What is Brain Tumor?

The body is made up of many types of cells. Each type of cell has special functions. Most cells in the body grow and then divide in an orderly way to form new cells as they are needed to keep the body healthy and working properly. When cells lose the ability to control their growth, they divide too often and without any order. The extra cells form a mass of tissue called a tumor.

Tumors are benign or malignant.

Benign brain tumors do not contain cancer cells. Usually these tumors can be removed, and they are not likely to recur. Benign brain tumors have clear borders. Although they do not invade nearby tissue, they can press on sensitive areas of the brain and cause symptoms.

Malignant brain tumors contain cancer cells. They interfere with vital functions and are life threatening. Malignant brain tumors are likely to grow rapidly and crowd or invade the tissue around them. Like a plant, these tumors may put out "roots" that grow into healthy brain tissue. If a malignant tumor remains compact and does not have roots, it is said to be encapsulated. When an otherwise benign tumor is located in a vital area of the brain and interferes with vital functions, it may be considered malignant (even though it contains no cancer cells).

Doctors refer to some brain tumors by grade--from low grade (grade I) to high grade (grade IV). The grade of a tumor refers to the way the cells look under a microscope. Cells from higher grade tumors are more abnormal looking and generally grow faster than cells from lower grade tumors; higher grade tumors are more malignant than lower grade tumors.

Tumors that begin in brain tissue are known as primary brain tumors. (Secondary tumors that develop when cancer spreads to the brain are discussed in the Secondary Brain Tumors section.) Primary brain tumors are classified by the type of tissue in which they begin. The most common brain tumors are gliomas, which begin in the glial (supportive) tissue.

There are several types of Gliomas:

• Astrocytomas arise from small, star-shaped cells called astrocytes. They may grow anywhere in the brain or spinal cord. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum. A grade III astrocytoma is sometimes called anaplastic astrocytoma. A grade IV astrocytoma is usually called glioblastoma multiforme.

• Brain stem gliomas occur in the lowest, stemlike part of the brain. The brain stem controls many vital functions. Tumors in this area generally cannot be removed. Most brain stem gliomas are high-grade astrocytomas.

• Ependymomas usually develop in the lining of the ventricles. They may also occur in the spinal cord. Although these tumors can develop at any age, they are most common in childhood and adolescence.

• Oligodendrogliomas arise in the cells that produce myelin, the fatty covering that protects nerves. These tumors usually arise in the cerebrum. They grow slowly and usually do not spread into surrounding brain tissue. Oligodendrogliomas are rare. They occur most often in middle-aged adults but have been found in people of all ages.

There are other types of brain tumors that do not begin in glial tissue. Some of the most common are described below:

• Medulloblastomas were once thought to develop from glial cells. However, recent research suggests that these tumors develop from primitive (developing) nerve cells that normally do not remain in the body after birth. For this reason, medulloblastomas are sometimes called primitive neuroectodermal tumors (PNET). Most medulloblastomas arise in the cerebellum; however, they may occur in other areas as well. These tumors occur most often in children and are more common in boys than in girls.

• Meningiomas grow from the meninges. They are usually benign. Because these tumors grow very slowly, the brain may be able to adjust to their presence; meningiomas often grow quite large before they cause symptoms. They occur most often in women between 30 and 50 years of age.

• Schwannomas are benign tumors that begin in Schwann cells, which produce the myelin that protects the acoustic nerve--the nerve of hearing. Acoustic neuromas are a type of schwannoma. They occur mainly in adults. These tumors affect women twice as often as men.

• Craniopharyngiomas develop in the region of the pituitary gland near the hypothalamus. They are usually benign; however, they are sometimes considered malignant because they can press on or damage the hypothalamus and affect vital functions. These tumors occur most often in children and adolescents.

• Germ cell tumors arise from primitive (developing) sex cells, or germ cells. The most frequent type of germ cell tumor in the brain is the germinoma.

• Pineal region tumors occur in or around the pineal gland, a tiny organ near the center of the brain. The tumor can be slow growing pineocytoma) or fast growing (pineoblastoma). The pineal region is very difficult to reach, and these tumors often cannot be removed.

