Brain tumor

Incidencia

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  • Brain tumors represent 85% to 90% of all primary tumors of the central nervous system.
  • The mortality rate is 4.22 deaths per 100,000 people a year.
  • Around 250,000 new cases are diagnosed per year worldwide.
  • There is a higher incidence among Caucasians.  The mortality rate is higher in men than in women.
  • Causes:
    • Although the causes of these tumors are not known exactly, exposure to vinyl chloride seems to predispose to the development of gliomas. Gliomas (anaplastic astrocytoma and glioblastoma multiforme) represent 38% of primary brain tumors. Meningiomas and other tumors account for approximately 27% of primary brain tumors in adults.
    • Primary lymphoma of the brain seems to be related to persons infected with the Epstein-Barr virus, having undergone a transplant or suffering from AIDS.  These persons could experience a higher incidence rate of primary lymphoma of the central nervous system.
    • Tumors with a lower incidence rate are: oligodendrogliomas, astrocytomas, low-grade lymphomas, medulloblastomas, ependymomas, schwannomas or pituitary.

The most common malignancy in the central nervous system is brain metastases.  It exceeds a ratio of 10/1 compared to primary tumors. Between 20% and 40% of malignant tumors produce brain metastases.  This figure may increase because patients are currently living longer as a result of the positive response to current cancer treatments.

Some tumors more than others produce brain metastases during their evolution.  They include lung cancer include (50%), breast cancer (15-20%), cancer of unknown primary origin (10-15%), melanoma (10%) and colon cancer (5%).

Symptoms

Symptoms that may occur in brain tumors are diverse and are related to the affected anatomical area of the nervous system. Symptoms may include:

  • Vomiting
  • Vision disorders
  • Dolor de cabeza
  • Headaches
  • Changes in mood or personality

These same symptoms can be produced by other diseases. It is necessary that a differential diagnosis be done by a specialist in order to determine their cause.

Diagnostic Imaging

    • CT (computed tomography) is an imaging test easily performed.  It provides information about the existence of cerebral edema or rules out symptoms caused by bleeding. It should always be done in conjunction with an MRI.
    • Resonancia magnética. Nos proporciona gran información anatómica y morfológica del sistema nervioso y si se complementa con estudios funcionales de perfusión (valora la angiogénesis), de espectroscopia (valora la proliferación celular o la hipoxia y necrosis existente en el tumor) o de difusión (valora la celularidad y la hipoxia) se convierte en el estudio principal de imagen en el diagnóstico de los tumores cerebrales.
    • The MRI provides a large quantity of anatomical and morphological information of the nervous system.  It determines whether additional functional studies are called for such as perfusion (evaluate angiogenesis), spectroscopy (evaluate cell proliferation or hypoxia and existing necrosis in the tumor) or dissemination (evaluate cellularity and hypoxia).  The MRI is the primary imaging study in the diagnosis of brain tumors.
    • PET-CT may also be used in order to evaluate the outcome after treatment or recurrences.

    The Diagnositic Imaging Systems at iTAcC are of the latest generation. They allow neuroradiology specialists to obtain precise diagnoses.

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Biopsy

It confirms or rules out the existence of a brain tumor.  It can be performed during surgery or by stereotactic needle puncture techniques. Specialists may decide to take a therapeutic approach without a biopsy only in exceptional cases such as when the tumor is in an inaccessible area and radiological findings are very clear.

A biopsy not only provides anatomopathological information about the tumor but also allows for carrying out genetic and immunohistochemical studies (altered tumor suppressor genes, oncogenes overexpressed).  It indicates the type of tumor in detail and allows specialists to implement a personalized treatment which improves the survival rate significantly in these patients.

Primary brain tumors

The treatment of malignant brain tumours is based on three main pillars:

  • Surgery
  • Radiotherapy
  • Chemotherapy.

The treatment sequence of different therapeutic modalities differs in relation to the anatomical area, size, histologic type, tumor grade as well as the patient’s state of health. A standard guideline to be looked at is surgery followed by radiotherapy in combination or not with chemotherapy or chemotherapy by itself.

