Brain Tumors

Treatment

Several options are available to help treat a brain tumor, and more than one type of treatment is often used. Various brain tumors respond differently to different types of treatment. Once your doctor has chosen your treatment plan based on your tumor type, you will work closely with a multidisciplinary care team, including a neurologist, radiologist, surgeon, nurse, financial counselor and others.

Making decisions about your treatment can be confusing because of the many options and factors that must be considered. Talk openly with your health care team and ask questions about your treatment options. Make sure you understand as much about your diagnosis as possible, including the potential risks and benefits of each treatment type, before making any decisions.

New treatments are evaluated in research studies known as clinical trials (see Clinical Trials). You are encouraged to talk to your health care team about the possibility of participating in a clinical trial. Clinical trials are available for children and adults. Following are common treatment options for brain tumors.

Surgery

Surgery is usually the primary treatment option for a brain tumor, whether it’s considered benign (noncancerous) or malignant (cancerous). Surgery may be performed to remove as much of the tumor as possible (as primary treatment or before chemotherapy or radiation therapy); to take a biopsy sample for testing; to place an implant for brain tumor treatment; or to help alleviate symptoms, such as seizures or pressure inside the skull.

A tumor is considered operable when the doctor believes it can be surgically removed with minimal risk of neurologic damage. A tumor is considered inoperable when the risk of brain damage is high due to the location of the tumor within the brain or central nervous system, or in relation to other structures responsible for important functions, such as language, vision or movement. Advancements in imaging techniques and neurosurgery have helped make it possible to surgically remove tumors that were once considered inoperable.

Several surgical procedures may be used to remove a brain tumor.

Craniotomy is the most common brain surgery used to treat brain tumors. A piece of the skull is removed to expose the brain so the surgeon can find and remove as much of the tumor as possible. The piece of skull is then replaced.

Craniectomy is almost the same as a craniotomy; however, the piece of skull removed at the beginning of the procedure is not replaced at the end. The surgeon may do a craniectomy in situations where the piece of skull was damaged by the tumor or if the brain is expected to swell after surgery. In cases of expected swelling, the piece of skull may be saved and replaced at a later time, but this rarely happens.

Complete removal or gross total resection is when the surgeon removes the entire tumor. After surgery, diagnostic imaging tests may be performed to look for any remaining tumor. Even if it appears that the entire tumor was removed, there still may be microscopic tumor cells that are too small to see with current imaging methods. Depending on the pathology results, additional treatment may be recommended to help destroy any possible remaining tumor cells.

Partial removal is when the surgeon chooses to remove only part of the tumor because of a risk of brain damage. Additional therapy, such as radiation therapy or drug therapy, is often recommended to treat the remaining tumor.

Debulking surgery is removal of as much of a tumor as possible when it’s unlikely that the entire tumor or multiple tumors can be completely removed. This procedure is typically done to reduce the pressure the tumor is placing on the brain or surrounding structures.

Neuroendoscopy involves the use of a long, narrow tube with a camera and light that is inserted into the hollow pathways of the brain through a small hole drilled in the skull. A laser may also be attached to the endoscope, allowing the surgeon to perform biopsies and remove small tumors, cysts or blockages within the ventricles.

Laser interstitial thermal therapy (LITT) involves the use of a laser to heat and destroy brain tissue while being monitored by magnetic resonance imaging (MRI). The laser is directed at the tumor through one or more small holes drilled into the skull. This procedure may be used for tumors that pose a health risk or are unreachable with a craniotomy.

Photodynamic therapy (PDT) is a procedure in which a “sensitizing” drug, or a drug that will be absorbed by the tumor, is injected into a vein or artery shortly before surgery. The drug contains a compound that allows the cells to glow a fluorescent color. These cells can then be viewed with use of special microscopic filters. During the procedure, the surgeon aims a laser at the glowing cells, which activates the drug and kills the tumor cells.

Skull base surgery involves the use of specialized techniques, including neuroendoscopy. This surgery is very difficult because the skull base is a delicate area containing several nerves and blood vessels that are crucial for sensory and motor functions.

Transsphenoidal surgery is done by going through the nostril to reach the pituitary gland, or making an incision in the upper lip above the teeth to access the tumor through the sphenoid sinus. It is most often used to treat pituitary adenomas and craniopharyngiomas.

Embolization is used to stop the flow of blood to tumors that have a large number of surrounding blood vessels. This procedure is done to prevent excessive bleeding during surgery. Before surgery, an angiogram is performed to map the blood vessels around the tumor. The neurosurgeon or interventional radiologist then inserts a plug in the blood vessels feeding the tumor to stop blood flow to the tumor. Surgery to remove the tumor is typically done within a few days.

Shunt placement involves placing a shunt, or catheter, into one of the four ventricles of the brain or a cyst to drain fluid that may be causing increased pressure inside the skull. The pressure is often caused by excess fluid buildup or blocked fluid pathways as a result of the tumor itself, or swelling caused by the tumor. The shunt drains cerebrospinal fluid or tumor fluid away from the brain and into the body, where it can be absorbed through normal processes. A shunt can be permanent or temporary. If a temporary shunt is connected to an external bag instead of directly into the body, it’s called an external ventriculostomy. Shunt maintenance to correct any blockages, issues with the catheter or infection is known as shunt revision.

Ultrasonic aspiration involves the use of vibrations caused by ultrasonic waves to break apart the brain tumor, which is then aspirated (removed with suction).

Chemotherapy

Chemotherapy is the use of drugs to destroy cancer cells. Chemotherapy may be used as the primary treatment option for certain tumors, before surgery to help shrink the tumor, or, more commonly, after surgery to destroy any remaining cells. Chemotherapy is sometimes given with radiation therapy (known as chemoradiation) to make the radiation more effective.

