Physicians Perspective

Treating Brain Tumors in the 21st Century

The discovery of a brain mass can be a frightening and confusing experience for a patient. The presentation of symptoms and diagnostic workup are often nuanced and can be fraught with anxiety and uncertainty for patients and their loved ones. Thanks to recent advances, however, we now have more options and technology than ever before for effectively treating and managing brain tumors. As we continue to make strides in medicine, survival and meaningful outcomes for these patients continue to improve. 

Intracranial tumors—abnormal masses of tissue that grow unchecked in the brain, no longer subject to the mechanisms that typically control normal cell growth—can be broadly grouped as primary versus metastatic.

Primary brain tumors, which are lesions that originate from brain tissue or from nearby areas surrounding the brain, can be malignant (cancerous) or benign (noncancerous). Although benign tumors generally grow less quickly, they still can result in neurologic dysfunction caused by brain compression, cerebral edema or the obstruction of cerebrospinal fluid outflow.

Most brain tumors are metastatic lesions, meaning that they arise from cancer cells originating in another part of the body and traveling to the brain. Metastatic brain tumors can occur in 10–30% of adults with systemic cancer. Certain types of cancer, such as lung and breast cancer, are more prone to metastatic spread to the brain. By definition, metastatic lesions to the brain are considered malignant.

Brain Tumor Symptoms

Varying based on the location of a brain tumor and its surrounding structures, symptoms can include headaches, weakness on one side of the body, confusion and memory loss, changes in personality, seizures, difficulty using and understanding language, nausea and vomiting, vision changes, hearing loss, or difficulty with balance.

Occasionally, the patient may have no obvious symptoms. Asymptomatic tumors are often found incidentally on routine oncology screenings or on cranial imaging performed for other reasons, such as head trauma.

Managing Brain Tumors

Techniques for managing intracranial tumors can vary, depending on the type of lesion and the location of the mass. Certain tumors, such as meningiomas (tumors that form in the tissue surrounding the brain), can be slow-growing and, if asymptomatic, may be monitored with MRI imaging taken at specific time intervals to check for tumor growth.

When needed, brain tumor treatment typically consists of surgery, radiation and chemotherapeutic agents—or some combination of the three. A multidisciplinary approach involving neurosurgery, medical oncology and radiation oncology allows for a comprehensive treatment plan, and is proven to improve outcomes for the patient.

Surgical Treatment Options

The goal of the neurosurgeon is typically to achieve maximal, safe tumor resection—to remove as much of the brain tumor as possible without worsening neurologic function. Surgery is typically accomplished through the skull by a craniotomy, a surgical procedure in which a portion of the skull is temporarily removed to access the brain. 

Occasionally, due to the location of a lesion, a biopsy to obtain tissue diagnosis is recommended, either before or in lieu of a craniotomy. This can be performed using a less invasive procedure called a stereotactic brain biopsy. Some lesions are actually best treated without resection, and a stereotactic brain biopsy enables tumor diagnosis without the more involved craniotomy procedure.

Technology for cranial surgery has advanced substantially over the past few decades. 3D navigation systems have been developed and refined, allowing the neurosurgeon to locate the tumor accurately and precisely, as well as to better understand the orientation of the mass and vital surrounding structures in the brain. These systems can aid in tumor resection while minimizing impact to the surrounding brain tissue, as well as permit stereotactic biopsies of tumors through very small incisions.

Tumors are sometimes located within or near areas of the brain that are essential for movement or language. In such cases, techniques such as intraoperative motor and/or language mapping can assist in determining whether an entire tumor, or certain portions of a tumor, can be safely resected. Intraoperative language mapping is performed on a conscious patient (awake craniotomy) in order to map the anatomy vital to language function, optimize tumor resection and help preserve critical neurological functions.

Another concern involves the development of vasculature, or blood vessels, around a tumor, raising the chance of increased blood loss during surgical resection. In these cases, surgeons can use neurointerventional radiology techniques to enter the blood vessels of the brain and block off those vessels that are supplying blood to a tumor.

Treating Brain Tumors with Radiation 

Radiation therapy utilizes high-energy radiation to control and kill cancer cells, thus decreasing the size of a brain tumor. Techniques range from whole-brain radiation to stereotactic radiosurgery, which uses multiple beams to target a tumor and limit injury to normal tissue.

Radiation can be used in different scenarios, including cases where a tumor cannot be surgically resected. It is also frequently used as an adjunct after surgical tumor resection to control recurrence of the tumor. 

Recently, there has been more evidence supporting the use of stereotactic radiosurgery for metastatic tumors prior to surgery, potentially decreasing the risk of harming healthy surrounding brain tissue. Such preoperative treatment also may decrease incidence of leptomeningeal disease, a condition that occurs when cancer cells migrate into the cerebrospinal fluid that bathes the brain and spinal cord.

Systemic Therapies

Systemic therapies such as chemotherapy and immunotherapy are often used in addition to the aforementioned treatments. The brain is a privileged space in the body, however, and the blood-brain barrier can impede the effectiveness of systemic therapies. 

In certain situations, intrathecal treatment, in which chemotherapeutic agents are injected directly into the cerebrospinal fluid space, can be beneficial.

Neurosurgery and Neurosciences at Sentara Martha Jefferson Hospital

The diagnosis of a brain tumor is an often unexpected and frightening experience for the patient. Our team of neurosurgeons, neurologists and neurointerventional radiologists is highly trained and skilled in diagnosing and treating a comprehensive range of neurological conditions—from common problems like traumatic brain injuries to highly complex brain tumors. We collaborate closely with medical oncologists, radiation oncologists and rehabilitation specialists to provide patients with safe, effective and comprehensive treatment options for optimal outcomes and improved quality of life.

CALLOUT:

To learn more about Sentara Martha Jefferson Neurosciences, visit Sentara.com or call 434-654-8960. 

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