Diagnosis and treatment of brain tumors with surgery, radiotherapy, chemotherapy and their complications

Dr. Moradi, a neurologist

If you have symptoms that suggest a brain tumor, your doctor will give you a physical exam and ask about your personal and family health history.

People with brain tumors have several treatment options. The options are surgery, radiation therapy, and chemotherapy. Many people get a combination of treatments.

How are brain tumors diagnosed?

You may have one or more of the following tests:

  • Neurologic exam: Your doctor checks your vision, hearing, alertness, muscle strength, coordination, and reflexes. Your doctor also examines your eyes to look for swelling caused by a tumor pressing on the nerve that connects the eye and the brain.
  • MRI A large machine with a strong magnet linked to a computer is used to make detailed pictures of areas inside your head. Sometimes a special dye (contrast material) is injected into a blood vessel in your arm or hand to help show differences in the tissues of the brain. The pictures can show abnormal areas, such as a tumor.
  • CT scan: An x-ray machine linked to a computer takes a series of detailed pictures of your head. You may receive contrast material by injection into a blood vessel in your arm or hand. The contrast material makes abnormal areas easier to see. Your doctor may ask for other tests:
  • Angiogram: Dye injected into the bloodstream makes blood vessels in the brain show up on an x-ray. If a tumor is present, the x-ray may show the tumor or blood vessels that are feeding into the tumor.
  • Spinal tap: Your doctor may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). This procedure is performed with local anesthesia. The doctor uses a long, thin needle to remove fluid from the lower part of the spinal column. A spinal tap takes about 30 minutes. You must lie flat for several hours afterward to keep from getting a headache. A laboratory checks the fluid for cancer cells or other signs of problems.
  • Biopsy: The removal of tissue to look for tumor cells is called a biopsy. A pathologist looks at the cells under a microscope to check for abnormal cells. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to diagnose a brain tumor, learn what grade it is, and plan treatment. Surgeons can obtain tissue to look for tumor cells in two ways:
    • Biopsy at the same time as treatment: The surgeon takes a tissue sample when you have surgery to remove part or all of the tumor. See the Surgery section.
    • Stereotactic biopsy: You may get local or general anesthesia and wear a rigid head frame for this procedure. The surgeon makes a small incision in the scalp and drills a small hole (a burr hole) into the skull. CT or MRI is used to guide the needle through the burr hole to the location of the tumor. The surgeon withdraws a sample of tissue with the needle. A needle biopsy may be used when a tumor is deep inside the brain or in a part of the brain that can't be operated on.

However, if the tumor is in the brain stem or certain other areas, the surgeon may not be able to remove tissue from the tumor without harming normal brain tissue. In this case, the doctor uses MRI, CT, or other imaging tests to learn as much as possible about the brain tumor.

A person who needs a biopsy may want to ask the doctor the following questions:

  • Why do I need a biopsy? How will the biopsy results affect my treatment plan?
  • What kind of biopsy will I have?
  • How long will it take? Will I be awake? Will it hurt?
  • What are the chances of infection or bleeding after the biopsy? Are there any other risks?
  • How soon will I know the results?
  • If I do have a brain tumor, who will talk with me about treatment? When?

What is the treatment for a brain tumor?

The choice of treatment depends mainly on the following:

  • The type and grade of brain tumor
  • Its location in the brain
  • Its size
  • Your age and general health

For some types of brain cancer, the doctor also needs to know whether cancer cells were found in the cerebrospinal fluid.

Your doctor can describe your treatment choices, the expected results, and the possible side effects. Because cancer therapy often damages healthy cells and tissues, side effects are common. Before treatment starts, ask your health care team about possible side effects and how treatment may change your normal activities. You and your health care team can work together to develop a treatment plan that meets your medical and personal needs.

You may want to talk with your doctor about taking part in a clinical trial, a research study of new treatment methods.

Your doctor may refer you to a specialist, or you may ask for a referral. Specialists who treat brain tumors include neurologists, neurosurgeons, neuro-oncologists, medical oncologists, radiation oncologists, and neuroradiologists.

