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Brain, Spine and Skull Base Cancer Program

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Treating a brain, spine, or skull base tumor begins with accurately diagnosing the tumor type then determining course of treatment.

Diagnosis

Diagnosing a brain, spine, or skull base tumor may involve one or more of the following:

Neurological Exam
A neurological exam assesses the brain and the major nerves that relay information to and from the brain. This exam can include the following tests:

  • Eye movement test. The patient follows an object with their eyes.
  • Pupil reaction test. A light is flashed into the patient's eye to see how the pupil reacts to the light.
  • Optic nerve test. The physician looks into the eye with a special tool to asses if the nerve is swollen due to pressure on the brain.
  • Reflex test. The physician taps reflex points on the body such as the knee, wrist, and elbow.
  • Balance and coordination test.The patient walks on his or her heels and toes.
  • Facial muscles test. The patient smiles and grimaces.
  • Tongue movement test. The patient sticks out his or her tongue.
  • Mental status test. The patient answers questions that address judgment.
  • Abstract thinking test. The patient answers questions that address reasoning.
  • Memory test. The patient answers questions that require accessing short- and long-term memory.
  • Motor strength test. Strength in major muscle groups is tested to determine any muscular weakness.
  • Sensory testing. The patient's skin sensation is tested using light touch, pinpricks, and warm or cold objects to determine any deficits.

These non-invasive tests provide the physician with helpful information. The doctor will explain what the results mean and any steps to further diagnose what's causing the symptoms. Abnormal results do not necessarily mean a person has a brain tumor; other diseases can lead to abnormal neurological exam results. For this reason, the doctor may recommend lab work and/or medical imaging.

Medical Imaging
Medical imaging such as magnetic resonance imaging (MRI) and computerized tomography (CT) are used to produce an electronic image of the brain, spinal fluid, and bones. These images are then viewed by a neuroradiologist, a doctor who has special training to identify normal anatomy from abnormal areas.

These images help the physician determine if signs and symptoms from the neurological exam are the result of a tumor or lesion in the brain. They also help rule out any other neurological disease that could be causing the symptoms. Images can locate the tumor, show involved structures, determine tumor size, and help lead to a diagnosis of the tumor type.

A special MRI called a magnetic resonance spectroscopy (MRS) may also be used to evaluate the chemical composition of normal brain tissue and compare it to abnormal brain tissue.

Laboratory Test
A lumbar puncture (spinal tap) is a procedure that involves collecting cerebrospinal fluid (CSF).

Once a sample is collected, it is sent to the lab to test it for any infection, tumor cells, or protein, and to see if any blood is present. This information is helpful to diagnose particular types of cancers.

Blood and/or urine tests may be done to examine if the tumor is impacting or involving the endocrine system of the brain (the pituitary and hypothalamus, specifically).

Biopsy
A biopsy is a surgical procedure that removes a small amount of the tumor for inspection by a pathologist, a physician who specializes in identifying cells within tissue. The pathologist will determine the exact type of tumor. Biopsies are also conducted as a part of a surgery when attempting to remove the tumor.

There are two types of biopsies:

  • Open biopsy. During this procedure, surgery is performed to expose the tumor and remove a tissue sample.
  • Stereotactic needle biopsy. During this procedure, a small incision is made into the skin and a hole is drilled into the skull. A needle is then maneuvered into the tumor under computer guidance and a small amount of the tumor is aspirated into the needle. This procedure provides a safer approach to difficult biopsies or tumors that are deep in the brain or located in or around critical areas.

Treatments

Once a diagnosis is made, the doctor will discuss the many different ways to help treat and manage the specific type of tumor. A patient may be referred to one or more of the following:

Surgery
Surgery is often the first option considered and the preferred first step for treatment. The purpose of surgery is to do the following:

  • Remove as much of the tumor as possible
  • Retrieve tissue for a biopsy and determine tumor type
  • Reduce the size of the tumor to alleviate pressure caused by the tumor and to reduce the amount of tumor treated by chemotherapy and/or radiation
  • Provide a way for chemotherapy to be administered directly to the tumor
  • Help reduce the symptoms caused by the tumor

An "awake" surgery is sometimes necessary for patients with tumors in locations close to speech or motor areas. Patients receive sedation for the majority of the surgery, but are allowed to regain consciousness with adequate pain control and sedation to allow for neurological testing during the tumor removal.

