What is a brain tumor?
A brain tumor is a cluster of abnormal cells growing in the brain. Brain tumors can be benign (non-cancerous) or malignant (cancerous). They can start growing in the brain - a primary tumor, or they can be formed when cancer cells from another part of the body travel to the brain - a metastatic brain tumor. Approximately half of all primary brain tumors are benign. All metastatic brain tumors are malignant. More than 110,000 people are diagnosed each year with a brain tumor. Approximately 80,000 of tumors are metastatic. There are more than a dozen different types of brain tumors and they are classified by level of malignancy, size and degree to which the cancer has spread. First, metastatic brain tumors often are formed when cancers of the lung, breast, colon, prostate and skin spread to the brain.
Improvements in treating these diseases have prolonged the life of victims, giving the cancer a greater opportunity to spread. Second, significant advances in diagnosing brain tumors have been made while many brain tumors may have gone undiagnosed in the past.
The Brain
The brain is a soft, spongy mass of tissue. It is protected by: The bones of the skull Three thin layers of tissue (meninges) Watery fluid (cerebrospinal fluid) that flows through spaces between the meninges and through spaces (ventricles) within the brain The brain directs the things we choose to do (like walking and talking) and the things our body does without thinking (like breathing). The brain is also in charge of our senses (sight, hearing, touch, taste, and smell), memory, emotions, and personality.
A network of nerves carries messages back and forth between the brain and the rest of the body. Some nerves go directly from the brain to the eyes, ears, and other parts of the head. Other nerves run through the spinal cord to connect the brain with the other parts of the body. Within the brain and spinal cord, glial cells surround nerve cells and hold them in place.
The three major parts of the brain control different activities:
Cerebrum: The cerebrum uses information from our senses to tell us what is going on around us and tells our body how to respond. It controls reading, thinking, learning, speech, and emotions. The cerebrum is divided into the left and right cerebral hemispheres. The right hemisphere controls the muscles on the left side of the body. The left hemisphere controls the muscles on the right side of the body.
Cerebellum: The cerebellum controls balance for walking and standing, and other complex actions.
Brain stem: The brain stem connects the brain with the spinal cord. It controls breathing, body temperature, blood pressure, and other basic body functions.
Tumor Grades and Types Tumor Grade Types of Primary Brain Tumors When most normal cells grow old or get damaged, they die, and new cells take their place. Sometimes, this process goes wrong.
New cells form when the body doesn't need them, and old or damaged cells don't die as they should. The buildup of extra cells often forms a mass of tissue called a growth or tumor.
Primary brain tumors can be benign or malignant:
Benign brain tumors do not contain cancer cells: Usually, benign tumors can be removed, and they seldom grow back. Benign brain tumors usually have an obvious border or edge. Cells from benign tumors rarely invade tissues around them. They don't spread to other parts of the body. However, benign tumors can press on sensitive areas of the brain and cause serious health problems. Unlike benign tumors in most other parts of the body, benign brain tumors are sometimes life threatening. Benign brain tumors may become malignant. Malignant brain tumors (also called brain cancer) contain cancer cells: Malignant brain tumors are generally more serious and often are a threat to life. They are likely to grow rapidly and crowd or invade the nearby healthy brain tissue. Cancer cells may break away from malignant brain tumors and spread to other parts of the brain or to the spinal cord. They rarely spread to other parts of the body.
Tumor Grade
Doctors group brain tumors by grade. The grade of a tumor refers to the way the cells look under a microscope:
Grade I: The tissue is benign. The cells look nearly like normal brain cells, and they grow slowly.
Grade II: The tissue is malignant. The cells look less like normal cells than do the cells in a Grade I tumor.
Grade III: The malignant tissue has cells that look very different from normal cells. The abnormal cells are actively growing (anaplastic).
Grade IV: The malignant tissue has cells that look most abnormal and tend to grow quickly. Cells from low-grade tumors (grades I and II) look more normal and generally grow more slowly than cells from high-grade tumors (grades III and IV). Over time, a low-grade tumor may become a highgrade tumor. However, the change to a high-grade tumor happens more often among adults than children. You may want to read the NCI fact sheet Tumor Grade.
Types of Primary Brain Tumors:
There are many types of primary brain tumors. Primary brain tumors are named according to the type of cells or the part of the brain in which they begin. For example, most primary brain tumors begin in glial cells. This type of tumor is called a glioma. Among adults, the most common types are: Astrocytoma: The tumor arises from star-shaped glial cells called astrocytes. It can be any grade. In adults, an astrocytoma most often arises in the cerebrum. Grade I or II astrocytoma: It may be called a low-grade glioma. Grade III astrocytoma: It's sometimes called a high-grade or an anaplastic astrocytoma. Grade IV astrocytoma: It may be called a glioblastoma or malignant astrocytic glioma. Meningioma: The tumor arises in the meninges. It can be grade I, II, or III. It's usually benign (grade I) and grows slowly. Oligodendroglioma: The tumor arises from cells that make the fatty substance that covers and protects nerves. It usually occurs in the cerebrum. It's most common in middle-aged adults. It can be grade II or III.
Among children, the most common types are:
Medulloblastoma: The tumor usually arises in the cerebellum. It's sometimes called a primitive neuroectodermal tumor. It is grade IV. Grade I or II astrocytoma: In children, this lowgrade tumor occurs anywhere in the brain. The most common astrocytoma among children is juvenile pilocytic astrocytoma. It's grade I. Ependymoma: The tumor arises from cells that line the ventricles or the central canal of the spinal cord. It's most commonly found in children and young adults. It can be grade I, II, or III. Brain stem glioma: The tumor occurs in the lowest part of the brain. It can be a low-grade or high-grade tumor. The most common type is diffuse intrinsic pontine glioma .
