Seminar On Brain Tumor
Seminar On Brain Tumor
Seminar On Brain Tumor
Introduction:-
A brain tumor is a localized intracranial lesion that occupies space within the skull. A tumor
usually grows as a spherical mass, but it also can grow diffusely and infiltrate tissue. The
effects of neoplasms are caused by the compression and infiltration of tissue.
Benign tumours usually have slow-growing cells and clear borders (margins), and they rarely
spread. However, they may be found in essential areas of the brain that control vital life
functions, which can make them life-threatening. Malignant tumours usually grow rapidly
and spread within the brain and spinal cord. Malignant brain tumours can also be life-
threatening. About 40% of brain and spinal cord tumours are malignant.
Definition:-
Brain and spinal cord tumors are masses of abnormal cells in the brain or spinal cord that
have grown out of control.
Or
A tumour occurs when cells in the central nervous system grow and divide in an
uncontrollable way, forming a lump. The lump may press on or grow into different areas of
the brain or spinal cord, which can cause various symptoms such as loss of movement. A
tumour can be benign or malignant, but sometimes it is difficult to tell the difference between
them.
Anatomy & Physiology of Central Nervous System:-
To understand brain and spinal cord tumors, it helps to know about the normal structure and
function of the central nervous system (CNS), which is the medical name for the brain and
spinal cord.
The brain is the center of thought, feeling, memory, speech, vision, hearing, movement, and
much more. The spinal cord and special nerves in the head called cranial nerves help carry
messages between the brain and the rest of the body. These messages tell our muscles how to
move, transmit information gathered by our senses, and help coordinate the functions of our
internal organs. The brain is protected by the skull. Likewise, the spinal cord is protected by
the bones (vertebrae) of the spinal column. The brain and spinal cord are surrounded and
cushioned by a special liquid, called cerebrospinal fluid (CSF). Cerebrospinal fluid is made
by the choroid plexus, which is located in spaces within the brain called ventricles. The
ventricles and the spaces around the brain and spinal cord are filled with CSF.
Spinal cord: The spinal cord has bundles of very long nerve fibers that carry signals that
control muscles, sensation or feeling, and bladder and bowel control. Spinal cord tumors can
cause weakness, paralysis, or numbness. The spinal cord is a narrow structure, so tumors
within it usually cause symptoms on both sides of the body (for example, weakness or
numbness of both legs). This is different from most brain tumors, which often affect only one
side of the body. The nerves that reach the arms begin in the spinal cord at the level of the
neck (cervical spine). Nerves that branch off the spinal cord to the legs, bowel, and bladder
arise in the back (thoracic and lumbar spine). Most tumors of the spinal cord start in the neck
(cervical spine) and can cause symptoms in the arms and legs, as well as affect bowel and
bladder function. Spinal cord tumors below the neck only affect the legs and bowel and
bladder function.
Tumors that start in the brain (primary brain tumors) are not the same as tumors that start in
other organs, such as the lung or breast, and then spread to the brain (metastatic or secondary
brain tumors). In adults, metastatic tumors to the brain are actually more common than
primary brain tumors. Brain tumors may be classified into several groups: those arising from
the coverings of the brain (eg, dural meningioma), those developing in or on the cranial
nerves (eg, acoustic neuroma), those originating within brain tissue (eg, glioma), and
metastatic lesions originating elsewhere in the body. Tumors of the pituitary and pineal
glands and of cerebral blood vessels are also types of brain tumors. The most common types
of tumor are as follows:
I. INTRACEREBRAL TUMOR:
A. Gliomas: Glial tumors, the most common type of intracerebral brain neoplasm.
Gliomas are not a specific type of brain tumor. It is a general term for a group of
tumors that start in glial cells. About 3 out of 10 of all brain tumors are gliomas. Most
fast-growing brain tumors are gliomas. It infiltrate in any portion of the brain.
1. Astrocytomas:- Astrocytomas are tumors that start in glial cells called astrocytes.
Astrocytomas are the most common type of glioma and are graded from I to IV,
indicating the degree of malignancy. The grade is based on cellular density, cell
mitosis, and appearance. Usually, these tumors spread by infiltrating into the
surrounding neural connective tissue and therefore cannot be totally removed without
causing considerable damage to vital structures.