During the appointment visit, the doctor will discuss all pros and cons, risk and benefits, and potential side effects of surgery.

For some patients, surgery isn't an option due to the following:

  • Tumor location. Depending on the location of the tumor, surgery may cause damage to parts of the brain that control speech, movement, hearing, or vision.
  • General health of the patient. Patients with a history of heart, lung, and other medical conditions may not be candidates for surgery.
  • Tumor type. Small, benign tumors that don't increase in size, do not cause any symptoms, and are considered stable may not require surgery.

Chemotherapy
During the appointment, the neuro-oncologist will determine if the patient is a candidate for chemotherapy.

Chemotherapy is the use of medicines to treat or manage malignant, high grade, low grade, and benign tumors. The goal of chemotherapy is to slow, stop, or kill rapid, uncontrollable cell growth. Chemotherapy drugs that slow or stop tumor cells are called cytostatic. Chemotherapy drugs that kill the tumor cells are called cytotoxic.

Chemotherapy works in one of two ways:

  • Cell-cycle-specific chemotherapy works by interrupting one of the steps necessary for a cell to divide.
  • Non-cell-cycle-specific chemotherapy is effective during any part of cell division.

These drugs are sometimes used together to provide a wider range of treatment.

Chemotherapy is given in different ways:

  • Systemic chemotherapy is given through the body orally or intravenously.
  • Local chemotherapy is delivered through doses within or around a tumor. To provide this type of delivery, the surgeon places a "wafer" directly onto the tumor or places a catheter in spaces in the brain so the chemotherapy can be injected directly into the spaces. This allows the chemotherapy to have direct contact with the tumor.

The most common side effects of chemotherapy include the following:

  • Diarrhea
  • Mouth sores
  • Fatigue
  • Nausea
  • Vomiting
  • Risk of infection (neutropenia)

Inform the neuro-oncologist of any side effects that occur. There are many options for managing side effects.

During chemotherapy, tests are performed to track the treatment's effectiveness.

Radiation Therapy
The purpose of radiation is to kill the cell directly or halt the cell from progressing. Radiation affects both tumor cells and healthy cells, but the healthy cells have a faster recovery rate. As radiation treatment continues, the tumor cells die and the tumor reduces in size.

Some patients, depending on the tumor type, will receive radiation and chemotherapy at the same time. This is called concurrent therapy.

Radiation treatment is an outpatient procedure and requires little preparation on the patient's part. On a patient's first visit, a mask of the patient's face is made to insure that the radiation is delivered precisely each treatment. After the mask is made, a technician takes the patient to a treatment room. The patient lies on a table, the mask is secured, and the technician leaves. The patient is monitored on close-circuit television and can communicate with the technician.

Radiation treatment is painless and quick. During treatment some people experience an unusual smell or see flashes of light even with closed eyes. The patient will hear noises made by the machine and will experience periodic pauses as the technician adjusts the machine or the patient. The typical treatment schedule is five times a week for six weeks. The radiation oncologist will discuss the best treatment plan for each patient.

The main types of radiation treatments for patients with brain, spine, and skull base tumors are whole brain radiation, stereotactic radiosurgery, and stereotactic radiotherapy.

  • Whole Brain Radiation: This process delivers radiation to a patient's entire brain. The indications for whole brain radiation are dependent upon the size of the tumor, the location of the tumor, the number of lesions in the brain, and the type of brain tumor.
  • Stereotactic Radiosurgery: This technique delivers a high dose of radiation to a small, well-defined area. The goal is to kill cancerous tissue within a targeted area while sparing surrounding normal tissue. Stereotactic radiosurgery treats both primary brain tumors and those that have metastasized to the brain from another site. As with any treatment, it has advantages and disadvantages. The main limitation is determined by the size of the tumor (the larger the tumor the less likely it can be treated). The advantage is that it provides the ability to treat tumors almost anywhere in the brain and spare nearby critical tissue. This technique is done on an outpatient basis and offers a good option for people who may be poor candidates for surgery.
  • Stereotatic Radiotherapy: This is the same concept as stereotactic radiosurgery, but it is repeated several times using a smaller dose of radiation.

Possible side effects of radiation include the following:

  • Fatigue
  • Hair Loss
  • Skin Changes
  • Brain swelling (edema)

Patients experiencing any of these side effects should discuss them with their health care team.