Symptoms:
The symptoms of a brain tumor depend on tumor size, type, and location. Symptoms may be caused when a tumor presses on a nerve or harms a part of the brain. Also, they may be caused when a tumor blocks the fluid that flows through and around the brain, or when the brain swells because of the buildup of fluid.
These are the most common symptoms of brain tumors: .
Headaches (usually worse in the morning) .Nausea and vomiting .Changes in speech, vision, or hearing .Problems balancing or walking .Changes in mood, personality, or ability to concentrate .Problems with memory .Muscle jerking or twitching (seizures or convulsions) Numbness or tingling in the arms or legs Most often, these symptoms are not due to a brain tumor. Another health problem could cause them. If you have any of these symptoms, you should tell your doctor so that problems can be diagnosed and treated.
Diagnosis: 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.
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.
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.
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?
Treatment Surgery Radiation Therapy Chemotherapy People with brain tumors have several treatment options. The options are surgery, radiation therapy, and chemotherapy. Many people get a combination of treatments. 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 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?
Surgery:
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 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 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.
Second Opinion
Before starting treatment, you might want a second opinion about your diagnosis and treatment plan. Some people worry that the doctor will be offended if they ask for a second opinion. Usually the opposite is true. Most doctors welcome a second opinion. And many health insurance companies will pay for a second opinion if you or your doctor requests it. Some companies require a second opinion. If you get a second opinion, the doctor may agree with your first doctor's diagnosis and treatment plan. Or the second doctor may suggest another approach.
Either way, you'll have more information and perhaps a greater sense of control. You can feel more confident about the decisions you make, knowing that you've looked at your options. It may take some time and effort to gather your medical records and see another doctor. In many cases, it's not a problem to take several weeks to get a second opinion. The delay in starting treatment usually won't make treatment less effective. To make sure, you should discuss this delay with your doctor. Some people with a brain tumor need treatment right away.
Return to healthy eating: While healthy eating by itself cannot keep cancer from coming back, it can help you regain strength, rebuild tissue, and improve how you feel after treatment ends. Here are some ways to eat well after treatment ends: .Prepare simple meals that you like and are easy to make. .Cook 2 or 3 meals at a time. Freeze the extras to eat later on. .Stock up on frozen dinners. .Make cooking easy, such as buying cut-up vegetables from a salad bar. .Eat many different kinds of foods. No single food has all the vitamins and nutrients you need. .Eat lots of fruits and vegetables. This includes eating raw and cooked vegetables, fruits, and fruit juices. These all have vitamins, minerals, and fiber. .Eat whole wheat bread, oats, brown rice, or other whole grains and cereals. These have needed complex carbohydrates, vitamins, minerals, and fiber. .Add beans, peas, and lentils to your diet and eat them often. .Go easy on fat, salt, sugar, alcohol, and smoked or pickled foods. .Choose low-fat milk products. .Eat small portions (about 6 to 7 ounces each day) of lean meat and poultry without skin. .Use low-fat cooking methods, such as broiling, steaming, grilling, and roasting.
Follow-up Care After Cancer Treatment
.How are follow-up care schedules planned?
The frequency and nature of follow-up care is individualized based on the type of cancer, the type of treatment received, and the person’s overall health, including possible treatment-related problems. In general, people return to the doctor for follow-up appointments every 3 to 4 months during the first 2 to 3 years after treatment, and once or twice a year after that. At these follow-up appointments, the doctor may recommend tests to check for recurrence or to screen for other types of cancer. In many cases, it is not clear that special follow-up tests improve survival or quality of life.
This is why it is important for the doctor to help determine what follow-up care plan is appropriate. The doctor may not need to perform any tests if the person appears to be in good physical condition and does not have any symptoms. It is important for the patient to talk with the doctor about any questions or concerns related to the follow-up care plan. When planning a follow-up care schedule, patients should consider who will provide the follow-up care and who will provide other medical care. They should select a doctor with whom they feel comfortable. This may be the same doctor who provided the person’s cancer treatment. For other medical care, people should continue to see a family doctor or medical specialist as needed. Some people might not have a choice in who provides their follow-up care, because some insurance plans pay for follow-up care only with certain doctors and for a set number of visits.
In planning follow-up care, patients may want to check their health insurance plan to see what restrictions, if any, apply to them.
What should patients talk to their doctor about once cancer treatment ends?
Every cancer survivor should request a comprehensive care summary and follow-up plan from their doctor once they complete their treatment. Patients should ask their doctor the following questions once cancer treatment ends. The answers can help inform the patient about their care and what to expect next.
(See Question 7 for more information about plans for follow-up care.) .
What treatments and drugs have I been given?
How often should I have a routine visit?
Which doctor should I see for my follow-up cancer care?
What are the chances that my cancer will come back or that I will get another type of cancer?
What follow-up tests, if any, should I have?
How often will I need these tests?
What symptoms should I watch for?
If I develop any of these symptoms, whom should I call?
What are the common long-term and late effects of the treatment I received?
What should I do to maintain my health and well-being?
Will I have trouble getting health insurance or keeping a job because of my cancer?
Are there support groups I can turn to?
Many patients find it helpful to write these questions down and take notes or tape record their discussions with the doctor to refer to at a later time