Astrocytomas are often classified as high grade, intermediate grade, or low grade, based
largely on how the cells look under the microscope:
High grade astrocytomas, known as glioblastomas (or glioblastoma multiforme),
are the fastest growing. These tumors make up about two-thirds of astrocytomas and
are the most common malignant brain tumors in adults.
Intermediate-grade astrocytomas, or anaplastic astrocytomas, grow at a moderate
rate.
Low-grade (diffuse) astrocytomas tend to be slow growing, but they can become more
aggressive and fast growing over time.
Some low-grade types called non-infiltrating astrocytomas do not usually grow into
nearby tissues and tend to have a good prognosis. These include pilocytic
astrocytomas and dysembryoplastic neuroepithelial tumors (DNETs). They are more
common in children than in adults.
Grade II (atypical or invasive) meningiomas usually have cells that look slightly more
abnormal. About 15% to 20% of meningiomas are grade II. They can grow directly
into nearby brain tissue and bone and are more likely to come back (recur) after
surgery.
Grade III (anaplastic) meningiomas have cells that look the most abnormal. They
make up only about 1% to 3% of meningiomas. They tend to grow quickly, can grow
into nearby brain tissue and bone, and are the most likely to come back after
treatment. Some may even spread to other parts of the body.
B. Neuromas:
1. Acoustic neuroma:- An acoustic neuroma is a tumor of the eighth cranial nerve, the
cranial nerve most responsible for hearing and balance. It usually arises just within
the internal auditory meatus, where it frequently expands before filling the
cerebellopontine recess. An acoustic neuroma may grow slowly and attain
considerable size before it is correctly diagnosed. As the tumor becomes larger,
painful sensations of the face may occur on the same side, as a result of the tumor’s
compression of the fifth cranial nerve. Many acoustic neuromas are benign and can
be managed conservatively. Many that continue to grow can be surgically removed
and have a good prognosis. Some acoustic neuromas may be suitable for stereotactic
radiotherapy rather than open craniotomy.
2. Schwannoma (neurilemmomas):- Schwannomas develop from Schwann cells,
which surround and insulate cranial nerves and other nerves. They make up about 8%
of all CNS tumors. Schwannomas are almost always benign tumors. They can arise
from any cranial nerve. When they form on the cranial nerve responsible for hearing
and balance near the cerebellum they are called vestibular schwannomas or acoustic
neuromas. They can also start on spinal nerves after the point where they have left the
spinal cord. When this happens, they can press on the spinal cord, causing weakness,
and sensory loss, and bowel and bladder problems.
C. Pituitary adenomas: Pituitary tumors represent about 10% to 15% of all brain
tumors and cause symptoms as a result of pressure on adjacent structures or hormonal
changes such as hyperfunction or hypofunction of the pituitary.
Corpus callosum
3rd ventricle area Astrocytoma
Ependymoma Oligodendroglioma
Lateral ventricle Lipoma
Ependymoma
Glioblastoma
Multiforme Cerebrum
Astrocytoma
Oligodendroglioma
Optic chiasm Lymphoma
Astrocytoma Metastatic tumors
Pineal area
Pineocytoma
Pituitary area Pineoblastom
Craniopharyngioma a
Pituitary adenoma
Epidermoid cyst
Cerebellum
Acoustic nerve Medulloblastoma
Neuroma Astrocytoma
Hemangioblastoma
Brain stem Metastatic tumors
Astrocytoma
Glioblastoma 4th ventricle
Multiforme Ependymoma
Metastatic tumors
o Radiotherapy:- People who have had radiation to the head, usually to treat another
type of cancer, may be at an increased risk of developing a tumour. This may affect
people who had radiotherapy for childhood leukaemia.
o Family history:- Most people with brain tumors do not have a family history of the
disease, but in rare cases brain and spinal cord cancers run in families. Some of these
families have well-defined disorders, such as:
b) Neurofibromatosis type 2 (NF2)- This condition, which is much less common than
NF1, is associated with vestibular schwannomas (acoustic neuromas), which almost
always occur on both sides of the head. It is also linked with an increased risk of
meningiomas or spinal cord ependymomas. Changes in the NF2 gene are responsible
for neurofibromatosis type 2. Like NF1, the gene changes are inherited in about half
of cases or may occur before birth in children without a family history.
