Adult Brain Tumors

Adult brain tumor facts*

*Adult brain tumor facts Medically Edited by: Charles P. Davis, MD, PhD

• The brain is a soft mass of tissue that has three major parts, the cerebrum, cerebellum and the brain stem, all of which are effectively surrounded and protected by the bones of the skull; the brain is the tissue that controls people's voluntary and involuntary actions.
  
• Cancer is the unregulated growth of abnormal cells in the body (cancer cells are also termed malignant cells).
  
• Malignant brain tumors contain cancer cells; benign brain tumors do not contain cancer cells but do contain abnormally replicating cells that do not metastasize (spread to other organs) but may still cause problems, often because of their size and are regulated to grow in a specific area.
  
• Primary brain tumors are composed of abnormal types of brain cells with unregulated growth; the most common type is termed gliomas that arise from brain glial cells, but there are many other types (for example, astrocytomas, ependymomas, medulloblastomas and others).
  
• Secondary brain tumors are tumors that have spread to the brain tissue, but are composed of cancer cells from other organs (for example, breast, lung).
  
• The exact cause of brain tumors is unknown; however, people at higher risk for them are children and the elderly, white males, people with family members that have brain tumors, radiation exposure, and exposures to many different chemicals.
  
• Symptoms of brain tumors, many of which are non-specific and occur in other diseases, may include headaches, nausea, vomiting, speech, hearing or vision changes, memory problems, personality changes and paresthesias (an abnormal sensation of the skin such as numbness, tingling, prickling, burning, or creeping on the skin that has no objective cause).
  
• Brain tumors are diagnosed preliminarily by many methods including detailed physical exam, CT and/or MRI exams, angiograms, and X-rays; definitive diagnosis is by removing tissue from the tumor (tumor biopsy) and examining the cells microscopically.
  
• Treatment choices for a brain tumor depends on joint decisions made by the patient and the patient's physician team (team members may include oncologists, surgeons, therapists and others the patient may choose, including other doctors who may give a second opinion); treatment methods are based on the individual's disease and may consist of surgery, chemotherapy, radiation therapy, combinations of these methods or no treatment.
  
• Side effects of treatments are common and numerous but vary from patient to patient depending on the disease, method(s) used and the effectiveness of medications and other methods to reduce them; some of the most common side effects are weakness, nausea, edema, skin changes and hair loss but may include more serious problems such as infections, seizures, disabilities such as speech problems, mental changes and occasionally, death.
  
• Rehabilitation is frequently included in the treatment plan; specialists like physical, occupational and speech therapists can help the patient improve.
  
• Follow-up appointments are part of the treatment plan for brain tumors to catch any recurrent disease and to help with rehabilitation treatments.
  
• Support groups are available to patients with brain tumors and to patients who have and are undergoing treatments; for example, the American Cancer Society, American Brain Tumor Society.

What are adult brain tumors?

Adult brain tumors are diseases in which cancer (malignant) cells begin to grow in the tissues of the brain. The brain controls memory and learning, senses (hearing, sight, smell, taste, and touch), and emotion. It also controls other parts of the body, including muscles, organs, and blood vessels. Tumors that start in the brain are called primary brain tumors.

What are metastatic brain tumors?

Often, tumors found in the brain have started somewhere else in the body and spread (metastasized) to the brain. These are called metastatic brain tumors.

What are the symptoms of an adult brain tumor?

A doctor should be seen if the following symptoms appear:

• Frequent headaches.
• Vomiting.
• Loss of appetite.
• Changes in mood and personality.
• Changes in ability to think and learn.
• Seizures.

What tests are used to find and diagnose adult brain tumors?

Tests that examine the brain and spinal cord are used to detect (find) adult brain tumor. The following tests and procedures may be used:

• CT scan (CAT scan): A procedure that makes a series of detailed pictures of areas inside the body, taken from different angles. The pictures are made by a computer linked to an x-ray machine. A dye may be injected into a vein or swallowed to help the organs or tissues show up more clearly. This procedure is also called computed tomography, computerized tomography, or computerized axial tomography.
• MRI (magnetic resonance imaging): A procedure that uses a magnet, radio waves, and a computer to make a series of detailed pictures of the brain and spinal cord. A substance called gadolinium is injected into the patient through a vein. The gadolinium collects around the cancer cells so they show up brighter in the picture. This procedure is also called nuclear magnetic resonance imaging (NMRI).

