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Brain Cancer Treatment By Tumor Types

The brain cancer treatment depends on many factors, including but not limited to, the type of tumor, grade of the disease, location, resectability, size, the extent of spread, patient’s age, and performance status of the patient.

Following are the preferred treatment approaches for different types of brain tumors, but the final decision is taken after clinical assessment of the patient by an oncologist.

CNS TUMOR TYPE TREATMENT
Astrocytomas In the case of low-grade astrocytomas (e.g. pilocytic astrocytoma, and SEGA), maximal tumor excision without compromising any neurological function is considered the preferred treatment approach.
Post-operative radiation therapy should be considered in high-risk individuals and those with incomplete resection.

For SEGA that can not be removed completely, targeted therapy may be employed to shrink the tumor.

In the case of high-grade astrocytomas (e.g. Anaplastic astrocytoma and glioblastoma), maximal tumor excision without compromising on important neurological function is considered as the first-line treatment. Radiotherapy with or without chemotherapy is generally indicated after surgery.
Oligodendrogliomas In the case of oligodendrogliomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. Post-operative radiotherapy and/or chemotherapy may be considered in the case of high-grade disease or incomplete resection.
Ependymomas In the case of ependymomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. Post-operative radiotherapy should be considered in the case of high-grade disease, incomplete resection, or presence of cancer cells in the CSF a few weeks after surgery.
Meningiomas In the case of low-grade asymptomatic meningiomas (tumor size <3 cm), observation without any treatment is considered as the preferred approach, especially in elderly patients.
In case of symptomatic meningiomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach.

Post-operative radiotherapy may be considered in the case of high-grade disease, incomplete resection, or high-risk individuals.

Radiotherapy can be employed as the first-line treatment for patients who are not good candidates for surgery.
Embryonal tumors In the case of embryonal tumors, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. Post-operative radiotherapy and chemotherapy may be employed in the case of high-risk individuals (large cell or anaplastic medulloblastoma, supratentorial PNET, disease dissemination, unresectable or residual tumors).
Mixed glial and neuronal tumors Maximal tumor excision without compromising any neurological function is considered the preferred treatment approach for these tumors. In the case of a negative resection margin, patients may be observed without any additional therapy.
Post-operative radiotherapy should be considered in the case of high-grade disease or incomplete resection.
Germ Cell Tumors Most germ cell tumors are not amenable to surgical resection due to their invading/spreading nature and non-accessible location. Thus, most germ cell tumors are treated with radiotherapy as the first line treatment. Post-radiation chemotherapy may be employed in the case of large tumors or remaining tumor cells.
Schwannomas In the case of schwannomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach.
Postoperative radiotherapy (radiosurgery) should be considered in the case of incomplete resection or where complete resection is not possible.
Craniopharyngiomas In the case of craniopharyngiomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. In the case of complete resection, no other treatment is required. However, complete tumor resection is not possible in most cases due to the proximity of the tumor to important structures, like the pituitary gland, hypothalamus, optic nerves, and blood vessels. Thus, postoperative radiotherapy (radiosurgery) is generally employed to kill any remaining tumor cells.
Chordomas and Chondrosarcomas In the case of chordomas and chondrosarcomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. In the case of complete resection, no other treatment is required. However, complete tumor resection is not possible in most cases due to the inaccessible tumor location, infiltrative nature of the tumor, and the proximity of the tumor to important structures, like the chiasm or the brainstem. Thus, postoperative radiotherapy (radiosurgery) is generally employed (especially in the case of chondrosarcoma) to kill any remaining tumor cells.
Primary CNS NHLs In the case of primary CNS NHLs, intravenous chemotherapy is considered the first-line treatment. Intrathecal chemotherapy may also be employed in case of the presence of cancer cells in the CSF. Concurrent administration of corticosteroid is usually employed to relieve disease symptoms.
Radiotherapy is also a part of chemotherapy regimens, but may be avoided in elderly patients in view of side effects.
In the case of the functional prolactin-secreting adenoma, drugs that inhibit prolactin secretion (e.g. cabergoline or bromocriptine) are used as the preferred treatment.

In the case of the functional growth hormone (GH)-secreting adenoma, surgical resection of the tumor is the preferred treatment option. Somatostatin analogs (e.g. Octreotide, lanreotide, and pasireotide) are given before surgery to shrink the tumor size. Radiotherapy may be employed if the tumor was not completely removed by surgery.

In the case of functional corticotropin (ACTH)-secreting adenomas, surgical resection of the tumor is the preferred treatment option. Radiotherapy may be employed if the tumor was not completely removed by surgery.

In the case of the thyrotropin (TSH)- secreting adenoma, surgical resection of the tumor is the preferred treatment option. Drugs (e.g. Octreotide, lanreotide, cabergoline, or bromocriptine) are given if the surgery did not reduce the hormonal level. Radiotherapy may be employed if the tumor was not completely removed by surgery.