Metastasis is the spread of cancer. Cancer that begins in other parts of the body may spread to the brain and cause secondary tumors. These tumors are not the same as primary brain tumors. Cancer that spreads to the brain is the same disease and has the same name as the original (primary) cancer. For example, if lung cancer spreads to the brain, the disease is called metastatic lung cancer because the cells in the secondary tumor resemble abnormal lung cells, not abnormal brain cells.

Treatment for secondary brain tumors depends on where the cancer started and the extent of the spread as well as other factors, including the patient's age, general health, and response to previous treatment.

The causes of brain tumors are not known. Researchers are trying to solve this problem. The more they can find out about the causes of brain tumors, the better the chances of finding ways to prevent them. Doctors cannot explain why one person gets a brain tumor and another doesn't, but they do know that no one can "catch" a brain tumor from another person. Brain tumors are not contagious.

By studying large numbers of patients, researchers have found certain risk factors that increase a person's chance of developing a brain tumor. People with these risk factors have a higher-than-average risk of getting a brain tumor. For example, studies show that some types of brain tumors are more frequent among workers in certain industries, such as oil refining, rubber manufacturing, and drug manufacturing. Other studies have shown that chemists and embalmers have a higher incidence of brain tumors. Researchers also are looking at exposure to viruses as a possible cause.

Because brain tumors sometimes occur in several members of the same family, researchers are studying families with a history of brain tumors to see whether heredity is a cause. At this time, scientists do not believe that head injuries cause brain tumors to develop. In most cases, patients with a brain tumor have no clear risk factors. The disease is probably the result of several factors acting together.

The symptoms of brain tumors depend mainly on their size and their location in the brain. Symptoms are caused by damage to vital tissue and by pressure on the brain as the tumor grows within the limited space in the skull. They also may be caused by swelling and a buildup of fluid around the tumor, a condition called edema. Symptoms may also be due to hydrocephalus, which occurs when the tumor blocks the flow of cerebrospinal fluid and causes it to build up in the ventricles. If a brain tumor grows very slowly, its symptoms may appear so gradually that they are overlooked for a long time. The most frequent symptoms of brain tumors include:

• Headaches that tend to be worse in the morning and ease during the day,

• Seizures (convulsions),

• Nausea or vomiting,

• Weakness or loss of feeling in the arms or legs,

• Stumbling or lack of coordination in walking (ataxic gait),

• Abnormal eye movements or changes in vision,

• Drowsiness,

• Changes in personality or memory, and

• Changes in speech.

These symptoms may be caused by brain tumors or by other problems. Only a doctor can make a diagnosis.

Diagnosis

To find the cause of a person's symptoms, the doctor asks about the patient's personal and family medical history and performs a complete physical examination. In addition to checking general signs of health, the doctor does a neurologic exam. This includes checks for alertness, muscle strength, coordination, reflexes, and response to pain. The doctor also examines the eyes to look for swelling caused by a tumor pressing on the nerve that connects the eye and the brain.

Depending on the results of the physical and neurologic examinations, the doctor may request one or both of the following:

• A CT (or CAT) scan is a series of detailed pictures of the brain. The pictures are created by a computer linked to an x-ray machine. In some cases, a special dye is injected into a vein before the scan. The dye helps to show differences in the tissues of the brain.

• MRI (magnetic resonance imaging) gives pictures of the brain, using a powerful magnet linked to a computer. MRI is especially useful in diagnosing brain tumors because it can "see" through the bones of the skull to the tissue underneath. A special dye may be used to enhance the likelihood of detecting a brain tumor.

The doctor may also request other tests such as:

• A skull x-ray can show changes in the bones of the skull caused by a tumor. It can also show calcium deposits, which are present in some types of brain tumors.

• A brain scan reveals areas of abnormal growth in the brain and records them on special film. A small amount of a radioactive material is injected into a vein. This dye is absorbed by the tumor, and the growth shows up on the film. (The radiation leaves the body within 6 hours and is not dangerous.)

• An angiogram, or arteriogram, is a series of x-rays taken after a special dye is injected into an artery (usually in the area where the abdomen joins the top of the leg). The dye, which flows through the blood vessels of the brain, can be seen on the x-rays. These x-rays can show the tumor and blood vessels that lead to it.

