Medical and Surgical Management of Brain Tumors

MEDICAL AND SURGICAL
MANAGEMENT OF BRAIN TUMOURS
Batul Najmuddin Johar

I MPT(Neurological Sciences)
CONTENTS
• Objectives
• Steroid therapy
• Operative management
• Radiotherapy
• Complications of radiotherapy
• Chemotherapy
• Problems with chemotherapy
• Reference
OBJECTIVES
By the end of the class students should be able to understand

• Management of brain tumours via steroid therapy
• Operative management of brain tumour
• Radiotherapy and its complications
• Chemotherapy and its problems
STEROID THERAPY
• Steroids help reduce oedema surrounding intracranial tumors, but do

not affect tumor growth.
• A loading dose of 12 mg i.v. dexamethasone followed by 4 mg q.i.d.
orally or by injection often reverses progressive clinical deterioration
within a few hours. After several days treatment, gradual dose
reduction minimizes the risk of unwanted side effects.
OPERATIVE MANAGEMENT
• Image Guided Surgery :It is essential to accurately identify the tumor site on
pre-operative imaging and to be able to use this information to guide the
surgeon to the tumor whether for biopsy or for resection.
• Stereotactic surgery: by rigidly attaching the frame to the patient’s head and
using a CT or MRI to identify the position of the locating rods, coordinates are
determined for a selected target allowing accurate placement of a biopsy needle
to within 1 mm. This technique is routinely used to biopsy selected points
within the tumor. When a craniotomy is planned, most now use
neuronavigation (‘frameless’ stereotaxy) if available.
• Neuro navigation: this technique requires rigid fixation of the head in a standard
three pin head holder, but avoids the use of a frame .The system accurately
detects the position of the handheld probe in relation to the skull and allows the
surgeon to see where the probe tip lies in relation to pre-operative imaging.
Although often routinely used, this technique also fails to take into account brain
shift which can occur on opening the bone flap or if cerebrospinal fluid is drained
off thus limiting accuracy.
• Real-time intra-operative imaging: some centers have now acquired CT or MR
imaging available within the operative theatre. Although costly, this real-time
imaging overcomes problems encountered with brain shift and not only helps to
locate the tumor, but also shows the extent of tumor resection as the operation
progresses. Ultrasound has also been combined with neuronavigation to provide
real-time imaging at a more realistic expense.
Surgery in Eloquent Areas

When intrinsic tumors lie adjacent to or within eloquent areas within the brain,
i.e. speech area, motor strip, basal ganglia and internal capsule, resection is
potentially hazardous. Various techniques have been developed to try to minimize
this risk.
1. fMRI/Diffusion Tensor Imaging (Tractography): Superimposing speech
and/or motor strip areas seen on fMRI and white matter tracts seen on
tractography on to the standard MR image, demonstrates the relationship of
the tumor to these crucial structures. When these images are incorporated into
the neuro-navigation system it enables the surgeon to avoid extending the
tumor resection into these areas and causing irreversible neurological deficits.
2. Awake’ craniotomy: by either performing the surgery wholly under sedation

with local anesthetic, or by giving an anesthetic for opening and closing the
craniotomy and waking the patient up in between, gives the surgeon the
opportunity to identify eloquent areas by applying electrical stimulation direct to
the cortical surface and observing the functional effect. Studies show that patients
tolerate the technique well and maximal tumor resection is possible with a low
risk of deficit.
RADIOTHERAPY
Treatment of intracranial tumours with radiotherapy utilises one of the

following:
• Megavoltage X-rays (by far the most common method)
• Electron beam from a linear accelerator (which can also produce
megavoltage X-rays)
• Accelerated particles from a cyclotron, e.g. nuclei of helium, protons
• γ rays from cobalt 60
RADIOTHERAPY
• Conformal therapy where standard radiotherapy is administered, but the beams are
shaped by the use of variable collimators or blocks which conform with the shape of
the tumor, thereby eliminating normal brain.
• Stereotactic radiosurgery (SRS) where multiple converging beams from a linear
accelerator or from multiple cobalt60 sources are focused on a selected target in a
single treatment. Stereotactic radiotherapy (SRT) uses the same localization method
but with fractionated treatment as used in conventional radiotherapy
RADIOTHERAPY
• Interstitial techniques where the tumor is treated from within (brachytherapy)

by the implantation of multiple radioactive seeds, e.g. iodine125.
• Beam intensity modulated radiotherapy (IMRT) uses non-uniform beams of
varying intensity (in contrast to the conventional uniform dose intensity) to
complex tumor volumes. This helps protect surrounding structures, yet allows a
higher dose.
COMPLICATIONS OF RADIOTHERAPY
Following treatment, deterioration in a patient’s condition may occur for a variety of

reasons:
• Increased oedema – during treatment – reversible.
• Demyelination – after weeks, months – usually reversible.
• Radio necrosis – in usually 1–2 years (range 6 months–10 years) – irreversible.
• Cognitive impairment – whole brain irradiation causes dementia, ataxia and
incontinence in over 10% at one year. Radiotherapy should be avoided in children
under 3 years of age.
• Radiation induced tumors e.g. meningioma, may result many years after the treatment.
CHEMOTHERAPY
• Chemotherapeutic agents have been used for many years in the management of
malignant brain tumours, but their benefits remain limited.
• Temozolomide, an oral alkylating agent with excellent blood brain barrier
penetration and modest toxicity is established as an alternative treatment for
patients with recurrent high grade gliomas.
PROBLEMS WITH CHEMOTHERAPY
Problems of drug administration

• Toxicity: The ideal cytotoxic drug selectively kills tumor cells; but tumor cell
response relates directly to the dose. High drug dosage frequently causes bone
marrow suppression which may limit cytotoxic activity before an adequate
therapeutic dose is reached.
• Drug access: ‘Toxic’ doses are usually required before sufficient amounts
penetrate the blood– brain barrier and gain access to the tumor cells.
• Intrinsic resistance: Some tumor cells appear to have an inbuilt resistance to
certain drugs. The vast array of available cytotoxic drugs and the infinite
permutations of combined therapy creates difficulties in drug selection
REFERENCE
• Lindsay KW, Bone I, Fuller G. Neurology and Neurosurgery illustrated, 5 th

edition 2010 May 21.

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MEDICAL AND SURGICAL

MANAGEMENT OF BRAIN TUMOURS

Batul Najmuddin Johar

By the end of the class students should be able to understand

• Steroids help reduce oedema surrounding intracranial tumors, but do

Surgery in Eloquent Areas

2. Awake’ craniotomy: by either performing the surgery wholly under sedation

Treatment of intracranial tumours with radiotherapy utilises one of the

• Interstitial techniques where the tumor is treated from within (brachytherapy)

Following treatment, deterioration in a patient’s condition may occur for a variety of

Problems of drug administration

• Lindsay KW, Bone I, Fuller G. Neurology and Neurosurgery illustrated, 5 th

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