Brain Tumors

Treatment Options

Feeling overwhelmed from a brain tumor diagnosis is normal. Lean on your health care team to learn as much as possible about the details of your diagnosis and how that will affect your treatment plan. Ask your health care team if the goal of treatment is to cure the cancer or to keep it under control and relieve symptoms. Ask if clinical trials are an option for you. Understanding the goal, as well as being aware of the benefits and risks of each option, will help you be more prepared to make shared treatment decisions with your doctor.

Many factors will influence your treatment options, including the stage of disease, the location, size and type of tumor, and your overall health status. Once you’ve agreed on your treatment plan, you will work closely with a multidisciplinary care team, including a neuro-oncologist, neurosurgeon, financial counselor and others (see Overview). Talk openly with them and ask questions about your treatment, including potential clinical trials (see Clinical Trials). Following are the current most common treatment options.

Surgery

Surgery is typically the first treatment option whether a brain tumor is considered benign (noncancerous) or malignant (cancerous). The main goal is to remove as much of the tumor as possible before drug therapy or radiation therapy. However, it may also be done for other reasons, including taking a biopsy of the tumor, inserting an implant for treatment or alleviating symptoms, such as seizures or pressure inside the skull caused by the tumor.

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 like 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 the removal of 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, tumor cells that are too small to see using current imaging methods may remain. Additional treatment may be recommended to destroy them.
  • Partial removal of a tumor may be done to avoid the risk of brain damage. Additional therapy, such as radiation therapy or drug therapy, is often recommended to treat the remaining tumor.
  • Debulking surgery is the 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 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 equipped 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 seen with the 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, such as 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 by 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 into 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.
  • 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 uses drugs to destroy cancer cells. It may be used as the primary treatment 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. It may be given as a single drug or in combination and may be given by mouth (orally), through an IV or injected directly into cerebrospinal fluid, which is called intrathecal chemotherapy.

Using chemotherapy for brain tumors is different from treating any other type of tumor because of the blood-brain barrier, a network of blood vessels and tissue that protects the brain from harmful substances. 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 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 CT and MRI images of brain tumors that may be otherwise difficult to see.
  • Polymer wafer implants contain a chemotherapy drug that may be inserted into the tumor site after surgery to treat 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 uses high-energy X-rays or particles to destroy cancer cells. It may be given as primary treatment for certain brain tumors when surgery is not an option, before surgery to shrink the tumor or after surgery to destroy remaining cancer cells. It may be used with some chemotherapy drugs (chemoradiation) to improve its effectiveness. Radiation therapy may also be used to relieve symptoms caused by the brain tumor.

Types of radiation therapy used to treat brain tumors include conventional radiation therapy, three-dimensional conformal radiation therapy (3D-CRT), intensity-modulated radiation therapy (IMRT), volumetric arc-based therapy (VMAT), craniospinal radiation, stereotactic radiosurgery, fractionated stereotactic radiation therapy and proton therapy.

Delivering radiation to the same place every time is crucial. You may be fitted with a radiation mask to 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.

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 make the cells more likely to be destroyed by radiation.

Targeted Therapy

Targeted therapy drugs attack specific substances in or around cancer cells that help the cancer cells grow. They may be given to shrink the tumor or slow its growth for some time, especially if it cannot be completely removed surgically. Targeted therapy may be used with chemotherapy 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.

To determine if targeted therapy is a good option for you, your doctor will run biomarker tests for specific targets, such as vascular endothelial growth factor (VEGF) or neurotrophic receptor tyrosine kinase (NTRK) gene fusion. One monoclonal antibody drug blocks the VEGF protein. 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. The newest targeted therapy to treat brain tumors inhibits NTRK fusion and is a more recent discovery.

Alternating Electric Field Therapy

Alternating electric field therapy using tumor treating fields (TTFields) prevents cancer cells from reproducing and causes them to die with the goal of preventing a recurrence, specifically in glioblastomas. This portable, non-invasive device resembles a swim cap and attaches to the scalp to deliver low-intensity, intermediate frequency alternating electric fields. To use this device, the head must be shaved. 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. Because no drugs enter the bloodstream, this treatment seems to cause few or no side effects.

Immunotherapy

Immunotherapy uses the body’s own immune system to fight cancer cells. Immunotherapy is currently approved to treat a rare type of pediatric brain tumor, and researchers continue to evaluate other forms of immunotherapy through clinical trials.

 

Commonly Used Medications*

Chemotherapy

  • carmustine (BCNU)
  • carmustine implant (Gliadel Wafer or polifeprosan 20 with carmustine implant)
  • cyclophosphamide
  • lomustine (CCNU, Gleostine)
  • temozolomide (Temodar)
  • vincristine sulfate PFS

Combination Therapy

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

Corticosteroid

  • dexamethasone

Targeted Therapy

  • bevacizumab (Avastin)
  • bevacizumab-awwb (Mvasi)
  • everolimus (Afinitor, Afinitor Disperz)
  • larotrectinib (Vitrakvi)

Immunotherapy

  • dinutuximab (Unituxin**)

 

*As of 4/26/19
.**Indicated for a specific type of high-risk pediatric neuroblastoma

 

Monitoring for Recurrence

Even after successful treatment, brain tumors have the potential to recur (return). As part of your follow-up care, you’ll continue to receive imaging scans to monitor for this. Recurrent brain tumors often return near where the first tumor was found but can show up in another location. If a tumor returns, a new cycle of diagnostic tests will be done. Treatment for a recurrent tumor may require a new approach. Ask your doctor for more information about your risk of recurrence and what to watch for, as it is critical to contact your doctor at the first sign of the return of cancer.

 

Additional Resources

 

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