Brain Cancer

Clarification of the jargon

The term brain cancer is commonly used, but can be a
confusing term as it makes all brain cancers sound like one type of
cancer. Brain cancer as a term actually encompasses a variety of
cancers. There can be actual brain tumors which arise from the brain
itself, known as primary brain cancers and of which there are several.
There can also be brain metastases, which represent the spread of
other cancers, such as lung or breast, to the brain.. Please see the
section below on "What are brain tumors?" for more explanation.

What is the brain?

The brain is the organ in a person's skull that controls the
functions of all of the other organs. Together, the brain and spine
make up the central nervous system. The brain is responsible for the
experience of the five senses (taste, touch, sight, hearing and smell).
The brain is also the seat of thought, language, personality, creativity
and memory. The brain controls movement, sensation, balance, and
coordination. In order to do its job, the brain requires an enormous
amount of the oxygen and nutrient energy that a person takes in
regularly.
The brain is comprised of nerve cells (called neurons) which carry
signals, and the cells which support the nerve cells (called glial cells ).
There are a number of different types of glial cells, all with different
names and functions. The glial cells outnumber the neurons in the
brain by a ratio of 10:1

What are brain tumors?

Brain tumors occur when cells in the brain begin to divide out of
control and start to displace or invade nearby tissues. Large collections
of this "out of control" tissue are called tumors. Occasionally, brain
tumors can spread throughout the body. Tumors that have the
potential to spread to other sites of the brain or body are called
malignant. When tumors start in the brain, they are called primary
brain tumors. Any of the various normal cell types of the brain can
mutate and become a primary tumor, and the particular cell type
which makes up the tumor controls how the tumor is likely to behave.
Brain tumors are not really thought of as a single disease, but rather
as a collection of several diseases that are characterized by the cell

type that makes them up, by how they behave, and by how they are
treated. One of the special characteristics of brain tumors is that
benign (non-cancerous) tumors in the brain can be just as bad as
malignant (cancerous) brain tumors. This is because the brain is such
an important organ. It is locked into place by the skull and can't move
out of the way if a tumor is growing near it. Even a benign tumor can
cause pressure on the brain, and this pressure can be both
symptomatic and life-threatening.
The brain is also a frequent site of metastases. Metastases are
tumors which have spread from a cancer that started in a different
body part; they do not start in the brain, but instead take up residence
there after traveling from a separate cancer (like a lung cancer or
breast cancer). These are not classified as primary brain tumors, but
instead as brain metastases.

How are brain tumors classified?

Brain tumors are classified by the both the cell of the brain that
makes them up, and how the tumor looks under a microscope. Primary
brain tumors can arise from any of the cells in the brain. They can
come from the neurons, the glial cells, the lining of the brain, or from
specific structures in the brain. Glial cells support the neurons of the
brain and tumors which arise from these cells are known as glial
tumors. The membrane that surrounds the brain can also develop
tumors and these are known as meningiomas. There are other types of
tumors, which involve other structures of the brain including
ependymomas among others. Metastases can travel from a variety of
different cancer types. When a special type of doctor (called a
pathologist ) looks at brain tumors under a microscope, he/she can get
a sense of how aggressive the tumor is by the way the cells look.

Am I at risk for a brain tumor?

In the United States in 2007, it is estimated that there were
approximately20,000 new cases of primary brain tumors, and 14,000
deaths from primary brain tumors. About 85% of primary brain tumors
arise from the glial cells of the brain. Unfortunately, many of these
tumors (35-45%) are the most aggressive type (Glioblastoma
Multiforme). The peak age at which people are diagnosed with brain
tumors varies with the tumor type, however when taking all types into