Adult brain tumor is diagnosed and removed in surgery. If a brain tumor is suspected, a biopsy is done by removing part of the skull and using a needle to remove a sample of the brain tissue. A pathologist views the tissue under a microscope to look for cancer cells. If cancer cells are found, the doctor will remove as much tumor as safely possible during the same surgery. An MRI may then be done to determine if any cancer cells remain after surgery. Tests are also done to find out the grade of the tumor.

What is the grade of a tumor?

The grade of a tumor refers to how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. The pathologist determines the grade of the tumor using tissue removed for biopsy. The following grading system may be used for adult brain tumors:
Grade I
The tumor grows slowly, has cells that look similar to normal cells, and rarely spreads into nearby tissues. It may be possible to remove the entire tumor by surgery.
Grade II
The tumor grows slowly, but may spread into nearby tissue and may become a higher-grade tumor.
Grade III
The tumor grows quickly, is likely to spread into nearby tissue, and the tumor cells look very different from normal cells.
Grade IV
The tumor grows very aggressively, has cells that look very different from normal cells, and is difficult to treat successfully.
The chance of recovery (prognosis) and choice of treatment depend on the type, grade, and location of the tumor and whether cancer cells remain after surgery and/or have spread to other parts of the brain.

Types of Adult Brain Tumors

The extent or spread of cancer is usually described as stages. There is no standard staging system for brain tumors. Primary brain tumors may spread within the central nervous system (brain and spinal cord), but they rarely spread to other parts of the body. For treatment, brain tumors are classified by the type of cell in which the tumor began, the location of the tumor in the central nervous system, and the grade of the tumor.
Types of adult brain tumors include the following:
Brain Stem Gliomas
These are tumors that form in the brain stem, the part of the brain connected to the spinal cord. They are often high-grade. Brain stem gliomas that are high-grade or spread widely throughout the brain stem are difficult to treat successfully. To prevent damage to healthy brain tissue, brain stem glioma is usually diagnosed without a biopsy.
Pineal Astrocytic Tumor
Pineal tumors form in or near the pineal gland. The pineal gland is a tiny organ in the brain that produces the hormone melatonin, a substance that helps control our sleeping and waking cycle. There are several kinds of pineal tumors. Pineal astrocytic tumors are astrocytomas that occur in the pineal region and may be any grade.
Pilocytic Astrocytoma (grade I)
Astrocytomas are tumors that start in brain cells called astrocytes. Pilocytic astrocytomas grow slowly and rarely spread into the tissues around them. These tumors occur most often in children and young adults. They usually can be treated successfully.
Diffuse Astrocytoma (grade II)
Diffuse astrocytomas grow slowly, but they often spread into nearby tissues. Some of them progress to a higher grade. They occur most often in young adults.
Anaplastic Astrocytoma (grade III)
Anaplastic astrocytomas are also called malignant astrocytomas. They grow rapidly and spread into nearby tissues. The tumor cells look different from normal cells. The average age of patients developing anaplastic astrocytomas is 41 years.
Glioblastoma (grade IV)
Glioblastomas are malignant astrocytomas that grow and spread aggressively. The cells look very different from normal cells. Glioblastoma is also called glioblastoma multiforme or grade IV astrocytoma. They occur most often in adults between the ages of 45 and 70 years.
Oligodendroglial Tumors
Oligodendroglial tumors begin in the brain cells called oligodendrocytes, which support and nourish nerve cells. Grades of oligodendroglial tumors include the following:

• Oligodendroglioma (grade II): Oligodendrogliomas are slow-growing tumors with cells that look very much like normal cells. These tumors occur most often in patients between the ages of 40 and 60 years.
• Anaplastic oligodendroglioma (grade III): Anaplastic oligodendrogliomas grow quickly and the cells look very different from normal cells.

Mixed Gliomas
Mixed gliomas are brain tumors that contain more than one type of cell. The prognosis is affected by the cell type with the highest grade present in the tumor.

• Oligoastrocytoma (grade II): Oligoastrocytomas are slow-growing tumors composed of cells that look like astrocytes and oligodendrocytes.
• Anaplastic oligoastrocytoma (grade III): These are higher-grade oligoastrocytomas. The average age of patients developing anaplastic oligoastrocytomas is 45 years.