c) Tuberous sclerosis- People with this condition may have subependymal giant cell
astrocytomas (SEGAs), which are low-grade astrocytomas that develop beneath the
ependymal cells of the ventricles. They may also have other benign tumors of the
brain, skin, heart, kidneys, and other organs. This condition is caused by changes in
either the TSC1 or the TSC2 gene. These gene changes can be inherited from a
parent, but most often they develop in people without a family history.
d) Von Hippel-Lindau disease- People with this condition tend to develop benign or
cancerous tumors in different parts of the body, including hemangioblastomas (blood
vessel tumors) in the brain, spinal cord, or retina, as well as tumors of the inner ear,
kidney, adrenal gland, and pancreas. It is caused by changes in the VHL gene. Most
often the gene changes are inherited, but in some cases the changes happen before
birth in people whose parents don’t have them.
e) Li-Fraumeni syndrome- People with this condition are at higher risk for developing
gliomas, along with breast cancer, soft tissue sarcomas, leukemia, and adrenal gland
cancer, and certain other types of cancer. It is caused by changes in the TP53 gene.
f) Other syndromes- Other inherited conditions are also linked with increased risks of
certain types of brain and spinal cord tumors, including:
Gorlin syndrome (basal cell nevus syndrome)
Turcot syndrome
Cowden syndrome
Some families may have genetic disorders that are not well recognized or that may
even be unique to a particular family.
General symptoms: Tumors in any part of the brain may cause the pressure inside the skull
(known as intracranial pressure) to rise. This can be caused by growth of the tumor itself,
swelling in the brain, or blockage of the flow of cerebrospinal fluid (CSF). Increased pressure
can lead to general symptoms such as:
Headache
Nausea
Vomiting
Blurred vision
Balance problems
Personality or behavior changes
Seizures
Drowsiness or even coma
Headaches that tend to get worse over time are a common symptom of brain tumors,
occurring in about half of patients.
Symptoms of tumors in different parts of the central nervous system: Brain and spinal
cord tumors often cause problems with the specific functions of the region they develop in.
But these symptoms can be caused by any disease in that particular location — they do not
always mean a person has a brain or spinal cord tumor.
Tumors in the parts of the cerebrum (the large, outer part of the brain) that control
movement or sensation can cause weakness or numbness of part of the body, often on
just one side.
Tumors in or near the parts of the cerebrum responsible for language can cause
problems with speech or even understanding words.
Tumors in the front part of the cerebrum can sometimes affect thinking, personality,
and language.
Tumors in an area of the brain called the basal ganglia typically cause abnormal
movements and an abnormal positioning of the body.
If the tumor is in the cerebellum, which controls coordination, a person might have
trouble with walking or other everyday functions, even eating.
Tumors in the back part of the cerebrum, or around the pituitary gland, the optic
nerve, or certain other cranial nerves can cause vision problems.
Tumors in or near other cranial nerves might lead to loss of hearing, balance
problems, weakness of some facial muscles, or trouble swallowing.
Diagnostic Evaluation:-
Medical history and physical examination
Magnetic resonance imaging (MRI) scan
CT scan
Magnetic resonance spectroscopy (MRS) scan
Single photon emission computerised tomography (SPECT or SPET) scan
Positron emission tomography (PET) scan
Lumbar puncture (spinal tap)
Surgical biopsy
Blood & urine tests
Grading and staging tumours helps doctors decide on the best treatment for cancer patients. Brain and
spinal cord tumours are usually given a grade on a scale of 1 to 4. The grade is worked out by looking
at the tumour cells and comparing them to normal cells. The tumour’s rate of growth and likeliness or
ability to spread into nearby tissue is also assessed.
Grades 1 and 2 These are the slowest-growing tumours. They are called
low-grade tumours
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:
Surgical Management:
Surgery in the central and peripheral nervous system is called neurosurgery. Some tumours
can be removed completely by neurosurgery. This type of operation is called a gross total
resection. In other cases, the surgeon may only be able to remove part of the tumour. This
procedure is called a partial resection. Sometimes a tumour cannot be removed because it
would be too dangerous. This is called an irresectable or unresectable tumour. For brain and
spinal cord tumors, surgery may be done for different reasons:
To get a biopsy sample to determine the type of tumor.
To remove as much of the tumor as possible.
To help prevent or treat possible complications from the tumor.