Not all brain tumors respond to chemotherapy. The brain is protected by a natural defense system called the blood-brain barrier, which acts as a filter to prevent harmful substances from entering the brain. Using chemotherapy for brain tumors is different from treating any other type of tumor because of this barrier. Only certain chemotherapy drugs are capable of passing through the barrier to treat the tumor. A process known as blood-brain barrier disruption may be used in some cases to temporarily disable the brain’s protective barrier. A drug is used to expand the blood vessels in the brain, during which time powerful doses of chemotherapy are injected into an artery or vein. The expanded blood vessels disrupt the barrier and allow the drugs to reach the tumor. As the drug wears off, the barrier is restored.

Other additional methods of delivering chemotherapy directly to the brain tumor are available.

Ommaya reservoir is a small container attached to a tube that is surgically implanted underneath the scalp. The tube leads into a ventricle or fluid-filled cyst within the brain, where chemotherapy may be delivered or fluid may be removed when needed.

Convection-enhanced delivery (CED) involves a catheter that is surgically inserted into the tumor. The other end is connected to a device that pumps chemotherapy drugs (or other therapeutic substances) into the catheter, allowing the drugs to flow directly into the tumor. CED is currently being studied in clinical trials for use in delivering additional therapies and tracers, which are injected past the blood-brain barrier to improve computed tomography (CT) and MRI images of brain tumors that may be otherwise difficult to see.

Polymer wafer implants, also called Gliadel wafers, contain a chemotherapy drug that may be inserted into the tumor site after surgery to treat any remaining tumor cells that may have spread into surrounding tissue. Up to eight of these nickel-sized wafers may be placed into the cavity during the procedure and remain in place until they dissolve and release the drug, which usually occurs over two to three weeks. Wafer implants are most commonly used to treat malignant gliomas.

Radiation Therapy

Radiation therapy is the use of high-energy X-rays or particles to destroy cancer. Radiation therapy may be given as primary treatment for certain brain tumors or when surgery is not an option. It may also be given before surgery to shrink the tumor or after surgery to destroy any remaining cancer cells. Radiation therapy may be given in combination with chemotherapy (chemoradiation), as some chemotherapy drugs can improve the effectiveness of radiation therapy. Radiation therapy may also be used as palliative therapy to relieve symptoms caused by the brain tumor.

Different types of radiation therapy used to treat brain tumors include three-dimensional conformal radiation therapy (3D-CRT), conventional radiation therapy, intensity-modulated radiation therapy (IMRT), volumetric arc-based therapy (VMAT), craniospinal radiation, stereotactic radiosurgery (e.g., Gamma Knife, CyberKnife) and proton therapy.

Before receiving radiation treatments for a brain tumor, you may be fitted with a radiation mask, which will help hold your head in place during the treatment session. The mask is made with a mesh material and will be shaped to your face. Marks made on the mask or tattooed onto your skin (if a mask is not used) will indicate exactly where treatment needs to be delivered each time.

Different brain tumors require different amounts of radiation therapy, but, just like any other tissue in the body, the brain can only withstand a certain amount of radiation. To increase the effectiveness of radiation therapy, a radiation boost (a type of local radiation) may be used in addition to conventional radiation. Drugs called radiosensitizers may also be given to increase the sensitivity of tumor cells to radiation; that is, to make the cells more likely to be destroyed by radiation.

Targeted Therapy

Targeted therapy drugs work by attacking specific substances in or around cancer cells that are responsible for helping the cancer cells grow. These drugs may be given with chemotherapy drugs to help prolong the time before certain types of brain tumors (especially glioblastomas) begin to grow again after surgery. These drugs may work when chemotherapy does not. They also often have less severe side effects than chemotherapy drugs.

One monoclonal antibody drug blocks a protein called vascular endothelial growth factor (VEGF). Normal cells make VEGF, but some cancer cells make too much VEGF. Blocking VEGF may prevent the growth of new blood vessels, including normal blood vessels and blood vessels that feed tumors. Another drug works by blocking a cell protein that normally helps cells grow and divide into new cells. For some types of tumors that can’t be removed completely by surgery, targeted therapy may shrink the tumor or slow its growth for some time.

Alternating Electric Field Therapy

This therapy, tumor treating fields (TTFields), is a treatment option that may be used for glioblastomas. TTFields is a portable, non-invasive device resembling a swim cap. It attaches to the scalp and delivers low-intensity, intermediate frequency, alternating electric fields that prevent cancer cells from reproducing and causes them to die. To use this device, the head must be shaved and four sets of electrodes are placed on the scalp. The electrodes are attached to a battery pack and are worn for most of the day. Talk to your doctor about this treatment (Optune) if you think it could be an option for you.

Because no drugs enter the bloodstream, this treatment seems to have little or no effect on cells in other parts of the body. Side effects can include skin irritation at the electrode sites and a slightly increased risk of headaches and seizures.

 

Some Commonly Used Drugs

Chemotherapy

  • carmustine (BCNU)
  • carmustine implant (Gliadel wafer or Polifeprosan 20 with Carmustine Implant)
  • cyclophosphamide
  • lomustine (CCNU, Gleostine)
  • temozolomide (Temodar)
  • vincristine sulfate PFS

Combination Therapies

  • PCV: procarbazine hydrochloride (Matulane); lomustine (CCNU, Gleostine) and vincristine sulfate PFS

Corticosteroids

  • dexamethasone

Targeted Therapy

  • bevacizumab (Avastin)
  • dinutuximab (Unituxin)
  • everolimus (Afinitor)

 

Additional Resources

 

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