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.

Types of Brain Tumor:-

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.

2. Oligodendrocytoma:- These tumors start in brain glial cells called oligodendrocytes.

Oligodendroglial tumors represent 20% of gliomas and are categorized as low grade
or high grade (anaplastic). The histologic distinction between astrocytomas and
oligodendrogliomas is difficult to make but important, because oligodendrogliomas
are more sensitive than astrocytomas to chemotherapy.
3. Ependymoma:- These tumors arise from ependymal cells, which line the ventricles.
They can range from fairly low-grade (less aggressive) tumors to higher grade ones,
which are called anaplastic ependymomas. Only about 2% of brain tumors are
ependymomas.
Ependymomas are more likely to spread along the CSF pathways than other gliomas
but do not spread outside the brain or spinal cord. Ependymomas may block the exit
of CSF from the ventricles, causing the ventricles to become very large
(hydrocephalus).
Unlike astrocytomas and oligodendrogliomas, ependymomas usually do not grow into
normal brain tissue. As a result, some (but not all) ependymomas can be removed
completely and cured by surgery.

4. Medulloblastoma:- Medulloblastomas develop from neuroectodermal cells

(primitive nerve cells) in the cerebellum. They are fast-growing tumors and often
spread throughout the CSF pathways, but they can be treated by surgery, radiation
therapy, and chemotherapy. Medulloblastomas occur much more often in children
than in adults. They are part of a class of tumors called primitive neuroectodermal
tumors (PNETs) that can also start in other parts of the central nervous system.
II. TUMORS ARISING FROM SUPPORTING STRUCTURES:
A. Meningiomas: Meningiomas, which represent 15% of all primary brain tumors, are
common benign encapsulated tumors of arachnoid cells on the meninges. They are
slow growing and occur most often in middle-aged adults (more often in women).
Meningiomas most often occur in areas proximal to the venous sinuses. Preferred
treatment for symptomatic lesions is surgery with complete removal or partial
dissection. Sometimes these tumors run in families, especially in those with
neurofibromatosis, a syndrome in which people develop many benign tumors of
nerve tissue. Meningiomas are often assigned a grade, based on how the cells look
under the microscope.
 Grade I (benign) tumors have cells that look the most like normal cells. They make up
about 80% of meningiomas. Most of these can be cured by surgery, but some grow
very close to vital structures in the brain or cranial nerves and cannot be cured by
surgery alone.

 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.

Pressure Effects of Pituitary Adenomas-

Pressure from a pituitary adenoma may be exerted on the optic nerves, optic chiasm,
or optic tracts or on the hypothalamus or the third ventricle if the tumor invades the
cavernous sinuses or expands into the sphenoid bone. These pressure effects produce
headache, visual dysfunction, hypothalamic disorders (disorders of sleep, appetite,
 temperature, and emotions), increased ICP, and enlargement and erosion of the sella
turcica.

Hormonal Effects of Pituitary Adenomas

Functioning pituitary tumors can produce one or more hormones normally produced
by the anterior pituitary. There are prolactin-secreting pituitary adenomas
(prolactinomas), growth hormone–secreting pituitary adenomas that produce
acromegaly in adults, and adrenocorticotropic hormone (ACTH)–producing pituitary
adenomas that result in Cushing’s disease. Adenomas that secrete thyroid-stimulating
hormone or follicle-stimulating hormone and luteinizing hormone occur infrequently,
whereas adenomas that produce both growth hormone and prolactin are relatively
common.
The female patient whose pituitary gland is secreting excessive quantities of prolactin
presents with amenorrhea or galactorrhea. Male patients with prolactinomas may
present with impotence and hypogonadism.

III. DEVELOPMENTAL TUMORS:

A. Angiomas: Brain angiomas (masses composed largely of abnormal blood vessels)
are found either in or on the surface of the brain. They occur in the cerebellum in
83% of cases. Some persist throughout life without causing symptoms; others cause
symptoms of a brain tumor. Occasionally, the diagnosis is suggested by the presence
of another angioma somewhere in the head or by a bruit (an abnormal sound) that is
audible over the skull. Because the walls of the blood vessels in Angiomas are thin,
these patients are at risk for hemorrhagic stroke. In fact, cerebral hemorrhage in
people younger than 40 years of age should suggest the possibility of an angioma.
 B. Dermoid, Epidermoid, Teroma, Craniopharyngioma:
Dermoid cysts contain elements of skin such as hair and sebaceous glands in addition
to desquamated keratin. They constitute approximately 0.3% of intracranial tumors.
Epidermoid cysts are epithelial lined collections of skin debris (desquamates skin).
Epidermoid cysts constitute approximately 1.5% of intracranial tumors. And
Craniopharyngioma are mixed solid and cystic tumors that arise at the base of brain
near the pituitary gland and hypothalamus. They represent approximately 3% of all
intracranial tumors, approximately half present in children and half in adults.