Ependymal Tumors
Ependymal tumors usually begin in cells that line the spaces in the brain and around the spinal cord. These spaces contain cerebrospinal fluid, a liquid that cushions and protects the brain and spinal cord. Grades of ependymal tumors include the following:

• Grade I and grade II ependymomas: These ependymomas grow slowly and have cells that look very much like normal cells. They can often be removed completely by surgery.
• Anaplastic ependymoma (grade III): Anaplastic ependymomas grow very quickly.

Medulloblastoma (grade IV)
Medulloblastomas are brain tumors that begin in the lower back of the brain. They are formed from abnormal brain cells at a very early stage in development. Medulloblastomas are usually found in children or young adults between the ages of 21 and 40 years. This type of cancer may spread from the brain to the spine through the cerebrospinal fluid.
Pineal Parenchymal Tumors
Pineal parenchymal tumors form from parenchymal cells or pinocytes, the cells that make up most of the pineal gland. These differ from pineal astrocytic tumors, which are astrocytomas that form in tissue that supports the pineal gland. Grades of pineal parenchymal tumors include the following:

• Pineocytomas (grade II): Pineocytomas are slow-growing pineal tumors that occur most often in adults aged 25 to 35.
• Pineoblastomas (grade IV): Pineoblastomas are rare and highly malignant. They usually occur in children.

Meningeal Tumors
Meningeal tumors form in the meninges, thin layers of tissue that cover the brain and spinal cord. Types of meningeal tumors include the following:

• Grade I meningioma: Meningiomas are the most common meningeal tumor. Grade 1 meningiomas are slow-growing and benign. They are found most often in women.
• Grade II and III meningiomas and hemangiopericytomas: These are rare malignant meningeal tumors. They grow quickly and are likely to spread within the brain and spinal cord. Grade III meningiomas are more common in men. Hemangiopericytomas often recur after treatment and most of them spread to other parts of the body.

Germ Cell Tumor
Germ cell tumors arise from germ cells, cells that are meant to form sperm in the testicles or eggs in the ovaries. These cells may travel to other parts of the body and form tumors. Types of germ cell tumors include germinomas, embryonal cell carcinomas, choriocarcinomas, and teratomas. They can occur anywhere in the body and can be either benign or malignant. In the brain, they usually form in the center, near the pineal gland, and can spread to other parts of the brain and spinal cord. Most germ cell tumors occur in children.
Craniopharyngioma (grade II)
Craniopharyngiomas occur in the sellar region of the brain, near the pituitary gland. The pituitary gland is a small organ about the size of a pea, located at the base of the brain. This gland controls many of the body's functions, especially growth. In adults, these tumors occur most often after the age of 50 years. Craniopharyngiomas can press on vital brain tissue and cause symptoms to appear. The tumors can also block fluid in the brain and cause swelling. The prognosis is good for craniopharyngiomas that are completely removed in surgery.
Pituitary tumors also occur in this region.
Recurrent Adult Brain Tumor
Recurrent adult brain tumor is a tumor that has recurred (come back) after it has been treated. Adult brain tumors often recur, sometimes many years after the first tumor. The tumor may come back in the brain or in other parts of the body.
Metastatic Brain Tumors
The types of cancer that commonly spread to the brain are cancers of the lung, breast, unknown primary site, melanoma, and colon. About half of metastatic spinal cord tumors are caused by lung cancer.
Prognosis depends on the following:

• Whether the patient is younger than 60 years.
• Whether there are fewer than 3 tumors in the brain and/or spinal cord.
• The location of the tumors in the brain and/or spinal cord.
• How well the tumor responds to treatment.
• Whether the primary tumor continues to grow or spread.

The prognosis is better for brain metastases from breast cancer than from other types of primary cancer.
The prognosis is worse for brain metastases from colon cancer.

How are adult brain tumors treated?

Different types of treatment are available for patients with adult brain tumor. Some treatments are standard (the currently used treatment), and some are being tested in clinical trials. Before starting treatment, patients may want to think about taking part in a clinical trial. A treatment clinical trial is a research study meant to help improve current treatments or obtain information on new treatments for patients with cancer. When clinical trials show that a new treatment is better than the standard treatment, the new treatment may become the standard treatment.
Clinical trials are taking place in many parts of the country. To learn more about clinical trials, call the Cancer Information Service at 1-800-4-CANCER (1-800-422-6237); TTY at 1-800-332-8615. Information about ongoing clinical trials is available from the NCI Web site. Choosing the most appropriate cancer treatment is a decision that ideally involves the patient, family, and health care team.

