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Surgery
The first step in therapy is to remove as much of
of tumor tissue as possible. Surgeons believe that patients
with smaller amounts of tumor when they start other treatments
will have a better prognosis. Also, radiation therapy is more
easily tolerated when the pressure from the tumor can be reduced.
There is great variability in the amount of tumor that can
be safely removed from the brain of a patient. The variability
is based mainly on the location of the tumor. For instance,
tumors in some brain areas can be removed with very low
risk, while in other brain areas surgery is too risky to
consider. The decision about the benefit and risk of surgical
removal is one that experienced brain tumor neurosurgeons
make every day. The underlying principle is that the surgery
should not worsen the patient’s condition. The goal
is for the patient to be the same or better after recovering
from brain tumor removal. When a tumor is located in a
sensitive area of the brain, a biopsy is performed with
a small needle, thereby avoiding further damage to brain
function. It is important to remember that gliomas infiltrate
into surrounding brain tissue, making complete removal
impossible in almost every case.
With modern neuro-imaging techniques such as MRI scans,
it is possible for doctors to have a high level of confidence
that a brain tumor is present prior to biopsy. In that
case, it is safe to perform a major surgical resection
at the same time as obtaining tumor tissue for the pathologist
to examine. In some cases, however, it is necessary to
perform a needle biopsy first, and later proceed to a full-scale
surgery.
A preliminary diagnosis (“frozen section diagnosis”)
is made by the neuropathologist during the surgery in order
to help the neurosurgeon know what type of tumor is present.
The patient and their family are informed of this preliminary
diagnosis immediately after surgery. However, further recommendations
about treatment are not made until the final pathology
report is available. The final report requires a minimum
of 2 working days after surgery. In difficult cases, the
final report can take a week. It is not uncommon for small,
but important, changes to be made in the diagnosis once
all of the biopsy sections have been examined.
An MRI scan is usually obtained within 3 days after tumor
removal. This post-operative MRI serves as a baseline for
future comparison.
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Radiation Therapy
Radiation therapy is an important part of the
treatment of high-grade gliomas. In typical situations,
patients begin radiation treatments within 2 to 4 weeks
after tumor resection. A physician who supervises radiation
treatments is called a radiation oncologist.
Following a “simulation” session in which the
radiation oncologist plans the shape of the radiation beam,
as well as, dose, treatments are given daily, Monday through
Friday, for 4 to 6 weeks, with the exception of holidays.
Each treatment takes only a few minutes. During radiation,
patients are seen weekly by the radiation oncologist, and
a nurse is available for questions every day. Most patients
feel better during radiation therapy if they are taking
a small dose of a steroid which reduces brain swelling,
called Decadron (also called dexamethasone).
There are usually no immediate side effects during each
treatment. As the treatment progresses, hair loss will
occur over the area where the radiation beam passes into
the tumor. Most patients experience some fatigue by the
second or third week. For many, a nap is helpful every
afternoon. There are a number of long-term side effects
from radiation therapy, ranging from those that are a minor
nuisance, to ones that can produce major health problems.
Fortunately, serious side effects are rare. Furthermore,
the potential risks of radiation therapy are outweighed
by the known risk of not treating the tumor. The radiation
oncologist will describe these risks prior to starting
therapy.
An MRI is usually obtained, about 2 to 4 weeks after the
end of radiation therapy, in order to judge the effect
of treatment. Most of the time this scan will show no change
from the post-operative MRI, which is good. Some shrinkage
is even better. Growth during radiation therapy is an unwanted
sign of an aggressive tumor.
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Chemotherapy
Chemotherapy is helpful in controlling the growth
of high-grade gliomas. Several different types of chemotherapy
drugs are available. A neuro-oncologist is skilled at recommending
these treatments. For many high grade gliomas, radiation
and chemotherapy are given concurrently, at the same time. Generally,
the chemotherapy is a drug called Temodar. A small
dose is taken each day during the course of radiation. Upon
completion, the drug is generally given in a 5 consecutive
day course every 28 days. But, remember, these decisions
are made on a patient to patient basis.
In addition to standard chemotherapy, there are studies
of new drugs, which are conducted in major research centers.
It is usually good to enter a research study if eligible,
both for reasons of personal benefit and for the benefit
of others in the future. Neuro-oncologists will provide
information about clinical trials.
The possible side effects of chemotherapy will be discussed
before beginning treatment. Today, chemotherapy is much
less toxic than even a few years ago. Although chemotherapy
is targeted against dividing tumor cells, there are normal
cells in the body which are also dividing. These normal
cells can also be temporarily affected by chemotherapy
and may lead to side effects. Specifically, the cells which
can be affected are those in the bone marrow and the cells
which line the gastrointestinal tract. The cells in the
bone marrow form the blood cells that are circulating in
the body. These cells include white blood cells which fight
infection, red blood cells which carry oxygen, and platelets
which prevent bleeding.
Two other types of cells which may be affected temporarily
or permanently are the female egg cells and those cells
which produce sperm in the man. In men, chemotherapy can
cause sterility and may make men unable to father a child.
Men should discuss this with the doctor before starting
chemotherapy.
Women of child-bearing years need to use a reliable birth
control method for the entire time, including the rest
periods, when receiving chemotherapy. Men should use a
condom when having sexual relations to protect their spouses
from exposure to the drug. The effects of many chemotherapy
drugs can be harmful to the growth and development of a
fetus, therefore it is crucial to not become pregnant or
father a child while receiving chemotherapy.
When receiving chemotherapy, and for 3 days after, it is
important that careful attention be paid to hand washing
after urination. Since many chemotherapy drugs are removed
from the body by the urine, careful hand washing will prevent
family members from being exposed to the chemotherapy.
If family members help with personal care of the patient,
they should wear rubber gloves when handling urine or vomitus.
Clothing soiled with urine, vomit, or feces should be washed
separately in hot soapy water.
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After treatment is completed
Once the recommended treatments have been completed,
an observation phase is entered. In the observation period,
visits to the neuro-oncologist occur every 2 to 4 months. A
surveillance MRI or CT is ordered several days prior to
the visit. During the visit, there is a review of
symptoms, medications, and physical condition. All
of the test results are discussed.
Regrowth of tumor
Surveillance and careful follow-up are necessary
because of the harsh reality that high-grade gliomas have
a well-known tendency to regrow. Most often regrowth occurs
at the same site where the tumor arose. If and when tumor
progression is discovered, brain tumor specialists may
recommend further surgery, radiation, or chemotherapy.
Prognosis
The prognosis is different for different tumors.
The specialists will discuss prognosis with you.
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