• A myelogram is an x-ray of the spine. A special dye is injected into the cerebrospinal fluid in the spine, and the patient is tilted to allow the dye to mix with the fluid. This test may be done when the doctor suspects a tumor in the spinal cord.

Treatment for a brain tumor depends on a number of factors. Among these are the type, location, and size of the tumor, as well as the patient's age and general health. Treatment methods and schedules often vary for children and adults. The doctor develops a treatment plan to fit each patient's needs.

The patient's doctor may want to discuss the case with other doctors who treat brain tumors. Also, the patient may want to talk with the doctor about taking part in a research study of new treatment methods, such as clinical trials.

Many patients want to learn all they can about their disease and their treatment choices so they can take an active part in decisions about their medical care.

Treatment Methods

Brain tumors are treated with surgery, radiation therapy, and chemotherapy. Depending on the patient's needs, several methods may be used. The patient may be referred to doctors who specialize in different kinds of treatment and work together as a team. This medical team often includes a neurosurgeon, a medical oncologist, a radiation oncologist, a nurse, a dietitian, and a social worker. The patient may also work with a physical therapist, an occupational therapist, and a speech therapist.

Before treatment begins, most patients are given steroids, which are drugs that relieve swelling (edema). They may also be given anticonvulsant medicine to prevent or control seizures. If hydrocephalus is present, the patient may need a shunt to drain the cerebrospinal fluid. A shunt is a long, thin tube placed in a ventricle of the brain and then threaded under the skin to another part of the body, usually the abdomen. It works like a drainpipe: Excess fluid is carried away from the brain and is absorbed in the abdomen. (In some cases, the fluid is drained into the heart.)

Surgery is the usual treatment for most brain tumors. To remove a brain tumor, a neurosurgeon makes an opening in the skull. This operation is called a craniotomy.

Whenever possible, the surgeon attempts to remove the entire tumor. However, if the tumor cannot be completely removed without damaging vital brain tissue, the doctor removes as much of the tumor as possible. Partial removal helps to relieve symptoms by reducing pressure on the brain and reduces the amount of tumor to be treated by radiation therapy or chemotherapy.

Some tumors cannot be removed. In such cases, the doctor may do only a biopsy. A small piece of the tumor is removed so that a pathologist can examine it under a microscope to determine the type of cells it contains. This helps the doctor decide which treatment to use.

Sometimes, a biopsy is done with a needle. Doctors use a special headframe like a halo) and CT scans or MRI to pinpoint the exact location of the tumor. The surgeon makes a small hole in the skull and then guides a needle to the tumor. (Using this technique to do a biopsy or for treatment is called stereotaxis.) Radiation therapy (also called radiotherapy) is the use of high-powered rays to damage cancer cells and stop them from growing. It is often used to destroy tumor tissue that cannot be removed with surgery or to kill cancer cells that may remain after surgery. Radiation therapy is also used when surgery is not possible.

Radiation therapy may be given in two ways. External radiation comes from a large machine. Generally, external radiation treatments are given 5 days a week for several weeks. The treatment schedule depends on the type and size of the tumor and the age of the patient. Giving the total dose of radiation over an extended period helps to protect healthy tissue in the area of the tumor.

Radiation can also come from radioactive material placed directly in the tumor (implant radiation therapy). Depending on the material used, the implant may be left in the brain for a short time or permanently. Implants lose a little radioactivity each day. The patient stays in the hospital for several days while the radiation is most active.

External radiation may be directed just to the tumor and the tissue close to it or, less often, to the entire brain. (Sometimes the radiation is also directed to the spinal cord.) When the whole brain is treated, the patient often receives an extra dose of radiation to the area of the tumor. This boost can come from external radiation or from an implant.

Stereotactic radiosurgery is another way to treat brain tumors. Doctors use the techniques described in the Surgery section to pinpoint the exact location of the tumor. Treatment is given in just one session; high-energy rays are aimed at the tumor from many angles. In this way, a high dose of radiation reaches the tumor without damaging other brain tissue. (This use of radiation therapy is sometimes called the gamma knife.)

