Treatment for brain tumours

Sometimes a tumour is considered unsafe to remove because it is too close to certain parts of the brain, and surgery would cause blindness, loss of speech, paralysis or other serious complications. These may be called inoperable or unresectable tumours.

A needle biopsy is still often possible and can help to guide treatment options. Your doctor will talk to you about what treatments you can have and ways to manage symptoms.

The different scans used to diagnose a brain tumour (such as MRI or CT scans) are often done again to plan surgery. Some people may have a functional MRI (fMRI) to help the surgeon avoid damaging the most important areas of the brain.

You will be asked to complete brain exercises during the MRI scan to show the exact areas of the brain that are used as you speak or move. These parts of the brain can also be found during surgery with brain mapping.

Tell your doctor about any blood-thinning or other medicines, and any supplements that you take. Some medicines interfere with the anaesthetic used during the operation, so you may need to stop taking them for a while.

If you smoke or vape, it is important to stop before surgery, as smoking or vaping can increase the risk of complications.

Different types of surgery may be used for brain and spinal cord tumours.

Removing a brain tumour (craniotomy)

This is the most common type of brain tumour surgery. A craniotomy removes all or part of the tumour (total or partial resection) and may be done under a general anaesthetic.

The surgeon cuts an area of bone (called the bone flap) from your skull to access the brain and remove the tumour. The bone is then put back and a small plate is screwed on to hold the piece of skill in place.

If you have a high-grade glioma, you drink a solution before surgery to make the tumour glow under a special blue light. This helps the surgeon remove as much of the tumour as possible, while avoiding normal brain tissue.

Brain mapping

An electrode is placed on the outside layer of the brain to stimulate and pinpoint important areas of the brain. Brain mapping may be done during surgery, or as part of an awake craniotomy.

Awake craniotomy

This operation may be recommended if the tumour is near parts of the brain that control speech or movement.

You are usually put to sleep (general anaesthetic) and are later woken up but relaxed (conscious) for part of the operation. The surgeon asks you to speak or move parts of your body to identify and avoid damaging those parts of the brain.

You may be worried that an awake craniotomy will be painful, but the brain itself does not feel pain and local anaesthetic is used to numb surrounding tissues.

Removing a pituitary tumour (endoscopic transsphenoidal surgery)

The most common surgery for pituitary gland tumours (and other tumours located near the base of the brain) is called endoscopic transsphenoidal surgery.

To remove the tumour, the surgeon inserts a long, thin tube with a light and camera (called an endoscope) through the nose and into the skull at the base of the brain. An ear, nose and throat (ENT) surgeon may also assist with this type of surgery.

You will be given a general anaesthetic for this operation.

Removing a spinal cord tumour (laminectomy)

The most common surgery for spinal cord tumours is a laminectomy. The surgeon makes an opening through the skin, muscle and a vertebra in the spinal column to remove the tumour. You usually have a general anaesthetic for this type of surgery.

Some spinal cord tumours may also need surgery to the spinal cord itself. Your surgeon will talk to you about this particular surgery, as it may have a risk of nerve or spinal cord injury.

You will be closely monitored for the first 12–24 hours after the operation. For the first day or two, you will be in the intensive care or high dependency unit.

You may stay in hospital for only 2 or up to 10 days. How long you stay in hospital will depend on whether you have any problems or side effects after the surgery

• Checks and observations – nurses will regularly check your breathing, blood pressure, pulse, temperature, pupil size, and arm and leg strength and function. You will also be asked questions to assess your level of consciousness. These are called neurological observations, and help to check how your brain and body are recovering from surgery. 
• Spinal cord checks – 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, to avoid damaging the wound.
• Pressure stockings – you will 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 have difficulty breathing.
• Rehabilitation – the surgery may cause a range of short-term or longer-term side effects. Before you can return home, you may need further treatment known as rehabilitation to help you regain your mobility and get back to your daily activities.
• Bandages and bruising – the wound is covered with a dressing, which varies from a small adhesive pad to bandaging covering your head. Some or all of your head may be shaved. After some surgery, your face and eyes may be swollen or bruised. It’s not usually painful and should ease in about a week. You may have dissolvable sutures (stitches) that don’t need to be removed, they simply fall out. Or you may have sutures or staples that need to be taken out once the wound has healed. You will have a scar, and your hair won’t grow in the scar – but it’s usually behind the hairline and once the rest of your hair grows back it isn’t easily seen
• Headaches and nausea – you may have a headache or nausea after the operation. Both can be treated with medicines.
• Having a shunt – rarely, there may be a build-up of cerebrospinal fluid in the brain, called hydrocephalus. It may be caused by the tumour or it can happen after surgery. To drain the extra fluid, you may have a temporary or permanent shunt (a long thin tube placed into your brain). For a temporary shunt (called an external ventricular drain), the tube drains fluid into a bag on the outside of the body. For a permanent shunt, the tube is inserted completely inside your body. It drains into your abdomen and the fluid is absorbed into your bloodstream. 
  
  

• Infection – although the risk is small, you may develop an infection at the wound site. This can usually be treated with antibiotics. A small number of people may need surgery to have the wound cleaned out and possibly the bone flap removed. Another surgery will usually be done later on to replace the missing area, for safety and to look natural.
• Bleeding – this is a rare but serious side effect. You will have a CT or MRI scan the day after surgery to check for any bleeding or swelling.
• Swelling – surgery can cause swelling in the brain, which increases the pressure inside the skull (intracranial pressure). Your medical team will monitor the swelling and try to reduce it with medicines.
• Other side effects – you may continue to feel confused and dizzy, have speech problems, weakness in parts of the body and seizures. You and your family or carers may be surprised that you may feel worse than before the surgery and worry that you are not recovering well. These side effects are normal and often improve with time.