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

Figure: Common brain tumor sites

Causes of Brain Tumor:-

The cause of most brain and spinal cord tumors is not fully understood. But researchers have
found some of the changes that occur in normal brain cells that may lead them to form brain
tumors. Normal human cells grow and function based mainly on the information contained in
each cell’s chromosomes. Chromosomes are long strands of DNA in each cell. Brain and
spinal cord tumors, like other tumors, are caused by changes in the DNA inside cells. In
recent years, researchers have found the gene changes that cause some rare inherited
syndromes (like neurofibromatosis, tuberous sclerosis, Li-Fraumeni syndrome, and von
Hippel-Lindau syndrome) and increase the risk of developing some brain and spinal cord
tumors. For example, the Li-Fraumeni syndrome is caused by changes in the TP53 tumor
suppressor gene. Normally, this gene prevents cells with damaged DNA from growing.
Changes in this gene increase the risk of developing brain tumors (particularly gliomas), as
well as some other cancers.

Risk factor of Brain Tumor:-

There are a few known risk factors for malignant brain tumours:

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:

a) Neurofibromatosis type 1 (NF1)- This genetic disorder, also known as von

Recklinghausen disease, is the most common syndrome linked to brain or spinal cord
tumors. People with this condition have higher risks of schwannomas, meningiomas,
and certain types of gliomas, as well as neurofibromas (benign tumors of peripheral
nerves). Changes in the NF1 gene cause this disorder. These changes are inherited
from a parent in about half of all cases. In the other half, the NF1 gene changes occur
before birth in people whose parents did not have this condition.

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.

o Immune system disorders:- People with impaired immune systems have an

increased risk of developing lymphomas of the brain or spinal cord (known as
primary CNS lymphomas). Lymphomas are cancers of lymphocytes, a type of white
blood cell that fights disease. Primary CNS lymphoma is less common than
lymphoma that develops outside the brain.
 o Mobile phones:- Some researchers have studied whether long-term or excessive use
of mobile phones increases a person’s risk of developing a brain tumour. It is possible
that there may be an increased risk of developing a glioma in people with high levels
of mobile phone use (i.e. more than 30 minutes a day). However, there is insufficient
scientific evidence to link regular mobile phone use to brain tumours. Research is
continuing in this area.

Signs and symptoms of brain tumor:-

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 of tumor:-

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

Grade 3 Tumours grow at a moderate rate.

Grade 4 These are the fastest-growing tumours. They are called

high-grade tumours.
.
The stage of a cancer is a measure of how far it has spread. A staging system is a standard
way for the cancer care team to describe the extent of this spread. But tumors of the brain and
spinal cord differ in some important ways from cancers in other parts of the body. Tumors
starting in the brain or spinal cord can spread to other parts of the central nervous system, but
they almost never spread to other organs. These tumors are dangerous because they can
interfere with essential functions of the brain. Because tumors in the brain or spinal cord
almost never spread to other parts of the body, there is no formal staging system for them.

Management of brain tumor:-

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
The aim of treatment is to remove the tumour, slow its growth, or relieve symptoms by
shrinking the tumour and any swelling.

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:

I. Biopsy – A small sample of tumour tissue is removed and examined under a

microscope. This is usually a diagnostic procedure but sometimes the entire tumour
can be removed.
II. Craniotomy – The most common type of brain tumour operation. Some hair will be
shaved off and you will be given a general anaesthetic. The surgeon will cut through
the scalp and move it aside, then remove a piece of skull above the tumour. The bone
and scalp are put back once the tumour is taken out.

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

Types of radiation therapy:

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:

 Three-dimensional conformal radiation therapy (3D-CRT): 3D-CRT uses the

results of imaging tests such as MRI and special computers to map the location of the
tumor precisely. Several radiation beams are then shaped and aimed at the tumor from
different directions. Each beam alone is fairly weak, which makes it less likely to
damage normal tissues, but the beams converge at the tumor to give a higher dose of
radiation there.
  Intensity modulated radiation therapy (IMRT): IMRT is an advanced form of 3D
therapy. It uses a computer-driven machine that moves around the patient as it
delivers radiation. Along with shaping the beams and aiming them at the tumor from
several angles, the intensity (strength) of the beams can be adjusted to limit the dose
reaching the most sensitive normal tissues.
 Conformal proton beam radiation therapy: Proton beam therapy is related to 3D-
CRT and uses a similar approach. But instead of using x-rays, it focuses proton beams
on the tumor. Protons are positive parts of atoms. Unlike x-rays, which release energy
both before and after they hit their target, protons cause little damage to tissues they
pass through and then release their energy after travelling a certain distance.
 Stereotactic radiosurgery: Stereotactic radiosurgery is a type of radiation therapy,
not a type of surgery. It is a non-invasive treatment that uses high doses of precisely
targeted radiation to treat a brain tumour in a single hospital visit. The treatment is so
accurate that surrounding areas of healthy brain tissue are not affected. It is most
commonly used for some meningiomas and pituitary tumours, and a type of neuroma
known as an acoustic neuroma. It is also used for metastatic cancers that have spread
from another part of the body. It is not usually used for gliomas.