Surgery for brain tumor- Surgery may be done as open surgery or stereotactic surgery. In
open surgery, a relatively large opening needs to be made in the skull to access the tumour. In
stereotactic surgery, only a small cut needs to be made. Surgeries as follows:
III. Craniectomy – This is similar to a craniotomy except that the piece of skull that is
removed for the operation is not replaced because the brain may swell. The bone may
be replaced in the future when it won’t cause extra pressure.
IV. Awake craniotomy – This operation is done if the tumour is near parts of the brain
that control speech or movement. When the brain is exposed, the level of anaesthetic
is reduced and the patient awakens (becomes conscious) so they can speak, move and
respond. This is not painful because the brain itself does not feel pain, and local
anaesthetic is used to numb surrounding tissues. During the operation, the surgeon
asks the patient to speak or move parts of the body so they can identify and avoid
certain parts of the brain. Once the tumour is removed, the patient is given general
anaesthetic again for the rest of the procedure.
V. Endoscopic transnasal brain surgery – This rarer type of surgery is used if the
tumour is near the base of the brain, for example a pituitary gland tumour. The
surgeon puts a long tube (endoscope) up the nose, and then uses small tools to remove
all or part of the tumour through the nostrils. This type of surgery has a faster
recovery time and fewer long-term side effects than a craniotomy.
VI. Stereotactic surgery - Often surgery is done using a computer to guide the surgeon.
This is called stereotactic surgery. It allows the surgeon to view 3-D images of the
brain and tumour. It is safer, more accurate and requires a smaller cut in the skull than
in open surgery. These days, surgery is usually done using small markers called
fiducial markers. This is known as a frameless procedure. The markers are taped or
glued to the scalp before a scan. The scan shows the brain and tumour in relation to
the markers. The computer also keeps track of where the surgical instruments are,
allowing the surgeon to operate precisely. Less common is the use of a lightweight
frame that is screwed to the scalp. The scan shows where the brain, tumour and
instruments are in relation to the frame.
Possible risks and side effects of surgery-
Complications during or after surgery such as bleeding, infections, or reactions to anaesthesia
are rare, but they can happen. A major concern after surgery is swelling in the brain.
Radiation therapy:
Radiation therapy uses high-energy rays or small particles to kill cancer cells. This type of
treatment is given by a doctor called a radiation oncologist. Radiation therapy may be used in
different situations:
· After surgery to try to kill any remaining tumor cells
· As the main treatment if surgery is not a good option and medicines are not effective
· To help prevent or relieve symptoms
1 External beam radiation therapy (EBRT) - The radiation is focused on the tumor
from a source outside the body. This is called external beam radiation therapy
(EBRT). This type of radiation therapy is much like getting an x-ray, but the dose of
radiation is much higher. High doses of radiation therapy can damage normal brain
tissue, so doctors try to deliver the radiation to the tumor with the lowest possible
dose to normal surrounding brain areas. Several techniques can help doctors focus the
radiation more precisely:
3 Whole brain and spinal cord radiation therapy (craniospinal radiation): If tests
like an MRI scan or lumbar puncture find the tumor has spread along the covering of
the spinal cord (meninges) or into the surrounding cerebrospinal fluid, then radiation
may be given to the whole brain and spinal cord. Some tumors such as ependymomas
and medulloblastomas are more likely to spread this way and often require
craniospinal radiation.
Chemotherapy:
Chemotherapy (chemo) uses anti-cancer drugs that are usually given into a vein (IV) or taken
by mouth. These drugs enter the bloodstream and reach almost all areas of the body.
However, many chemo drugs are not able to enter the brain and reach tumor cells. Some
types of brain tumors, such as medulloblastoma and lymphoma, tend to respond better to
chemotherapy. Chemotherapy is most often used along with other types of treatment such as
surgery and/or radiation therapy. Some of the chemo drugs used to treat brain tumors include:
Carboplatin
Carmustine (BCNU)
Cisplatin
Cyclophosphamide
Etoposide
Irinotecan
Lomustine (CCNU)
Methotrexate
Procarbazine
Temozolomide
Vincristine
These drugs can be used alone or in various combinations, depending on the type of brain
tumor. Doctors give chemo in cycles, with each period of treatment followed by a rest period
to give the body time to recover. Each cycle typically lasts for a few weeks.
Target therapy:
These targeted drugs work differently from standard chemotherapy drugs. They
sometimes work when chemo drugs don’t, and they often have different (and less
severe) side effects. These drugs do not yet play a large role in treating brain or spinal
cord tumors, but some of them may be helpful for certain types of tumors.