Three types of standard treatment are used.

1. Surgery: Surgery is used, when possible, to treat adult brain tumor, as described in the Description section of this summary.
2. Radiation therapy: Radiation therapy is a cancer treatment that uses high-energy x-rays or other types of radiation to kill cancer cells. There are two types of radiation therapy. External radiation therapy uses a machine outside the body to send radiation toward the cancer. Internal radiation therapy uses a radioactive substance sealed in needles, seeds, wires, or catheters that are placed directly into or near the cancer. The way the radiation therapy is given depends on the type and stage of the cancer being treated.
3. Chemotherapy: Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, either by killing the cells or by stopping the cells from dividing. When chemotherapy is taken by mouth or injected into a vein or muscle, the drugs enter the bloodstream and can reach cancer cells throughout the body (systemic chemotherapy). When chemotherapy is placed directly into the spinal column, an organ, or a body cavity such as the abdomen, the drugs mainly affect cancer cells in those areas (regional chemotherapy). A dissolving wafer may be used to deliver an anticancer drug directly into the brain tumor site after the tumor has been removed by surgery. The way the chemotherapy is given depends on the type and stage of the cancer being treated.

Other types of treatment are being tested in clinical trials.

New methods of delivering radiation therapy

• Radiosensitizers: Drugs that make tumor cells more sensitive to radiation. Combining radiation with radiosensitizers may kill more tumor cells.
• Hyperfractionation: Radiation therapy given in smaller-than-usual doses two or three times a day instead of once a day.
• Stereotactic radiosurgery: A radiation therapy technique that delivers radiation directly to the tumor with less damage to healthy tissue. The doctor uses a CT scan or MRI to find the exact location of the tumor. A rigid head frame is attached to the skull and high-dose radiation is directed to the tumor through openings in the head frame, reducing the amount of radiation given to normal brain tissue. This procedure does not involve surgery. This is also called stereotaxic radiosurgery and gamma knife therapy.

Hyperthermia therapy
Hyperthermia therapy is a treatment in which body tissue is exposed to high temperatures to damage and kill cancer cells or to make cancer cells more sensitive to the effects of radiation and certain anticancer drugs.
Biologic therapy
Biologic therapy is a treatment that uses the patient's immune system to fight cancer. Substances made by the body or made in a laboratory are used to boost, direct, or restore the body's natural defenses against cancer. This type of cancer treatment is also called biotherapy or immunotherapy.
How are metastatic brain tumors treated?
Tumors that have spread to the brain from somewhere else in the body are usually treated with radiation therapy and/or surgery. Chemotherapy may be used if the primary tumor is the kind that responds well to chemotherapy. Clinical trials are under way to study new treatments.

Treatment Options by Type of Adult Brain Tumor

Brain Stem Gliomas
Treatment of brain stem gliomas may include the following:

1. Hyperfractionated radiation therapy.
2. A clinical trial of new anticancer drugs and/or biologic therapy.

Pineal Astrocytic Tumors
Treatment of pineal astrocytic tumors may include the following:

1. Surgery and radiation therapy, with or without chemotherapy.
2. A clinical trial of external radiation therapy plus hyperthermia therapy or new methods of delivering radiation therapy.
3. A clinical trial of new anticancer drugs and biologic therapy following radiation therapy.

Pilocytic Astrocytomas
Treatment of pilocytic astrocytoma is usually surgery with or without radiation therapy.
Diffuse Astrocytomas
Treatment of diffuse astrocytoma may include the following:

1. Surgery, usually with radiation therapy.
2. A clinical trial of surgery and radiation therapy with or without chemotherapy for tumors that cannot be completely removed by surgery.
3. A clinical trial of radiation therapy delayed until the tumor progresses.
4. A clinical trial comparing high-dose and low-dose radiation therapy.

Anaplastic Astrocytomas
Treatment of anaplastic astrocytoma may include the following:

1. Surgery plus radiation therapy, with or without chemotherapy.
2. A clinical trial of external radiation therapy plus hyperthermia therapy or new methods of delivering radiation therapy.
3. A clinical trial of new anticancer drugs and biologic therapy following radiation therapy.
4. A clinical trial of chemotherapy combined with different methods of delivering radiation therapy.

