the seizure is over. Afterwards, remove the person from their seat, if possible. Roll them onto their side if there is food, water or vomit in their mouth.
  • If help is needed, call an ambulance (000) immediately.
  • Allow the person to rest after having a seizure.
  • For detailed information about seizures, contact Epilepsy Action Australia on 1300 374 537.

Palliative treatment

Palliative treatment helps to improve people’s quality of life by alleviating symptoms of cancer without trying to cure the disease. It is particularly important for people with advanced cancer. However, it is not just for end-of-life care and it can be used at different stages of cancer.

Often treatment is concerned with pain relief and stopping the spread of cancer, but it also involves the management of other physical and emotional symptoms.

Call Cancer Council 13 11 20 for more information about palliative care and advanced cancer.

Key points

  • The main treatments for brain or spinal cord tumours are surgery, radiotherapy and chemotherapy.
  • Some tumours can be completely removed in a gross total resection. Others can only be partially removed. This is a partial resection.
  • Different types of surgery are used for different types of tumours. The most common brain surgery is a craniotomy. A laminectomy removes tumours from the spinal cord.
  • Stereotactic surgery is when a computer guides the surgeon so the surgery is more precise.
  • Radiotherapy uses x-rays to kill cancer cells. It is rarely used for children under five. You will have a simulation appointment so the doctor can work out exactly where to direct the radiation.
  • Radiosurgery is a type of radiotherapy that precisely targets the treatment area in a single hospital visit.
  • Chemotherapy is the use of drugs to destroy or kill cancer cells. You may be given chemotherapy orally, into a vein via a drip, or as wafers that are placed directly in the brain during surgery.
  • Other treatments include steroids to reduce brain inflammation, and anticonvulsants to prevent seizures occurring.
  • Treatments may cause short- and long-term side effects. Talk to your doctors and nurses about managing symptoms and side effects, including if you will need rehabilitation. 

Reviewed by: A/Prof Kate Drummond, Neurosurgeon, Divisional Director of Neuroscience and Cancer and Infection Medicine, Director of Junior Surgical Training, The Royal Melbourne Hospital, VIC; Dr Dianne Clifton, Psychiatrist, Psycho-oncologist and Director, Department of Psychosocial Cancer Care at St Vincent’s Hospital, VIC; Dr Anthony Dowling, Medical Oncologist, St Vincent’s Hospital, VIC; Kate Fernandez, Clinical Nurse Coordinator, Central Nervous System Tumours, Women’s and Children’s Hospital, SA; Carmen Heathcote and Yvonne Howlett, Helpline Operators, Cancer Council Queensland, QLD; Dianne Legge, Brain Tumour Support Officer, Cancer Services, Olivia Newton-John Cancer and Wellness Centre, VIC; Scott Nussey, Consumer, SA; Dr Claire Phillips, Radiation Oncologist, Peter MacCallum Cancer Centre, VIC; and Janine Rhodes, Coordinator, Brain Tumour Support Service, Cancer Council Queensland, QLD.

Updated: 01 May, 2014