account the average age is about 50 years of age. Brain tumors

generally comprise about 2% of all newly diagnosed adult cancers.
Exposure to radiation has been linked to the development of
certain types of primary brain tumors, especially if the exposure took
place in childhood. Higher radiation doses are generally felt to increase
the risk of eventually developing a brain tumor, and radiation-induced
brain tumors can take anywhere from 10-30 years to form.
Although many chemicals have been shown to cause brain
tumors in laboratory animals, there have never been any definite
associations with chemical exposures proven in human beings.
Chemicals that have been shown to cause brain tumors in animals
include n-nitroso compounds, vinyl chloride, and certain organic
solvents. However, when examining populations exposed to these
various chemicals (like pesticide workers or workers in the
petrochemical industry), there has never been any conclusive evidence
to suggest that they get brain tumors at a higher rate than people
without the chemical exposures.
With the recent popularity of cellular phones, many people have
worried that their use may be a risk factor for developing brain
tumors. However, there has never been any data to support this idea.
In fact, a few studies have looked at this question and there has been
no conclusive evidence that cell phones increase the risk of brain
tumors. There has also been concern regarding exposure to powerful
magnetic fields (high power lines) and some sugar substitutes
( aspartame), however, there has not been any conclusive evidence
linking these factors to increased risk of brain cancer.
Certain hereditary disorders can predispose someone to the
development of certain brain tumors. Genetic diseases like
neurofibromatosis type 1, neurofibromatosis type 2, von Hippel-Lindau
disease, and tuberous sclerosis are all associated with an increased
risk of developing a primary brain tumor.
Because there are so many different types of brain tumors, there
are different risk factors for developing each of them. To learn about
the risk factors for developing a specific a specific type of brain tumor,
please refer to the OncoLink overview on that particular cancer.

How can I prevent brain tumors?

Currently, there are no proven strategies to prevent the
development of primary brain tumors. Studies of diets rich in anti-

oxidants have not shown any benefits in terms of lowering the risk of
developing primary brain tumors.
It is possible to decrease the risk of developing brain metastases
from certain tumors by decreasing the risk of developing the initial
primary tumor in the first place. (See the OncoLink overviews about
specific primary cancers for more information on preventing various
malignancies.) Sometimes, when patients have certain cancers (ie:
lung) that are well controlled, they will be offered preventive radiation
therapy to the brain in order to decrease the likelihood of developing
brain metastases in the future. This is called prophylactic cranial
radiation. (Please see the section of this overview below for more
information on radiation therapy.)

What screening tests are available?

Primary brain tumors are rare enough that they are not screened
for with any specific tests. The best way to pick up a diagnosis of a
brain tumor early is to see your doctor regularly for a thorough
physical examination and to report any new, worrisome symptoms
promptly. People with genetic disorders that predispose them for the
development of primary brain tumors will often get periodic imaging
studies of their brains to look for any evidence of abnormalities.

What are the signs of brain tumors?

Unfortunately, the very early stages of brain tumors may not cause
any symptoms. As the tumor grows in size, it can produce a variety of
symptoms, including:

headache

nausea

vomiting

loss of appetite

seizures

memory loss

weakness

visual changes

problems with speech and language

personality changes

thought processing problems

Many of these symptoms are non-specific, and could represent a

variety of different conditions; however, your doctor needs to see you
if you have any of these problems. Because the brain controls so many
different functions, the symptoms caused by brain tumors can be
extremely variable. Headache is the most common symptom for
patients with brain tumors, occurring in about 50% of cases.

How are brain tumors diagnosed and staged?

