Brain Tumor Surgery is the first mode of treatment for a benign or cancerous brain tumour, if it is in an operable area, with minimum risk of neurological damage.
Primary brain tumours are those originating in the brain itself. Secondary tumours are those that metastasise from other parts of the body most commonly from lung, breast, kidney, colon, and skin. There are no proven causes or risk factors for primary brain tumours except in children who get irradiation to the head, rare genetic conditions like neurofibromatosis, and adults in the age group of 65 to 79 years who are more prone to develop brain tumours.
Surgery is usually done to
Common types of brain tumours
Different types of cells make up the brain and central nervous system and tumours can arise from any of these cell groups. The commonest types seen are
Brain tumours are usually benign, their borders are well defined and they do not infiltrate the brain tissue, and hence easy to enucleate. However, they can recur after surgery. These tumours can also damage the surrounding brain cells and cause disabilities, or be life threatening if arising in a sensitive part of the brain.
Primary cancerous tumours spread to other parts of the brain and spinal cord only and not to other parts of the body.
Brain tumour grading
Grading of the tumour is on the basis of how normal or abnormal the cells look, and on how fast the tumour is going to grow and spread.
Very rarely, a benign tumour can turn cancerous, and a lower-grade tumour may recur as a higher grade tumour.
Symptoms of brain tumours
Symptoms of brain tumours are based on the type of tumour, and its location as different areas of the brain control different functions of the body, and the related symptoms.
Some tumours have no symptoms until they are quite large and then cause a serious, rapid decline in health. Other tumours may have symptoms that develop slowly. The most common symptoms are
It should also not be assumed that manifesting any of these symptoms means the cause is a brain tumour.
Diagnosing a brain tumour
The different ways of diagnosing a brain tumour and assessing its type is by the following methods:
Treatment of brain tumours
Treatment depends on the type and grade of the cancer, its location, size, age of patient and the general health status. Each of the following treatment modalities can be administered individually or in combination based on the requirements.
During the treatment, surrounding brain tissue can be damaged and hence counselling of patients for side effects and the adjuvant treatment for the same should be discussed. It is also important to consider and plan physical rehabilitation for any possible sequelae. This rehab will involve a physical therapist, speech therapist and an occupational therapist.
The common surgeries performed for brain tumours are
Chemotherapy for brain tumours
Chemotherapy is the use of anti-cancer drugs orally or through a vein to allow the drug to reach cancer cells throughout the body. For general information on cancer chemotherapy, click here. Chemotherapy is generally used to treat faster growing brain tumors viz. medulloblastoma and lymphoma, and these respond well to chemotherapy. Sometimes, the drugs are given directly into the cerebrospinal fluid space (CSF) either directly around the brain or though the spinal column for which a ventricular access catheter is inserted through a small hole in the skull. (see the Surgery brain tumours section). Chemotherapy is used individually or in combination with surgery and/or radiation therapy.
Some of the chemo drugs used to treat brain tumours include Carboplatin, Carmustine (BCNU), Cisplatin, Cyclophosphamide, Etoposide, Irinotecan, Lomustine (CCNU), Methotrexate, Procarbazine, Temozolomide and Vincristine. Carmustine dissolvable wafers are sometimes placed directly on to the site from where the tumour has been removed and this concentrates the drug at the tumour site, reducing the chances of systemic side effects.
Side effects of chemotherapy
Rapidly multiplying normal cells are also affected by chemotherapy drugs and the damage to these cells add to the side effects of the chemo drugs. Possible side effects depend on the drugs and the number of cycles administered and include
Usually these stop soon after treatment is completed, but specifically, drugs like cisplatin and carboplatin can cause kidney damage and hearing loss.
Radiation for brain tumours
Detailed information on Radiation therapy is given in Radiation Oncology.