Chemotherapy is the use of drugs to kill cancer cells. The doctor may use just one drug or a combination, usually giving the drugs by mouth or by injection into a blood vessel or muscle. Intrathecal chemotherapy involves injecting the drugs into the cerebrospinal fluid.

Chemotherapy is usually given in cycles: a treatment period followed by a recovery period, then another treatment period, and so on. Patients often do not need to stay in the hospital for treatment.

Side Effects of Treatment

Cancer treatment often causes side effects. These side effects occur because treatment to destroy cancer cells damages some healthy cells as well.

The side effects of cancer treatment vary. They depend on the type of treatment used and on the area being treated. Also, each person reacts differently. Doctors try to plan the patient's therapy to keep side effects to a minimum. They also watch patients very carefully so they can help with any problems that occur.

A craniotomy is a major operation. The surgery may damage normal brain tissue, and edema may occur. Weakness, coordination problems, personality changes, and difficulty in speaking and thinking may result. Patients may also have seizures. In fact, for a short time after surgery, symptoms may be worse than before. Most of the side effects of surgery lessen or disappear with time.

Most of the side effects of radiation therapy go away soon after treatment is over. However, some side effects may occur or persist long after treatment is complete.

Some patients have nausea for several hours after treatment. Patients receiving radiation therapy may become very tired as treatment continues. Resting is important, but doctors usually advise their patients to try to stay reasonably active. Radiation therapy to the scalp causes most patients to lose their hair. When it grows back, the new hair is sometimes softer and may be a slightly different color. In some cases, hair loss is permanent.

Skin reactions in the treated area are common. The scalp and ears may be red, itchy, or dark; these areas may look and feel sunburned. The treated area should be exposed to the air as much as possible but should be protected from the sun. Patients should not wear anything on the head that might cause irritation. Good skin care is important at this time. The doctor may suggest certain kinds of soap or ointment, and patients should not use any other lotions or creams on the scalp without the doctor's advice.

Sometimes brain cells killed by radiation form a mass in the brain. The mass may look like a tumor and may cause similar symptoms, such as headaches, memory loss, or seizures. Doctors may suggest surgery or steroids to relieve these problems. About 4 to 8 weeks after radiation therapy, patients may become quite sleepy or lose their appetite. These symptoms may last several weeks, but they usually go away on their own. Still, patients should notify the doctor if they occur.

The side effects of chemotherapy depend on the drugs that are given. In general, anticancer drugs affect rapidly growing cells, such as blood cells that fight infection, cells that line the digestive tract, and cells in hair follicles. As a result, patients may have a lower resistance to infection, loss of appetite, nausea, vomiting, or mouth sores. Patients may also have less energy and may lose their hair. These side effects usually go away gradually after treatment stops.

Some anticancer drugs can cause infertility. Women taking certain anticancer drugs may have symptoms of menopause (hot flashes and vaginal dryness; periods may be irregular or stop).

Certain drugs used in the treatment of brain tumors may cause kidney damage. Patients are given large amounts of fluid while taking these drugs. Patients may also have tingling in the fingers, ringing in the ears, or difficulty hearing. These problems may not clear up after treatment stops.

Treatment with steroids to reduce swelling in the brain may cause increased appetite and weight gain. Swelling of the face and feet is common. Steroids can also cause restlessness, mood swings, burning indigestion, and acne. However, patients should not stop using steroids or change their dose without consulting the doctor. The use of steroids must be stopped gradually to allow the body to adjust to the change.

Loss of appetite can be a problem for patients during therapy. People may not feel hungry when they are uncomfortable or tired. Some of the common side effects of cancer treatment, such as nausea and vomiting, can also make it hard to eat. Yet good nutrition is important because patients who eat well generally feel better and have more energy. Eating well means getting enough calories and protein to help prevent weight loss, regain strength, and rebuild normal tissues. Many patients find that eating several small meals and snacks during the day works better than trying to have three large meals.

Patients being treated for a brain tumor may develop a blood clot and inflammation in a vein, most often in the leg. This is called thrombophlebitis. A patient who notices swelling in the leg, leg pain, and/or redness in the leg should notify the doctor right away.

