Brain Cancer (cont.)

Medical Author:

Charles Patrick Davis, MD, PhD

Charles Patrick Davis, MD, PhD

Dr. Charles "Pat" Davis, MD, PhD, is a board certified Emergency Medicine doctor who currently practices as a consultant and staff member for hospitals. He has a PhD in Microbiology (UT at Austin), and the MD (Univ. Texas Medical Branch, Galveston). He is a Clinical Professor (retired) in the Division of Emergency Medicine, UT Health Science Center at San Antonio, and has been the Chief of Emergency Medicine at UT Medical Branch and at UTHSCSA with over 250 publications.

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Medical Editor:

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, Chief Medical Editor

Melissa Conrad Stöppler, MD, is a U.S. board-certified Anatomic Pathologist with subspecialty training in the fields of Experimental and Molecular Pathology. Dr. Stöppler's educational background includes a BA with Highest Distinction from the University of Virginia and an MD from the University of North Carolina. She completed residency training in Anatomic Pathology at Georgetown University followed by subspecialty fellowship training in molecular diagnostics and experimental pathology.

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Treatment of brain cancer is usually complex. Most treatment plans involve several consulting doctors.

• The team of doctors includes neurosurgeons (surgical specialists in the brain and nervous system), oncologists, radiation oncologists (doctors who practice radiation therapy), and of course, your primary health-care provider. A patient's team may include a dietitian, a social worker, a physical therapist, and probably other specialists.
• The treatment protocols vary widely according to the location of the tumor, its size, grade, and type, the patient's age, and any additional medical problems that the person may have.
• The most widely used treatments are surgery, radiation therapy, and chemotherapy. In some cases, more than one of these treatment types is used.

Most people with a brain tumor undergo surgery.

• The purposes of surgery are to confirm that the abnormality seen on the brain scan is indeed a tumor, to assign a grade to the tumor, and to remove the tumor. If the tumor cannot be removed, the surgeon will take a sample of the tumor to identify its type and grade.
• In some cases, mostly in benign tumors, symptoms can be completely cured by surgical removal of the tumor. A neurosurgeon will attempt to remove the tumor when possible.

Patients may undergo several treatments and procedures before surgery.

• They may be given a steroid drug, such as dexamethasone (Decadron), to relieve swelling.
• They may be treated with an anticonvulsant drug, such as levetiracetam (Keppra), phenytoin (Dilantin), or carbamazepine (Tegretol), to relieve or prevent seizures.

Overview of surgery for resection of brain tumor

The intent of surgery for tumors is to remove as much of the tumor as is safely possible with the minimal possible loss in brain function. The large majority of patients undergo this procedure under general anesthesia. Some surgeries are done awake or under light sedation for the purpose of mapping language function. For surgery done under general anesthesia, an endotracheal tube is placed, while for those done awake, a laryngeal mask airway (or no airway) is placed and the patient is deeply sedated. The head is appropriately positioned using a clamp system that holds the skull motionless. An image-guided navigation system is often used to help determine the precise location of the incision. The scalp is prepped, after the hair is clipped, the planned incision line is infiltrated with local anesthesia, and the scalp is then incised and pushed aside to expose the skull bone. A portion of the skull is temporarily cut away and the lining tissues of the brain are opened. If it is necessary to determine whether brain function is compromised, the patient is awakened from sedation in order to respond as mapping procedures are carried out.

In either case, tumor resection is then carried out. A portion of the tumor is usually sent to a pathologist for analysis. The surgeon may also decide to place biodegradable polymer wafers that deliver chemotherapy drugs (Gliadel wafers) into the tumor cavity. Once the tumor resection is complete, the membranes surrounding the brain are closed and the skull is closed, often with the use of titanium plates and screws that help hold it rigidly in its desired position. The scalp is closed; some surgeons use drains placed under the scalp for a day or two after surgery to minimize the accumulation of blood or fluid.

• Stereotactic radiosurgery is a newer "knifeless" technique that destroys a brain tumor without opening the skull. CT or MRI scan is used to pinpoint the exact location of the tumor in the brain. High-energy radiation beams are trained on the tumor from different angles. The radiation destroys the tumor. Equipment used to do radiosurgery varies in its radiation source; a gamma knife uses focused gamma rays, and a linear accelerator uses photons, while heavy-charged particle radiosurgery uses a proton beam.
• The advantages of knifeless procedures are that they have fewer complications and the recovery time is much shorter. Disadvantages include the lack of tissue available to send to a pathologist for diagnosis and brain swelling that can occur after the radiation therapy.
• If patients have excess cerebrospinal fluid buildup, a thin plastic tube called a shunt may be placed to drain the fluid. One end of the shunt is placed in the cavity where fluid collects, and the other is threaded under the skin to another part of the body. The fluid drains from the brain to a site from which the fluid can be easily eliminated.