Gamma Knife surgery for brain tumours
Gamma Knife/ Stereotactic Radiosurgery/ Cyber Knife is not an actual surgical procedure in the true sense of the word as there is no surgical incision made. Specialized medical equipment is used to deliver several small beams of radiation on a tumour with a great level of accuracy. Small multiple beams are made to converge on a certain point on the tumour or area for treatment, and together create a strong dose of radiation to kill/alter tumour cells.
Reasons for Gamma Knife Surgery
This is an alternative to conventional brain surgery for some specific conditions such as brain tumours, arteriovenous malformations (AVM – abnormal blood vessels in the brain), trigeminal neuralgia, some specific forms of epilepsy, etc. It is used especially when the tumour or AVM is hard to reach/visualize and when a less invasive method of treatment is preferred by the treating doctors and the patient.
Description of the Procedure
Before the Procedure
During the Procedure
After the Procedure
After the procedure, the head frame is removed. There may be slight pain at the sites where the pins are inserted. Some patients experience headache and nausea after the procedure and these are treated with medications. The patient can eat and drink normally after the procedure. Although the procedure per se is an outpatient procedure, the whole process of scanning and treatment usually takes up the entire day. Some patients are advised to stay overnight for observation.
Risks / Complications
As with any procedure, complications can occur. But since this procedure does not involve anaesthesia and incisions, complications / side effects are far less compared to conventional neurosurgery. Some of the early complications that can occur include:
These effect are usually temporary although some patients do experience long term side effects.
Unlike conventional surgery, the results of treatment can be seen over a period of time. They are not immediate. It usually depends on the condition being treated. In case of benign tumours of the brain, Gamma knife radiosurgery prevents the tumour from growing any further. The tumour may shrink in size over a period of time ranging anywhere from 6 months to 24 months. Regular reviews and scans will show the effect of the treatment.
In malignant tumours, the tumours usually shrink rapidly within a few months. Follow-up visits should be meticulously adhered to in order to monitor the progress of the recovery.
In epilepsy, it may take 18 to 24 months for the seizures to resolve. But it must be noted that not all types of epilepsy can be treated with Gamma knife radiosurgery.
In Arterio Venous Malformations, Gamma knife radiosurgery is used to gradually close off the feeder vessels and can take about 2 years.
In Trigeminal Neuralgia, this procedure creates a scar that blocks the pain signals from passing along the trigeminal nerve with substantial pain relief achieved after several months.
Brain surgery is unlike most other major surgeries in that the recovery can be deceiving. The brain does not experience pain, and the skin incision usually is not painful either. You may feel the day after surgery that nothing has changed. However, you have to remember that with any major surgery like brain surgery you need time to recover beyond the time needed for the incision to heal. You may look like your old self and your family may feel that you look like you have completely recovered relatively recently after surgery. Also, it is very common for all patients to have significant emotional reactions to big surgery such as this- particularly depression and anxiety, and this too is normal and will subside with time
From the day of surgery until the initial post-op visit (around two weeks after surgery) you should not lift anything heavier than a gallon of milk, and avoid any activities that could increase brain pressure, like straining or bending over at the waist. After your staples are out (roughly two weeks after surgery) you can liberalize your activities considerably. You can fly on a plane, you can do basically anything that you feel comfortable doing. You must not overstrain yourself. You may find that you are still easily fatigued, that is normal. You may also find that your level of energy and other surgery related symptoms – dizziness/ lightheadness, etc. wax and wane in severity. Some days may be better than others. This is also normal. For brain tumors, most patient feel able to return to work between six and twelve weeks after surgery
Whether radiosurgery is being used for metastatic disease, benign tumors, an arteriorvenous malformation, or another indication, there is always the risk of radiation complications.
Immediate complications include swelling of the brain at the border of the radiation target site. This may cause headache, nauseas, or if severe an altered level of consciousness.
Delayed side effects are reactions to the radiation that occur in weeks to months after treatment. In general they can usually be successfully managed with oral steroids.
Late complications of radiation treatment are principally thought to be radiation induced tumor formation.
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