General Questions

1. What is brain cancer?

 2. What is the central nervous system?

 3. What are symptoms of brain tumors?

• Headaches that tend to be worse in the morning

• Seizures

• Nausea and vomiting

• Weakness or loss of feeling in arms and legs

• Stumbling or lack of coordination in walking

• Abnormal eye movements or changes in vision

• Drowsiness

• Change in personality or memory

• Changes in speech

 4. What are the causes of brain tumors?

• Working in industries such as, oil refining, rubber manufacturing, and drug manufacturing.

• Other studies show chemists and embalmers have higher incidence of brain tumors.

• Researchers are looking at exposure to viruses as a possible cause.

• Brain tumors sometimes occur in several members of the same family so researchers are studying families to see whether heredity is a cause.

• At this time scientists do not believe that head injuries cause brain tumors to develop

 5. How is a brain tumor diagnosed?

• CT scan is a series of detailed pictures of the brain. The pictures are created by a computer linked to a x-ray machine, sometimes dyes are injected into the vein to help show differences in the tissue of the brain.

• MRI (magnetic resonance imaging) gives pictures using a powerful magnet linked to a computer. MRI is helpful in diagnosing brain tumors because it can "see" through the bone of the skull to the tissue underneath, a dye may be used to enhance the likelihood of detecting the tumor.

• Skull x-ray can show changes in bone or calcium deposits which are some times present in brain tumors.

• Brain scan reveals and records abnormal areas on special film. A small amount of radioactive material is injected into the vein. This dye is absorbed by the tumor and shows up on the film. The radiation leaves the body within 6 hours and is not dangerous.

• Angiogram or ateriogram is a series of x-rays after a dye is injected into an artery. These x-rays can show the tumor and blood vessels that lead to it.

• Myelogram is an x-ray of the spine. A special dye is injected into the cerebrospinal fluid in the spine, and the patient is titled to allow the dye to mix with the fluid. This test may be done if doctor suspects a tumor in the spinal cord.

 6. What are the types of brain tumors?

• Astrocytomas arise from small, star shaped cells called astrocytes. They may grow anywhere in the brain or spinal cord. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum. A grade III astrocytoma is sometimes called anaplastic astrocytoma. A grade IV astrocytoma is usually called glioblastoma multiforme.

• Brain stem gliomas occur in the lowest, stemlike part of the brain. The brain stem controls many vital functions. Tumors in this area generally cannot be removed. Most brain stem gliomas are high-grade astrocytomas.

• Ependymomas usually develop in the lining of the ventricles. They also may occur in the spinal cord. Although these can develop at any age, they are most common in childhood and adolescence.

• Oligodendrogliomas arise in the cells that produce myelin, the fatty covering that protects nerves. These tumors usually arise in the cerebrum. They grow slowly and usually do not spread into surrounding brain tissue. Oligodendrogliomas are rare. They occur most often in middle-aged adults but have been found in people of all ages.

• Medulloblastomas were once thought to develop from glial cells. However, recent research suggests that these tumors develop from primitive nerve cells that normally do not remain in the body after birth. For this reason, medulloblastomas are sometimes called primitive neuroectodermal tumors (PNET). Most medulloblastomas arise in the cerebellum; however, they may occur in other areas as well. These tumors occur most often in children and are more common in boys than in girls.

• Meningiomas grow from the meninges. They are usually benign. Because these tumors grow very slowly, the brain may be able to adjust to their presence; meningiomas often grow quite large before they cause symptoms. They occur most often in woman between 30 and 50 years of age.

• Schwannomas are benign tumors that begin in Schwann cell, which produce the myelin that protects the acoustic nerve-the nerve of hearing. Acoustic neuromas are a type of schwannoma. They occur mainly in adults. These tumors affect women twice as often as men.

• Craniopharyngiomas develop in the region of the pituitary gland near the hypothalamus. They are usually benign; however, they are sometimes considered malignant because they can press on or damage the hypothalamus and affect vital functions. These tumors occur most often in children and adolescents.

• Germ cell tumors arise from primitive sex cells, or germ cells. The most frequent type of germ cell in the brain is the germinoma.