2 Brachytherapy (internal radiotherapy): Unlike the external radiation approaches

above, brachytherapy involves inserting radioactive material directly into or near the
tumor. The radiation it gives off travels a very short distance, so it affects only the
tumor. This technique is most often used along with external radiation. It provides a
high dose of radiation at the tumor site, while the external radiation treats nearby
areas with a lower dose.

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.

Possible risks and side effects of radiation therapy-

Most side effects occur in the treatment area and are temporary, but some may be permanent
or last for a few months or years. Side effects tend to peak about 1–3 weeks after treatment
has ended. Some common short-term side effects include:
o Nausea
o Headaches
o Tiredness or fatigue
o Hair loss in the treatment area
o Red, sore, inflamed or flaky skin in the treatment area.
o Cognitive impairment
o Personality changes

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.

Possible risks and side effects of chemotherapy-

The side effects of chemo depend on the type of drugs, the amount taken, and the length of
treatment. Possible side effects can include:
o Hair loss
o Mouth sores
o Loss of appetite
o Nausea and vomiting
o Diarrhea
o Increased chance of infections (from having too few white blood cells)
o Easy bruising or bleeding (from having too few blood platelets)
o Fatigue (from having too few red blood cells, changes in metabolism, or other factors)

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.

 Bevacizumab (Avastin) - Bevacizumab is a man-made version of an immune system

protein called a monoclonal antibody. This antibody targets vascular endothelial
growth factor (VEGF), a protein that helps tumors forms new blood vessels to get
nutrients (a process known as angiogenesis).Tumors need new blood vessels to grow.

 Everolimus (Afinitor) - Everolimus works by blocking a cell protein known as

mTOR, which normally helps cells grow and divide into new cells. For subependymal
giant cell astrocytomas (SEGAs) that can’t be removed completely by surgery, it may
shrink the tumor or slow its growth for some time, although it’s not clear if it can help
people with these tumors live longer.

Other drugs treatment:

Some drugs commonly used in people with brain tumors do not treat the tumors
directly, but they may help lessen symptoms from the tumor or its treatment.
 Corticosteroids - Corticosteroid drugs such as dexamethasone (Decadron) are often
given to reduce swelling around brain tumors. This may help relieve headaches and
other symptoms.

 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.

 Post- operative care –

o Preparation of post anesthetic bed and reception the patient.
o Assess breath sound: Stridors, wheezing, or crowing indicates partial
obstruction.
o The nurse performs neurologic checks, monitors vital signs, maintains a
neurologic flow chart, spaces nursing interventions to prevent rapid increase in
ICP, and reorients the patient when necessary to person, time, and place.
o Observe chest movement for symmetry and use of accessory muscles.
o Assess pulse for rate rhythm and amplitude, weak, absent or irregular pulse
may reflect hypovolemia, decreased cardiac output. Bounding pulses indicate
hypertension, fluid overload or excitement.
o Assess level of consciousness by observing how the person responds to verbal
commands and touch, pupil reaction to light and reflexes should be observed.
o In patients with diminished gag response, care includes teaching the patient to
direct food and fluids toward the unaffected side, having the patient sit upright
to eat, offering a semisoft diet, and having suction readily available.
o Administer humidified oxygen.
o If the person is comatose or semiconscious, position on the side and keep an
oral airway in place to maintain airway potency.
o Remove any secretion by suctioning, if the person is unable to clear the airway
by coughing.
o Maintain intact dressing of the site of the surgical wound.
o Change during as ordered by the physician.

 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).

 Planning and Goals:

The goals for the patient include maintenance of a patent airway, normalization of
respiration, and adequate cerebral tissue perfusion through reduction in ICP,
restoration of fluid balance, absence of infection, and absence of complications.

 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.

 Achieving an Adequate Breathing Pattern - The patient must be monitored

constantly for respiratory irregularities. If hyperventilation therapy is deemed
appropriate to reduce ICP (by causing cerebral vasoconstriction and a decrease in
cerebral blood volume), the nurse collaborates with the respiratory therapist in
monitoring the PaCO2, which is usually maintained at less than 30 mm Hg. A
neurologic observation record is maintained, and all observations are made in
relation to the patient’s baseline condition.

 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.
 BIBLIOGRAPHY

 Brunner & Suddarth, (2013), Medical Surgical Nursing, (12th edition), wolter kluwer
(India) publisher, page no. 356-372.

 Lippincott willen & willen, the text book of manual nursing practice, (10th edition),
published by Jaypee brother, page no. 142-154.

 Basavantthappa BT (2007), medical surgical nursing, (9th edition), Jaypee brother

medical publisher, page no. 475-489.

 Ansari Javed (2011), comprehensive medical surgical nursing, part- B, Pee Vee
publication, page no. 158-190.

 Black M. Joyce & Wawks Hokanson Jane (2007), medical surgical nursing (7th
edition) volume- 2, Elsevier publication, page no. 342- 421.

 Wilson and Ross, Anatomy and Physiology in health and illness, (10th edition),
chapter 4th, page no. 386-476.

 Derrickson and tortora, (8th edition), principle of anatomy & physiology, (11th
edition), page no. 336-454.

 www.wikipedia.com//http:www.oralcancer.com