Treatment

• Surgery
• Radiotherapy
• Steroid drugs
• Anticonvulsants
• Chemotherapy
• Biological therapy
• Neurorehabilitation
• What is the treatment of recurrent brain tumours?

Most people will have surgery for their brain tumour as this is the most effective treatment to relieve selected symptoms at short notice. Surgery with the aim to remove all visible tumour may not be possible for most tumours particularly those which are growing in functionally vital parts of the brain – for example if they are growing next to the area responsible for maintaining breathing. In these cases a combination of radiotherapy and or chemotherapy may be used. In some cases surgery is possible but removing all of the tumour completely would cause too much brain damage and only part of the tumour is removed – this is called ‘debulking’ surgery. Depending on the type of brain tumour adjuvant treatment particularly radiotherapy and or chemotherapy is used to treat the remaining tumour or the previous tumour bed.

Surgery

Craniotomy

This is the main operation used for most brain tumours - a large incision is made and a flap of bone lifted from the skull to gain access to the brain underneath. It can be done under general or local anaesthesia. After completion of the operation the skull is wired back together. Initial recovery takes place in hospital with hospital stay ranging from 5-14 days. The scars tend to be behind the hairline and do not affect appearance in the longer term. Return to normal function after this type of surgery depends on several factors:

• Level of function before surgery
• Whether further damage was caused by surgery
• Whether neurorehabilitation is required
• Whether further treatment such as radiotherapy or chemotherapy is required.

Common problems after surgery include:

• Headaches – these normally resolve within two weeks but may persist for months
• Lack of concentration and memory problems – can gradually improve over several months
• Tiredness – likely to be severe for the first 2 weeks and then improve but does not always complete resolve.

A person who was well prior to their surgery and who does not need any neurorehabilitation or any further adjuvant treatment would be well enough to return to work 6-12 weeks after surgery.

A person with a neurological deficit such as weakness, clumsiness, memory problems or difficulty with speech should have access to neurorehabilitation. For mild problems this can be offered as an outpatient with regular therapy sessions including Physiotherapy, Occupational therapy and Speech and Language Therapy. This may be at a local hospital or via community teams and therapists.

For more severe deficits, for example where a person has to relearn how to walk and functionally participate in their own environment and society as a whole, this may involve a period as an inpatient on a neurorehabilitation ward. Access to intensive inpatient Neuro rehab is extremely restricted to many patients with primary brain tumours especially those with high grade tumours. This is because they have a limited prognosis. However, functional improvement can be seen in conjunction with active medical treatment e.g. radiotherapy/chemotherapy so timely access to appropriate therapy and other supportive services is essential. This can optimise rehabilitation opportunities and longer term functional management. Behaviour and personality changes can also be improved with neurorehabilitation techniques so access to neuro-psychology services is important.

Neurological deficits are likely to improve quickly for a few months and then improve much more slowly – over several years. This can vary and can be assessed by therapists who can monitor patients’ recovery at key stages of their pathway and offer appropriate intervention. Needs will decrease as improvement occurs. Some neurological deficits will not improve with rehabilitation and for some patients a neurological deficit may persist. Part of the rehabilitation process will include learning compensatory and coping skills to overcome disabling effects of both physical and cognitive impairment and to optimise function. This may include the use of adaptive devices or equipment to enable activities of daily living. A stable condition is likely to be reached in two years.

Other types of surgery

Shunts – these are plastic tubes which redirect CSF when a blockage has occurred – they relieve raised intracranial pressure and its symptoms. Shunts may be temporary or permanent. Recovery from this type of surgery takes up to a few weeks; it is not associated with any permanent neurological deficits.

Neuroendoscopy – this technique uses an endoscope to operate through, this means only one or two small burr holes have to be made in the skull and recovery is quicker, unfortunately it can only be used for a small proportion of brain tumours at the moment. A third ventriculostomy is an endoscopic operation to relieve raised intracranial pressure, avoiding a plastic shunt.

Transphenoidal surgery – this means an operation performed via the nose so there are no external scars. This type of surgery is virtually exclusively used for pituitary gland tumours as the pituitary gland is located behind the nose. There are no external scars after this type of surgery – recovery time is up to 6 weeks.

Radiosurgery – this is not surgery at all but highly focused and targeted radiotherapy treatment - see radiotherapy section.