Surgery

The patient’s state of health and location of the tumor within the central nervous system determine the surgical possibilities of its complete removal.

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The complete or subtotal resection of the tumor is recommended. A wide excision of the tumor influences patient survival.  It is greater than in those patients who have undergone only one biopsy. Complete resection of the tumor cannot be performed on many occasions.  Surgery is important in these patients because a histological diagnosis is obtained as well as reducing intracranial pressure while improving neurological function.

Stereotactic surgical techniques and neuronavigation systems are essential in order to carry out a surgery procedure with maximum guarantees. Collaborating neurosurgeons at iTAcC conduct neurophysiological studies during surgery to prevent surgical sequelae.

At iTAcC neurosurgical teams work have extensive experience in the treatment of brain tumors using the most advanced neuronavigation systems. The possibility of performing a hybrid surgical procedure is recommended.  It informs the surgeon of the surgical limits from the functional perspective of the patient and allows the intervention to be continued in a second stage using radiosurgery techniques.

The possibility exists to implant carmustine polymer wafers in the surgical site when the surgical resection is not fully performed.  It improves the outcome of cases in which tumor resection was subtotal.

Surgical treatment of brain metastases is indicated when it is a single metastasis and the extracranial disease is controlled or stabilized as well as in those cases when the metastasis itself or because of a hemorrhage, leads to a neurological deterioration of the patient that surgery will be able to resolve.  Radiotherapy must be done immediately afterwards.

Radiotherapy

High-grade tumors

Radiation therapy, like surgery, plays an important role in the treatment of high-grade gliomas. The advances that have occurred in the last decade have allowed for performing treatments with very low incidence of side effects using techniques of intensity modulated radiotherapy (IMRT) and image-guided radiotherapy (IGRT). iTAcC’s team of specialists has treated more than 2,000 patients using these approaches and is one of the pioneer teams in their implementation in the European Union.

Radiation therapy can be combined with temozolomide at a dose of 75 mg/m2 orally.  This increases the survival rate in a statistically significant way.

These patients may benefit from fractionated stereotactic body radiotherapy or (SBRT/SRS) stereotactic radio surgery treatments in very specific cases. (View La Razón)

Low-grade tumors

The low-grade brain tumors (low-grade astrocytomas, oligodendrogliomas, and mixed tumors) benefit from radiotherapy treatment to improve survival and slow down tumor progression.

Metastasis

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Brain metastases are multiple in the majority of times and the treatment of choice is holocranial radiotherapy. In select cases , modern techniques of radiation therapy (IMRT with IGRT) allow for carrying out holocranial treatments while protecting the thalamus and basal ganglia.  This results in an improvement in the patient’s quality of life after radiotherapy.

Radiosurgery treatment followed by cranial radiation is indicated in the case of a single metastasis or oligometastasis (less than 5 metastases and less than 4 cm in diameter) in order to slow the progression of micrometastases that may exist and was not detected by the imaging techniques.

iTAcC offers the  world’s most advanced radiosurgery system (Truebeam STX).  Radiosurgery treatments are performed under the supervision of a team of neurosurgeons, neuroradiologists and radiation oncologists.

Chemotherapy

Systemic chemotherapy

The drug of choice in the treatment of high grade gliomas is temozolomide.  It is administered orally and increases the survival rate in this group of patients. Temozolomide is initially administered at low doses in combination with radiotherapy. Afterwards higher doses are scheduled monthly in 6 to 12 cycles.

Intraoperative chemotherapy

Carmustine is another active drug used in the treatment of high grade gliomas.  It is placed in wafers in the tumor site during surgery in order to avoid the toxicity that it produces.  Temozolomide is administered to these patients except in the case of disease progression.

Biological therapies

Follow up

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iTAcC has the means to follow and control the progress of patients who have suffered a brain tumor in order to rule out the possibility of a recurrence of the disease.

Follow up is done as in the case of all oncological work at iTAcC, in a personalized manner and in cooperation with physicians who have been involved in the diagnosis and treatment of each case.

On occasion the patient may require support in the recovery of their daily functions and are treated by rehabilitation or speech therapists.