Rehabilitation after surgery

Some people recover and can gradually return to their usual activities. For others, there are longer-term changes to speech, movement, behaviour and thinking.

A range of therapies can help recovery or show you ways to manage any longer-term changes. These therapies are known as rehabilitation. At first, you may have some rehabilitation therapies in the hospital or a rehabilitation facility.

Once you return home, you can continue rehabilitation therapies as an outpatient. You may also be given equipment to use at home. You will have other changes, such as not being able to drive for a while. 

Stereotactic radiosurgery (SRS)

Stereotactic radiosurgery (SRS) is a specialised type of radiation therapy, not a type of surgery, and no cuts are made in the skull. A specialised radiation machine is used to give very precisely targeted radiation to the tumour.

Machine types include LINAC, Gamma Knife and CyberKnife. They deliver a high dose of radiation to the tumour while the surrounding healthy brain tissue receives very little.

SRS is not suitable for all types of brain tumours. It may be offered when neurosurgery is not possible, or as an alternative. It is mostly used for cancers that have spread to the brain from another part of the body.

Some meningiomas, pituitary tumours, schwannomas, and occasionally gliomas that have come back, may be treated this way. Often, only 2–3 doses of SRS are needed (though you may have 1–5 doses as treatment is personalised).

A treatment session may last 15–45 minutes, depending on the type of radiosurgery given. You will need to wear a special mask (see opposite) or frame during the treatment. You will usually be able to go home after the session ends.

Stereotactic radiation therapy (SRT)

A stereotactic radiosurgery machine may also be used to deliver a longer course of radiation, particularly for benign brain tumours. This is called stereotactic radiation therapy or SRT. The treatment is given as multiple small daily doses. 

Proton therapy

This uses protons rather than x-ray beams. Protons are tiny parts of atoms with a positive charge. Proton therapy is used for some types of brain and spinal cord tumours, and tumours near sensitive areas.

A proton therapy machine has been installed in South Australia. It is hoped it will start treating patients soon. Currently, there is funding in special cases to allow Australians to travel overseas for proton therapy.

Radiation therapy side effects generally occur in the treatment area and are usually temporary, but some may last for a few months or years, or be permanent.

The side effects vary depending on whether the tumour is in the brain or spinal cord, and may include:

• nausea – can occurs several hours after treatment
• headaches – can occur throughout the course of treatment
• tiredness or fatigue – worse at the end of treatment, can continue to build after treatment, but usually improves over a month or so
• dry, itchy, red, sore or flaky skin – may occur in the treatment area, usually mild and happens at the end of treatment and lasts 1-2 weeks before going away
• hair loss – may occur in a patch in the area of the head receiving treatment; usually temporary but in some cases permanent; if hair grows back, the texture or colour may be different
• dulled hearing – may occur if fluid builds up in the middle ear and is usually temporary but may be permanent.

Radiation therapy side effects for spinal cord tumours may include sore or dry throat and swallowing problems (if the neck area is treated) or diarrhoea (if the lower spine is treated). Both are temporary.

Talk to your radiation oncology team about how to manage any side effects.

A small number of adults who have had radiation therapy to the brain have side effects that appear months or years after treatment. These are called late effects, and can include symptoms such as poor memory, confusion and headaches.

High-dose radiation to the pituitary gland can cause it to produce too little of some hormones. This can affect body temperature, growth, sleep, weight and appetite. The hormone levels in your pituitary gland will be monitored during and after treatment.

There are many possible side effects of chemotherapy, depending on the type of drugs you are given. Talk to your doctor about ways to reduce or manage any side effects you have.

Side effects are mostly mild with temozolomide and may include:

• nausea or vomiting
• tiredness, fatigue and lack of energy
• increased risk of infection
• mouth sores and ulcers
• diarrhoea or constipation
• loss of appetite
• skin rash
• liver damage 
• breathlessness due to low levels of red blood cells (anaemia) 
• low levels of platelets (thrombocytopenia), increasing the risk of abnormal bleeding
• reduction in the production of blood cells in the bone marrow; you will usually have regular blood tests to monitor your blood levels 
• damage to ovaries or testicles, which can make you unable to have children naturally (infertile).

In some cases your hair may become thinner or patchy, but it is rare to lose all your hair with chemotherapy for brain and spinal cord tumours.

The side effects you may experience with steroids depend on the dose and length of treatment:

• Short-term use – You may experience increased appetite and weight gain; trouble sleeping; restlessness; mood swings; anxiety; and, in rare cases, more serious changes to thinking and behaviour. In people who have diabetes, steroids can quickly lead to high or unstable blood sugar levels. These short-term side effects can be managed. Eating before taking steroids can reduce the chance of them irritating your stomach.
• Longer-term use – If steroids are taken for several months, they can cause puffy skin (fluid retention or oedema) in the feet, hands or face; high blood pressure; weight gain; unstable blood sugar levels; diabetes; muscle weakness; and loss of bone density (osteoporosis). You are more likely to get infections. Your doctor may change your dose to manage your side effects. Most side effects go away after treatment ends.