Radiotherapy

This is a commonly used treatment for brain tumours, it is used as:

• primary treatment for tumours that cannot be removed by surgery
• adjuvant treatment for tumours that have been either completely removed or 'debulked' by surgery either after a time of observation (less aggressive tumours) or at first diagnosis of a malignant tumour. treatment of recurrent disease

Radiotherapy treatments are usually given daily (Monday to Fridays) over 6 weeks. Side effects occur but are not usually severe. Side effects include:

• Tiredness and sleepiness – if severe, towards the end of treatment the person having radiotherapy may do little other than sleep. In medical evidence this may be referred to as ‘somnolence syndrome’. This will usually improve significantly in the 8-12 weeks after treatment has finished.
• Sickness – may require treatment with anti-emetic drugs
• Worsening neurological deficit – problems caused by the tumour such as clumsiness or speech difficulty may get worse during treatment because of swelling within the treatment area. Steroid drugs are often used to treat this. Deficits associated with swelling will improve once treatment is complete.
• Hair loss and skin changes – hair in the treated area is likely to fall out permanently and there may be skin changes – see general notes.
• Disturbed hearing – hearing may be affected during treatment due to local inflammation but resolves once treatment is complete.
• Difficulty concentrating and remembering – this may take a long time to resolve and can be in selected cases be very disabling in terms care or mobility. It may affect employment and have other psychological implications.

In the long term mild problems with concentration and memory are common in people who have had radiotherapy treatment to the head but they are not necessarily disabling.

In patients with poor outlook sometimes a shorter course of radiotherapy (e.g. 2 weeks) is recommended to provide a better balance between the treatment related side effects and the very short expected survival time . This is a palliative treatment.

• Radiotherapy and Brachytherapy

Steroid drugs

These are commonly used in short courses to reduce brain swelling related to the tumour itself or its treatment particularly with surgery or radiotherapy – both of which cause tissue inflammation and swelling. Prolonged use of steroid drugs will have side effects – refer to general notes.

Anticonvulsants

Epileptic fits are common symptoms of brain tumours but they may also occur as a result of treatment such as radiotherapy or surgery. These drugs are commonly used prophylactically to prevent fits in people undergoing treatment whether they have had a fit because of their tumour or not. People who have had fits may need to take anticonvulsants permanently to control epilepsy. Disabling effects of epilepsy relate to frequency and type of fits – refer to epilepsy guidance.

Chemotherapy

This is not a primary treatment choice for most brain tumours but can prolong life if surgery is not possible or if a brain tumour has recurred after primary treatment. The exception to this is high grade glioma – the gold standard treatment is temozolomide and radiotherapy given after any surgery or biopsy. The total treatment time for such a radical approach is around 9 months.

Chemotherapy can occasionally be delivered directly into the tumour by placing a drug impregnated implant or wafer into the tumour bed at the time of surgery. More conventionally it is given in cycles using oral or intravenous combinations of chemotherapy drugs. Most chemotherapy for brain tumours is given either intravenously or by mouth (orally). See general notes for side effects of chemotherapy. Drugs likely to be used include:

• Temozolomide
• Carmustine
• Procarbazine
• Vincristine
• Irinotecan

Very rarely ‘high dose chemotherapy’ may also be used; this treatment involves high dose chemotherapy followed by peripheral blood stem cell transplant (PBSCT), stem cell rescue or bone marrow transplant. If a transplant is being used consult separate guidance on PBSCT for disabling effects.

• Side effects of Chemotherapy

Biological therapy

There are multiple options most of which will be used in the context of clinical trials. They include monoclonal antibodies (Avastin™), dendritic cell vaccination, tyrosine kinase inhibitors e.g. Glivec (Imatinib), gene therapy and oncolytic viruses. Side effects of these are generally milder compared to the effects of conventional chemotherapy.

Neurorehabilitation

Brain tumours and their treatment can damage the brain and affect its function. Brain damage or swelling can lead to neurological impairment and disability. Impairment and disability will depend on what part of the brain is affected. Some impairments are permanent and others temporary. Neurorehabilitation helps people with neurological deficits to improve physical functioning if their primary impairment is difficulty with movement. If behavioural or personality change is the main impairment this can also be treated. Improvement is likely to be quicker at first and then slow down. Symptoms due to surgery, radiotherapy and chemotherapy treatment, medication and tiredness are variable. There may be residual impairment when maximum improvement has been achieved. Some brain tumour patients especially the higher grades find it difficult to access Neuro rehab because of the limited available resources and being excluded from many services due to the possible progressive nature of their disease and their limited prognosis.

What is the treatment of recurrent brain tumours?

Often recurrent brain tumours cannot be cured but they can be controlled for a period of time. This will often involve treatment with steroids and radiotherapy (if not previously used) and or chemotherapy.

Amended November 2009