In the case of the gonadotropin (FSH/LH)- secreting adenoma, surgical resection of the tumor is the preferred treatment option. Radiotherapy may be employed if the tumor was not completely removed by surgery.

In the case of non-functional pituitary adenomas, observation without any treatment is considered as the preferred approach for small (<1 cm in size, and not causing any symptom) tumors. For large tumors pressing on nearby structures, surgical resection of the tumor is the preferred treatment option. Radiotherapy may be employed to kill any residual tumor cells.
Hemangioblastomas In the case of hemangioblastomas, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. Post-operative radiotherapy may be considered in the case of high-grade disease, or incomplete resection. Radiotherapy can be employed as the first-line treatment for patients who are not the good candidates for surgery.
Choroid Plexus Tumors In the case of choroid plexus papillomas (benign form), maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. Post-operative radiotherapy should be considered in the case of incomplete resection or where complete resection is not possible.

In the case of choroid plexus carcinoma, maximal tumor excision without compromising any neurological function is considered the preferred treatment approach. Post-operative radiotherapy should be considered in the case of high-grade disease, incomplete resection, or high-risk individuals. Radiotherapy can be employed as the first-line treatment for patients who are not the good candidates for surgery.

Instead of radiotherapy, chemotherapy may be employed after surgery in infants and young children.

Following is the brief description of various treatment types employed for CNS cancers/tumors:

  1. Surgery: Surgery is the treatment of choice for most low-grade and some intermediate-grade brain cancers/tumors that have not spread to distant parts and can be completely removed by a surgical procedure. Apart from the main objective of removing the maximum possible tumor tissue without compromising any neurological function, surgery can also be employed for other purposes, such as for the collection of the biopsy sample from the affected area and to relieve symptoms of a high-grade disease.

    Craniotomy is the most common surgical procedure employed for the treatment of intracranial tumors. Special instruments are used to cut open a piece of the skull over the tumor and tumor tissue is removed with the help of surgical instruments. Surgical treatment of brain cancer is generally complex and requires intensive planning with imaging studies.

  2. Radiation Therapy: Radiation therapy (or radiotherapy) uses high-energy x-rays or other high-energy radiations which are directed to the affected area to kill tumor cells. For the treatment of CNS tumor, radiotherapy is generally employed in conjunction with surgery to kill any residual cancer cells for non-resectable tumors, or as palliative therapy to relieve symptoms of an advanced disease.

    For the treatment of brain tumor, an external beam radiation therapy (EBRT) technique is generally employed. Three-dimensional conformal radiation therapy (3D-CRT), Intensity modulated radiation therapy (IMRT), Conformal proton beam radiation therapy, and Stereotactic radiosurgery (SRS)/stereotactic radiotherapy (SRT) are some advanced techniques commonly used for the brain cancer treatment.

  3. Chemotherapy: Chemotherapy means treatment with anti-cancer drugs that kill or decrease the growth of rapidly-growing cancer cells. Chemotherapeutic drugs have to cross the blood-brain barrier (BBB) before showing their effect on the brain tumor cells. Most conventional drugs cannot cross the BBB, and thus, are not useful for the treatment of brain tumor.

    Chemotherapy may be employed in combination with radiation therapy or surgery for the management of CNS tumors, especially in the case of aggressive cancer types. Depending upon the type of cancer, single drug or certain combination regimen involving multiple drugs can be used for the treatment of CNS tumors. Many pharmaceutical companies are conducting a number of clinical trials to find out new drugs and drug-combinations with increased efficacy and specificity to target CNS tumor cells.

  4. Targeted Therapy: Targeted drugs work by targeting a specific gene or protein characteristic of the cancer cells. For example, Bevacizumab is the targeted drug used for the treatment of brain tumors expressing vascular endothelial growth factor (VEGF) receptors, and Everolimus targets mTOR protein that helps cancer cells to grow. These drugs are employed for the treatment of recurrent or advanced-stage disease when other treatment options cannot be used or are not effective.

  5. Supportive Care: Supportive care is a very important component of CNS tumor therapy and may include management of disease symptoms or the side-effects of the primary treatment. Treatment with corticosteroids is provided to reduce inflammation, pain, and other symptoms. Anticonvulsant drugs are employed to control seizures. Hormonal supplements are provided in case of deficiency of certain hormones and hormonal analogs are used in case of excess secretion of the hormones by some functional tumors.

It is very important to assess the benefits of each treatment option versus the possible risks and side effects before making a treatment decision. Sometimes patient’s choice and health condition are also important to make a treatment choice.

Following are the goals of brain cancer treatment:

  • Prolongation of life.
  • Reduction of symptoms.
  • Improvement of overall quality of life.

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