When a patient presents with symptoms suggestive of a brain
tumor, the physician will perform a thorough history and physical
examination. After that, the key to making the diagnosis is appropriate
imaging.
Imaging can be performed with either a CT scan or MRI scan. A
CT scan is a three dimensional x-ray, and patients will often be
injected with a contrast agent to help visualize any abnormalities. CT
scans are good tests because they are quick and easy to obtain, and
will often be used as the first step towards making a diagnosis.
However, an MRI scan is a better test for evaluating abnormalities in
the brain. MRI scans utilize powerful magnets to make a threedimensional picture. An MRI picks up finer detail than a CT scan, and is
the study of choice to make the diagnosis of a brain tumor. MRI scans
are usually obtained with the use of an injectable contrast agent as
well.
There are some further imaging studies that may be used to
determine if a mass in the brain is a tumor (as opposed to other
causes, such as infection) and if it is a tumor, what type it is. There is
a special type of MRI, known as MR spectroscopy or MRS, which allows
your physician to learn more about the contents of the mass and helps
them determine what the mass is. A functional MRI is another special
type of MRI that can help define areas of the brain, which activate
when a person moves or speaks. This allows the doctor to map
the brain and helps the doctor know which areas to avoid during
surgery if the tumor is close to a portion of the brain, which is critical
for movement or speech. PET scans can also sometimes be used to
determine how active the mass is to help determine if it is really a
cancer. It can also sometimes be used to map functional parts of the
brain like functional MRI.
For many types of brain tumors, the imaging characteristics are
distinctive enough to give physicians a pretty good idea of the
diagnosis. The primary management of most brain tumors is surgery.

If imaging reveals that a mass suspicious for a brain tumor is in a

surgically accessible spot, the patient is generally scheduled for
surgery without any further diagnostic testing. After surgery, the
specimen can be examined under the microscope by a pathologist, and
a final diagnosis can be made. However, sometimes, tumors are not in
a safe location for surgery. In those cases, in order to make a
diagnosis, patients will often need a biopsy. A biopsy is a procedure
where a small piece of the tumor is obtained using a needle under
image guidance. The biopsy is usually done as a stereotactic biopsy,
where the head is immobilized with a frame that is attached to the
skull with pins. A scan of the brain is then done with the frame in
place. With the same immobilization device on, the person is taken to
surgery and the surgeon can use the scan to guide them precisely to
the tumor.
Occasionally, your physician may need to examine the fluid that
baths the brain (cerebrospinal fluid or CSF for short) to see if there are
any cancer cells that have spread to this liquid. This can be done with
a procedure known as a lumbar tap, or an LP for short. A need is
inserted between the vertebral bodies (bones of the spinal cord) and
into the sack which holds the spinal cord. Some of the CSF is then
taken out and a pathologist can examine it and determine if there are
cancer cells in the CSF.
Usually, if it is thought that the brain tumor is a metastasis,
imaging of the body will also be performed to determine if there is a
cancer somewhere else in the body which could be causing the
metastasis to the brain. This can be done with an X-ray or a CT scan.
Your physician may also order other laboratory tests to determine if
cancer is affecting other organs.
Primary brain tumors do not have a classic staging system the
way most other cancers do. This is because the size of a brain tumor is
less important than its location and the type of brain cell that makes it
up. The likelihood of curing a brain tumor has to do with its location,
the cell that makes it up, and how the tumor cells look under a
microscope. Your doctor will give you a sense of how dangerous your
tumor is and how it should be treated after weighing these factors.
Brain metastases are considered within the staging system of the
cancer from which they originated. Thus, the presence of brain

metastases automatically makes the primary tumor a stage IV cancer,

because stage IV means the presence of any metastasis.

What are the treatments for brain tumors?

There are a number of different treatments for brain tumors.
Most brain tumors are treated with a combination of multiple different
types of therapy. The exact location and type of brain tumor will
dictate which treatments are recommended.