• Pineal region tumors occur in or around the pineal gland, a tiny organ near the center of the brain. The tumor can be slow growing (pineocytoma) or fast growing (pineoblastoma). The pineal region is very difficult to reached and these tumors often cannot be removed.

 7. What are the treatments for brain tumors?

• Surgery is usual treatment for most brain tumors. To remove the tumor, the neurosurgeon makes and opening in the skull. This is called a craniotomy. Whenever possible the surgeon removes all of the brain tumor but sometimes only part can be removed if removing would cause damage to vital brain tissue. Some tumors can not be removed and biopsy is done to help decide treatment. Sometimes the biopsy can be done with CT scan or MRI to pinpoint exact location an only a small hole is needed in the skull. This is called stereotaxis.

• Radiation therapy uses high powered rays to damage cancer cells and stop them from growing. It is often used when surgery is not possible or not all of the tumor was removed. Radiation may be given in two ways.

  • External radiation treatments are given 5 days a week for several weeks. The treatment depends on type and size of the tumor and age of patient.

  • Direct radiation can also be placed directly into the tumor. Depending on material used, the implant may be left in the brain for a short time or permanently.

  • Stereotactic radiosurgery is another way to treat brain tumors. MRI or CT scan is used to pinpoint exact location of tumor and the treatment is given in one session. High-energy rays are aimed at the tumor from many angles. A high dose of radiation reaches the tumor without damaging other brain tissue. This may be referred to as the gamma knife.

  Chemotherapy is the use of drugs to kill cancer cells. The doctor may use one drug or a combination. The medications may be given by mouth or injection into muscle or vein. Sometimes chemotherapy is given intrathecal which is into cerebrospinal fluid. Chemotherapy is often given outpatient and is given in cycles; treatment period followed by a rest period then another treatment for several cycles.

  Clinical trails are designed to answer whether a new approach is both safe and effective. Areas they are looking at are:

  • Radiation twice daily.

  • Hyperthermia in which tumor is heated to increase effect of radiation.

  • Drugs injected into the artery leading to the brain or directly in the brain.

  • High dose chemo followed by bone marrow transplant.

  • Biological therapy which is a treatment to improve the body's immune system to fight the cancer.

8. What are the side effects of treatment?

• Surgery may damage normal brain tissue and edema may occur. Seizures, weakness, coordination problems, personality changes, and difficulty in speaking or thinking may result. Most side effects of surgery lessen or disappear with time.

• Radiation may cause fatique and hair loss which may be temporary or permanent. Skin reaction in treated area is common. The scalp and ears may be red, itch, or dark; these areas may feel and look sunburned. Patients should not use lotions without doctor advice. Sometimes radiation may cause headache, memory loss, or seizures because the brain cells killed from radiation may form a mass which causes pressure. Doctors may suggest surgery or steroids to relieve these problems. Patient may have fatique and lose their appetite 4 to 8 weeks after radiation and it may last for several weeks but will usually go away. Children who have radiation may have learning problems, partial loss of eyesight or not grow or develop normally.

• Chemotherapy side effects depend on the drugs used. Patient may experience lower resistance to infection, loss of appetite, nausea, vomiting, mouth sores, less energy, and hair loss. These side effects usually go away after treatment. Some chemotherapy causes sterility. Some chemotherapy can cause kidney damage so patient may be given large amounts of fluid while taking these drugs. Patient may also have tingling in fingers, ringing in ears, or difficulty hearing. These problems may not clear up after treatment.

• Steroids reduce swelling in the brain and may cause increased appetite, weight gain, swelling of the face and feet. Steroids can also cause restlessness, mood swings, burning indigestion, acne, and elevated glucose. The steroid treatment must be gradually stopped so the body can adjust.

 9. What questions should I ask the doctor?

• What treatment do you recommend?

• Are there other methods of treatment?

• What are the benefits of the various treatment options?

• What are the risks?

• What are you prescribing and what is it supposed to do?

• How should I expect to feel during treatment?

• What side effects, if any, can I expect from treatment?

• Should I bring someone with me for my treatments?

• Will the treatment or disease affect my ability to work, drive, or care for my family.

• How often are the treatments and checkups.