Your health care team may also include an oncology nurse, a registered dietitian, a mental health counselor, a social worker, a physical therapist, an occupational therapist, a speech therapist, and a physical medicine specialist.

You may want to ask your doctor these questions before you begin treatment:

  • What type of brain tumor do I have?
  • Is it benign or malignant?
  • What is the grade of the tumor?
  • What are my treatment choices? Which do you recommend for me? Why?
  • What are the expected benefits of each kind of treatment?
  • What can I do to prepare for treatment?
  • Will I need to stay in the hospital? If so, for how long?
  • What are the risks and possible side effects of each treatment? How can side effects be managed?
  • What is the treatment likely to cost? Will my insurance cover it?
  • How will treatment affect my normal activities? What is the chance that I will have to learn how to walk, speak, read, or write after treatment?
  • Would a research study (clinical trial) be appropriate for me?
  • Can you recommend other doctors who could give me a second opinion about my treatment options? How often should I have checkups?

What type of surgery is available for brain tumors?

Surgery is the usual first treatment for most brain tumors. Before surgery begins, you may be given general anesthesia, and your scalp is shaved. You probably won't need your entire head shaved.

Surgery to open the skull is called a craniotomy. The surgeon makes an incision in your scalp and uses a special type of saw to remove a piece of bone from the skull.

You may be awake when the surgeon removes part or all of the brain tumor. The surgeon removes as much tumor as possible. You may be asked to move a leg, count, say the alphabet, or tell a story. Your ability to follow these commands helps the surgeon protect important parts of the brain.

After the tumor is removed, the surgeon covers the opening in the skull with the piece of bone or with a piece of metal or fabric. The surgeon then closes the incision in the scalp.

Sometimes surgery isn't possible. If the tumor is in the brain stem or certain other areas, the surgeon may not be able to remove the tumor without harming normal brain tissue. People who can't have surgery may receive radiation therapy or other treatment.

You may have a headache or be uncomfortable for the first few days after surgery. However, medicine can usually control pain. Before surgery, you should discuss the plan for pain relief with your health care team. After surgery, your team can adjust the plan if you need more relief.

You may also feel tired or weak. The time it takes to heal after surgery is different for everyone. You will probably spend a few days in the hospital.

Other, less common problems may occur after surgery for a brain tumor. The brain may swell or fluid may build up within the skull. The health care team will monitor you for signs of swelling or fluid buildup. You may receive steroids to help relieve swelling. A second surgery may be needed to drain the fluid. The surgeon may place a long, thin tube (shunt) in a ventricle of the brain. (For some people, the shunt is placed before performing surgery on the brain tumor.) The tube is threaded under the skin to another part of the body, usually the abdomen. Excess fluid is carried from the brain and drained into the abdomen. Sometimes the fluid is drained into the heart instead.

Infection is another problem that may develop after surgery. If this happens, the health care team will give you an antibiotic.

Brain surgery may harm normal tissue. Brain damage can be a serious problem. It can cause problems with thinking, seeing, or speaking. It can also cause personality changes or seizures. Most of these problems lessen or disappear with time. But sometimes damage to the brain is permanent. You may need physical therapy, speech therapy, or occupational therapy.

You may want to ask your doctor these questions about surgery:

  • Do you suggest surgery for me?
  • How will I feel after the operation?
  • What will you do for me if I have pain?
  • How long will I be in the hospital?
  • Will I have any long-term effects? Will my hair grow back? Are there any side effects from using metal or fabric to replace the bone in the skull?
  • When can I get back to my normal activities?
  • What is my chance of a full recovery?

Radiation therapy for brain tumors

Radiation therapy kills brain tumor cells with high-energy x-rays, gamma rays, or protons.

Radiation therapy usually follows surgery. The radiation kills tumor cells that may remain in the area. Sometimes, people who can't have surgery have radiation therapy instead.