Anti-seizure drugs (anti-epileptics) - Drugs may also be given to lower the chance
of seizures in people with brain tumors. Different anti-seizure drugs can be used.
Because many of these drugs can affect how other drugs such as chemotherapy work
in the body, they are not usually given unless the tumor has caused seizures.
Hormones - The pituitary gland helps control the levels of many different hormones
in the body. If the pituitary gland is damaged by the tumor itself or by tumor
treatments (such as surgery or radiation therapy).
Nursing management:
The patient with a brain tumor may be at increased risk for aspiration as a result of
cranial nerve dysfunction. The pre & post operative nursing care are as follows:
Pre-operative care –
o Discuss with the patient to give full information about the surgery.
o Allow the patient to ask question and clear all his doubts.
o Explain what happens during anesthesia.
o Obtain the consent from the patients / guardian for each operation after
explaining the nature of the operation and anesthesia.
o Assist the doctor to carry out a through physical examination from hand to
foot, assess the physical health of the patient.
o The gag reflex and ability to swallow are evaluated.
o Ask the patient appropriate questions to obtain past and present medical
history in order to exclude anemia, jaundice, drug reaction, previous operation
etc.
o Carry out the investigation that the doctor ordered, such as blood for HB, TC
SR, blood, urea, blood sugar etc.
o Collect all the baseline data.
o Part preparation is done according to the surgery
o Administer the pre – medications to the patient one hour before surgery. These
are the drugs that reduce anxiety of patient.
o Before giving the Pre – medications. Check the vital signs of the patient such
as blood pressure, temperature, pulse, respiration etc. Record the vital signs in
the patient chart as baseline data.
Nursing Diagnosis:
Ineffective airway clearance related to diminished protective reflexes (cough,
gag).
Ineffective breathing patterns related to neurologic dysfunction (brain stem
compression, structural displacement)
Ineffective cerebral tissue perfusion related to the effects of increased ICP.
Deficient fluid volume related to fluid restriction.
Risk for infection related to ICP monitoring system (fiberoptic or
intraventricular catheter).
Nursing Intervention:
Maintaining a Patent Airway - The patency of the airway is assessed. Secretions
that are obstructing the airway must be suctioned with care, because transient
elevations of ICP occur with suctioning. Elevating the head of the bed may aid in
clearing secretions and improve venous drainage of the brain.
Optimizing Cerebral Tissue Perfusion - Proper positioning helps reduce ICP. The
patient’s head is kept in a neutral (midline) position, to promote venous drainage.
Elevation of the head is maintained at 30 to 45 degrees unless contraindicated.
Extreme rotation of the neck and flexion of the neck are avoided, because
compression or distortion of the jugular veins increases ICP. Extreme hip flexion
is also avoided, because this position causes an increase in intra-abdominal and
intrathoracic pressures, which can produce an increase in ICP.
Maintaining Negative Fluid Balance – Skin turgor, mucous membranes, urine
output, and serum and urine osmolality are monitored to assess fluid status. If IV
fluids are prescribed, the nurse ensures that they are administered at a slow to
moderate rate with an IV infusion pump, to prevent too-rapid administration and
avoid over-hydration.
Preventing Infection - Aseptic technique must be used when managing the system
and changing the ventricular drainage bag. The drainage system is also checked
for loose connections. The nurse observes the character of the CSF drainage and
reports increasing cloudiness or blood. The patient is monitored for signs and
symptoms of meningitis: fever, chills, nuchal (neck) rigidity and increasing or
persistent headache.
Conclusion:
The occurrence of oncologic or degenerative disease processes in the neurologic system
produces a unique set of nursing challenges. Oncologic disorders of the brain and spinal cord
include several types of neoplasms, each with its own biology, prognosis, and treatment
options, because of the unique anatomy and physiology of the central nervous system (CNS).
These tumors are treating with surgery, radiation, chemotherapy and other therapies.
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Ansari Javed (2011), comprehensive medical surgical nursing, part- B, Pee Vee
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Black M. Joyce & Wawks Hokanson Jane (2007), medical surgical nursing (7th
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Wilson and Ross, Anatomy and Physiology in health and illness, (10th edition),
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www.wikipedia.com//http:www.oralcancer.com