Treatment for brain tumours

Sunday 1 May, 2016

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On this page: Surgery | Radiotherapy | Stereotactic radiosurgery | Chemotherapy | Steroids | 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 anti- convulsants (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 is to remove the tumour, slow its growth, or relieve symptoms by shrinking the tumour and swelling.

Your choice of treatment will depend on:

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

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 fully recover and return to leading an active life. However, you may also have other treatments, including radiotherapy and chemotherapy.

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.

Preparing for surgery

The types of scans used for diagnosing the tumour (e.g. CT, MRI or MRS scans) are often done again when planning surgery to precisely pinpoint the location of the tumour. If a stereotactic surgery is planned, these scans will be imported into a computer and be used to guide the surgeon during the operation (see below). 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.

Identifying the brain’s sensitive areas can help the surgeon avoid causing damage during the operation. Brain mapping is another way to find these parts of the brain. A tiny electrode is placed on the outside layer of the brain during the surgery and stimulated with a low dose of electrical current. The night before or on the day of surgery you may be sent for a stereotactic CT or MRI scan. Stereotactic surgery may require the surgeon to use small markers called fiducial markers. See below for more information.

Before surgery, talk to your doctor about any medicines you are taking. Some medicines 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 surgery.

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. You are given a general anaesthetic and 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. After the tumour is taken out, the bone and scalp are put back. The surgeon uses small plates and screws to hold the piece of skull in place.

Patients with a high grade glioma may be given a solution of Gliolan® (5-ALA) prior to surgery. This makes the tumour glow red under ultraviolet light. It ensures the surgeon is able to remove as much of the tumour as possible, while avoiding normal brain matter.

Awake craniotomy

This operation is used if the tumour is near parts of the brain that control speech or movement. All or part of this 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 surgery, 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 and identify the important areas of the brain.

Endoscopic transphenoidal surgery

A rarer type of surgery 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. Recovery may be faster than a craniotomy. An Ear, Nose and Throat surgeon (ENT) may assist with this type of surgery.

Craniectomy

This is similar to a craniotomy, except the piece of skull removed is not replaced. 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.

"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
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 most common surgery to access 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. 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 you will be asked questions to assess your level of consciousness. These neurological observations 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 recovering from surgery. Tell your doctor or nurse 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 medicines.

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. Your doctor will tell you when you can start regular activities again.

Your length of stay in hospital will depend on whether you have any problems or side effects following surgery. You may require a period of rehabilitation before you can return home.

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 itself is usually painless, though you may experience side effects afterwards (see below).

Before your radiotherapy begins, you will need to have a simulation or planning appointment to plan the treatment. A radiation therapist will take measurements of your body, as well as doing a CT scan, to work out the precise area to be treated.

If you are receiving radiotherapy treatment for a spinal cord tumour, some small tattoos may be marked on your skin to indicate the treatment area. If you are having radiotherapy for a brain tumour, a face mask is made before your CT session to keep the head in position.

The face mask is made of a tight-fitting mesh, but you will only wear it for about 10 minutes at a time. You can see and breathe through the mask but it may feel strange and uncomfortable at first. Your treating team can talk to you about techniques to help you manage if you need them.

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.

Stereotactic radiosurgery

Stereotactic radiosurgery is a specialised type of radiation therapy, not a type of surgery. Stereotactic radiosurgery is sometimes called Gamma Knife® or CyberKnife® treatment, after the machines used to give it.

It is a non-invasive treatment that uses high doses of precisely targeted radiation to treat a brain tumour. Treatment is so accurate that surrounding areas of healthy brain tissue are unlikely to be affected.

A treatment session usually lasts between 15 minutes and two hours, depending on the type of radiosurgery given. You will usually be able to return home afterwards.

Radiosurgery may be offered when traditional surgery is not suitable or as an alternative to open surgery. 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.

Stereotactic radiotherapy 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.

Radiosurgery is not usually used for gliomas, as they require a larger treatment area.

Side effects of radiotherapy

Radiotherapy side effects commonly occur in the treatment area and are usually 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 – may occur in the treatment area, usually happens at the end of treatment for brain tumours, but can and may worsen before improving
  • hair loss – may occur in the brain tumour treatment area
  • swallowing problems (dysphagia) – may occur following treatment for spinal cord tumours
  • diarrhoea – may occur after radiotherapy 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 rehabilition therapy or medication. Your treatment team may also monitor the hormone levels in your pituitary gland.

For more information on radiotherapy treatment, call Cancer Council 13 11 20 for a free copy of Understanding Radiotherapy.

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 harmful substances that may be circulating in the blood, such as germs or chemicals. 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.

Oral temozolomide is commonly used to treat gliomas because it is generally effective and well tolerated. If the tumour progresses or recurs while you are taking temozolomide, your onocologist may consider changing the dose or switching to a different chemotherapy drug or combination.

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.

For more information on chemotherapy call Cancer Council 13 11 20 for a free copy of Understanding Chemotherapy.

Steroids

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 before, during and after surgery and radiotherapy. Dexamethasone is the most commonly prescribed steroid.

It is important to 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. If you are prescribed steroids for a short period, you may experience increased appetite, weight gain, insomnia, restlessness, mood swings, anxiety and very occasionally more serious disturbances of thought and behaviour.

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 and osteoporosis. 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. An experienced counsellor, psychologist or psychiatrist can help you manage mood swings or behavioural changes. A physiotherapist can assist with muscle weakness. If you or your family members are worried about side effects, talk to your doctor, nurse or a counsellor.

"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

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. Palliative care services can be accessed in the home as well as in a hospital or residential care.

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, and psychosocial support for patients and families.

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

"I’ve been having palliative care treatment for five years. I’m not trying to get rid of the disease, just keeping it under control – and my quality of life is excellent." - Cate

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. You will have a planning appointment so the doctor can work out exactly where to direct the radiation. It is rarely used for children under five.
  • Radiosurgery is a type of radiotherapy that precisely targets the treatment area.
  • 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 anti- convulsants 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 Matthew Foote, Associate Professor, University of Queensland and Staff Specialist, Radiation Oncology, Princess Alexandra Hospital, QLD; Dr Jason Papacostas, Neurosurgeon, Mater Private Hospital, QLD; Dr Dianne Clifton, Psychiatrist and Coordinator of Education, Psychosocial Cancer Care and Palliative Care, St Vincent’s Hospital, VIC; A/Prof Georgia Halkett, Assocaite Professor, Senior Research Fellow, School of Nursing and Midwifery, Faculty of Health Sciences, Curtin University, WA; Lawrence Cher, Neurologist and Neuro-oncologist, Olivia Newton John Cancer & Wellness Centre, Austin Hospital, VIC; Kate Brennan, Occupational Therapist, Princess Alexandra Hospital, QLD; Vivien Biggs, Neuro-oncology nurse practitioner, Briz Brain & Spine, QLD; Lindy Cohn, 13 11 20 advisor, Cancer Council NSW, NSW; Ms Dianne Legge, Brain Tumour Support Officer, Cancer Services, Olivia Newton-John Cancer & Wellness Centre, Austin Hospital, VIC; Russ Talbot, consumer, SA.

Updated: 01 May, 2016