Glioblastoma
Treatment of glioblastoma may include the following:

1. Surgery plus radiation therapy, with or without chemotherapy.
2. A clinical trial of chemotherapy placed into the brain during surgery.
3. A clinical trial of radiation and concurrent chemotherapy.
4. A clinical trial of external radiation therapy plus hyperthermia therapy or new methods of delivering radiation therapy.
5. A clinical trial of new anticancer drugs and biologic therapy following radiation therapy.
6. A clinical trial of chemotherapy and new methods of delivering radiation therapy.
7. Clinical trials of new treatments.

Oligodendroglial Tumors
Treatment of oligodendrogliomas may include the following:

1. Surgery, usually with radiation therapy.
2. A clinical trial of surgery and radiation therapy with or without chemotherapy for tumors that cannot be completely removed by surgery.
3. A clinical trial of chemotherapy using one or more drugs.

Treatment of anaplastic oligodendroglioma may include the following:

1. Surgery plus radiation therapy with or without chemotherapy.
2. Chemotherapy using more than one drug.
3. Radiation therapy with or without chemotherapy using more than one drug.
4. Clinical trials of new treatments.

Mixed Gliomas
Treatment of mixed gliomas may include the following:

1. Surgery plus radiation therapy with or without chemotherapy.
2. A clinical trial of external radiation therapy plus hyperthermia therapy or new methods of delivering radiation therapy.
3. A clinical trial of new anticancer drugs or biologic therapy following radiation therapy.

Ependymal Tumors
Treatment of grade I and grade II ependymomas is usually surgery with or without radiation therapy.
Treatment of anaplastic ependymoma may include the following:

1. Surgery plus radiation therapy.
2. A clinical trial of surgery followed by chemotherapy before, during, and after radiation therapy.
3. A clinical trial of chemotherapy and/or biologic therapy.

Medulloblastoma
Treatment of medulloblastomas may include the following:

1. Surgery plus radiation therapy to the brain and spine.
2. A clinical trial of surgery and radiation therapy to the brain and spine for tumors that are more difficult to treat successfully.
3. A clinical trial of chemotherapy.

Pineal Parenchymal Tumors
Treatment of pineal parenchymal tumors may include the following:

1. Surgery plus radiation therapy with or without chemotherapy.
2. A clinical trial of external radiation therapy plus hyperthermia therapy or new methods of delivering radiation therapy.
3. A clinical trial of new anticancer drugs and biologic therapy following radiation therapy.

Meningeal Tumors
Treatment of meningiomas may include the following:

1. Surgery with or without radiation therapy.
2. Radiation therapy for tumors that cannot be removed by surgery.

Treatment of malignant meningioma may include the following:

1. Surgery plus radiation therapy.
2. A clinical trial of external radiation therapy plus hyperthermia therapy or new methods of delivering radiation therapy.
3. A clinical trial of new anticancer drugs and/or biologic therapy following radiation therapy.

Germ Cell Tumors
Treatment of central nervous system germ cell tumors depends on the type of cancer cells, the location of the tumor, whether the cancer can be removed in an operation, and other factors.
Craniopharyngioma
Treatment of craniopharyngiomas may include the following:

1. Surgery to remove the entire tumor.
2. Surgery to remove as much of the tumor as possible, followed by radiation therapy.

Recurrent Adult Brain Tumor
Treatment of recurrent adult brain tumors may include the following:

1. Surgery with or without chemotherapy.
2. Radiation therapy, if not used during previous treatment, with or without chemotherapy.
3. Internal radiation therapy.
4. Chemotherapy.
5. A clinical trial of new anticancer drugs.
6. A clinical trial of chemotherapy placed into the brain during surgery.
7. A clinical trial of biologic therapy.

Metastatic Brain Tumors
Treatment of a single metastatic brain tumor is usually surgery followed by radiation therapy to the brain.
Treatment of more than one metastatic brain tumor may include the following:

1. Radiation therapy to the brain.
2. Surgery, for large tumors that are pressing on areas of the brain and causing symptoms.

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SOURCES: 
U.S. National Institutes of Health. National Cancer Institute. Adult Brain Tumors.

 Medicinenet.com.