Surgery
Surgical resection is recommended for the majority of brain
tumors. It is rare that a primary brain tumor can be cured without a
surgical resection. However, the location of the brain tumor will dictate
whether or not surgery is an option. Some tumors are seated in places
in the brain that are just too dangerous to operate on, and surgery
cannot be employed. The risks to the patient from surgery depend on
the location and size of the tumor. Talk to your neurosurgeon about
the specific risks of your planned surgery.
Chemotherapy
Chemotherapy is the use of anti-cancer drugs that go throughout
the entire body. These drugs may be given through a vein or with pills
by mouth. One of the special challenges in treating brain tumors with
chemotherapy is that there is a natural barrier between the brain and
the blood, which blocks many medications from entering the brain.
Only certain chemotherapy drugs can cross this blood-brain barrier to
treat disease in the nervous system. One of the new ways that
chemotherapy can be delivered for brain tumors is by implantation on
a biodegradable wafer that is inserted by the neurosurgeon into the
space left behind after surgery (called the tumor bed ). The
chemotherapy wafer can then deliver high doses of chemotherapy to a
localized area. Chemotherapy wafers are only approved for certain
brain tumors, although future research may prove this approach useful
for more diseases.
For advanced brain tumors (Stage IV also known as Glioblastoma
Multiforme) the most commonly used chemotherapy is known as
Temozolamide, an alkylating chemotherapy. It has been shown to be
effective when used with radiation after surgery. Additional

temozolamide is given about four weeks after completing radiation and

chemotherapy, usually for 6 months.
There are many other different chemotherapy drugs used for
brain tumors, and your medical oncologist can explain why he or she
recommends one particular regimen over another in your case.
Radiation
Radiation therapy uses high energy rays (similar to x-rays) to kill
cancer cells. Radiation can come from an external source (called
external beam radiation therapy ), and it requires patients to come in
5 days a week for up to 6-8 weeks to a radiation therapy treatment
center. The treatment takes just a few minutes, and it is painless.
External beam radiation therapy is often employed for brain tumors,
both as primary treatment for unresectable tumors and in addition to
surgery.
Radiation therapy can also be given to a very focused area of the
brain using a technique called stereotactic radiosurgery. Stereotactic
radiosurgery requires a patient to have a head frame attached, so that
a precise map can be made of the patient's head. Radiation is then
focused from a variety of different angles to deliver a large radiation
dose to the tumor or tumor bed. This can be performed using the
same machine that delivers external beam radiation or by a special
machine called a gamma knife.
Radiation can also be given internally by implanting high strength
radioactive sources in the vicinity of the tumor or the tumor bed. This
is called brachytherapy. This can be done with radioactive seeds which
are placed directly into the tumor bed or by using a balloon like device,
known as a GliaSite, which can be placed into the cavity left after the
surgery. The balloon is connected to a small button (also
known as a port) which is placed under the skin of the scalp. Your
physician can then perform a brain CT and determine how much
radiation is needed to treat the tumor bed. The port can be accessed
with a needle through the skin, which allows the physician to inject a
radioactive liquid into the balloon, which can then treat the tumor bed.
After injecting the radioactive liquid, you usually need to stay in the
hospital while the radiation is working (usually about 5 days). The
radioactive liquid is then removed and, often times, the balloon is then
removed surgically.

Occasionally, your physician may recommend a type of radiation

known as Intensity Modulated Radiation Therapy (IMRT) for
treatment. If the brain tumor is close to critical structures within the
brain which are more sensitive to radiation damage, such as the
nerves of the eyes or the brainstem, IMRT can be used to avoid these
structures. IMRT is not beneficial in ever case and your physician can
discuss this treatment option with you further.
Your radiation oncologist can answer questions about the utility,
process, and side effects of any of the above mentioned types of
radiation and can recommend the best type of radiation therapy in
your particular case.

Follow-up testing
Once a patient has been treated for a brain tumor, he or she
needs to be closely followed for a recurrence. At first, the patient will
have follow-up visits fairly often. The longer he or she is free of
disease, the less often he or she will have to go for checkups with
examinations. The doctor will decide when to obtain follow-up MRI
scans or PET scans.
Clinical trials are extremely important in furthering our
knowledge of this disease. It is though clinical trials that we know what
we do today, and many exciting new therapies are currently being
tested. Talk to your doctor about participating in clinical trials in your
area.
This article is meant to give you a better understanding of brain
tumors. Use this knowledge when meeting with your physician, making
treatment decisions, and continuing your search for information. You
can learn more about other brain tumors on OncoLink through the
related links to the left.

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