Doctors use external and internal types of radiation therapy to treat brain tumors:

  • External radiation therapy: You'll go to a hospital or clinic for treatment. A large machine outside the body is aimed to direct beams of radiation at either the whole brain or more commonly, at specific portions of the brain. Some people need radiation aimed at the spinal cord also. The treatment schedule depends on your age, and the type and size of the tumor. Fractionated external beam therapy, in which small doses or fractions of radiation are given usually once each day, is the most common method of radiation therapy used for people with brain tumors. Giving the total dose of radiation over several weeks helps to protect healthy tissue in the area of the tumor. Treatments are usually 5 days a week for several weeks. A typical visit lasts less than an hour, and each treatment takes only a few minutes.Some treatment centers are studying other ways of delivering external beam radiation therapy:
    • Intensity-modulated radiation therapy or 3-dimensional conformal radiation therapy: These types of treatment use computers to more closely target the brain tumor to lessen the damage to healthy tissue.
    • Proton beam radiation therapy: The source of radiation is protons rather than X-rays. The doctor aims the proton beam at the tumor. The dose of radiation to normal tissue from a proton beam is less than the dose from an X-ray beam.
    • Stereotactic radiation therapy: Narrow beams of X-rays or gamma rays are directed at the tumor from different angles. For this procedure, you wear a rigid head frame. The therapy may be given during a single visit (stereotactic radiosurgery) or over several visits.
  • Internal radiation therapy (implant radiation therapy or brachytherapy): Internal radiation isn't commonly used for treating brain tumors and is under study. The radiation comes from radioactive material usually contained in very small implants called seeds. The seeds are placed inside the brain and give off radiation for months. They don't need to be removed once the radiation is gone.

Some people have no or few side effects after treatment. Rarely, people may have nausea for several hours after external radiation therapy. The health care team can suggest ways to help you cope with this problem. Radiation therapy also may cause you to become very tired with each radiation treatment. Resting is important, but doctors usually advise people to try to stay as active as they can.

Also, external radiation therapy commonly causes hair loss from the part of the head that was treated. Hair usually grows back within a few months. Radiation therapy also may make the skin on the scalp and ears red, dry, and tender. The health care team can suggest ways to relieve these problems.

Sometimes radiation therapy causes brain tissue to swell. You may get a headache or feel pressure. The health care team watches for signs of this problem. They can provide medicine to reduce the discomfort. Radiation sometimes kills healthy brain tissue. Although rare, this side effect can cause headaches, seizures, or even death.

Radiation may harm the pituitary gland and other areas of the brain. For children, this damage could cause learning problems or slow down growth and development. In addition, radiation increases the risk of secondary tumors later in life.

You may want to ask your doctor these questions about radiation therapy:

  • Why do I need this treatment?
  • When will the treatments begin? When will they end?
  • How will I feel during therapy? Are there side effects?
  • What can I do to take care of myself during therapy?
  • How will we know if the radiation is working?
  • Will I be able to continue my normal activities during treatment?

Chemotherapy for brain tumors

Chemotherapy, the use of drugs to kill cancer cells, is sometimes used to treat brain tumors. Drugs may be given in the following ways:

  • By mouth or vein (intravenous): Chemotherapy may be given during and after radiation therapy. The drugs enter the bloodstream and travel throughout the body. They may be given in an outpatient part of the hospital, at the doctor's office, or at home. Rarely, you may need to stay in the hospital. The side effects of chemotherapy depend mainly on which drugs are given and how much. Common side effects include nausea and vomiting, loss of appetite, headache, fever and chills, and weakness. If the drugs lower the levels of healthy blood cells, you're more likely to get infections, bruise or bleed easily, and feel very weak and tired. Your health care team will check for low levels of blood cells. Some side effects may be relieved with medicine.
  • In wafers that are put into the brain: For some adults with high-grade glioma, the surgeon implants several wafers into the brain. Each wafer is about the size of a dime. Over several weeks, the wafers dissolve, releasing the drug into the brain. The drug kills cancer cells. It may help prevent the tumor from returning in the brain after surgery to remove the tumor. People who receive an implant (a wafer) that contains a drug are monitored by the health care team for signs of infection after surgery. An infection can be treated with an antibiotic.