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Brain and Spinal TumoursIntroduction
Brain or spinal tumours also referred to as central nervous system (CNS) tumours are a mass (lump) formed by an abnormal growth of cells. Although tumours can be classified as being benign or malignant, brain and spinal tumours are usually classified according to grade, location and cell type. As there are many different types of brain and spinal tumours it is essential that you talk to the doctor or nurse looking after you to clarify your condition. There are many different types of CNS tumours and not all of them are cancerous (malignant).
Unlike tumours of other parts of the body, little is known about the cause of primary CNS tumours. Some CNS tumours are known to be associated with certain inherited conditions such as Neurofibromatosis, Tuberous Sclerosis, Li-Fraumeni syndrome, Von Hippel-Lindau syndrome, Turcot syndrome and Gorlin syndrome. You may already be aware if you have one of these conditions or your Consultant Neurosurgeon or Neurologist will explain more to you if any of these are suspected.
Environmental factors such as exposure to radiation have also contributed to the development of a brain tumour on rare occasions.
CNS tumours can be primary or secondary (metastatic). Primary tumours originate from the tissues of the brain or spine or the immediate surroundings. Secondary tumours spread to the brain or spine from a cancer elsewhere in the body. Primary tumours are less common than secondary tumours.
Signs and symptoms
Symptoms experienced from a brain or spinal tumour will depend on what part of the brain or spine is affected. They can be subtle and develop slowly or they can be sudden and pronounced.
Often if someone experiences seizure or stroke like symptoms they will most likely be seen in an emergency department and have tests done that will aid the diagnoses of a brain or spinal tumour quickly. However if the onset is subtle and slow to develop it can take several visits to a General Practitioner (GP) before the right tests are ordered. This is because Brain and Spinal tumours are not very common.
- Headache Not all headaches are the sign of a brain tumour; they can also be caused by many reasons including tiredness, dehydration, stress, tension etc. If they are severe, repeated and associated with vomiting or are worse in the morning time they should be taken seriously and medical advice sought
- Visual Problems Some people experience diplopia (double vision), blurring, decreased peripheral vision or an inability to see anything to one side.
- Speech Difficulties If your tumour is in your temporal lobe speech problems can be a major symptom. Dysarthria (slurring of speech), dysphasia (jumbling of words) are two of the most common problems. You may sometimes have problems trying to express yourself as you know what to say but the wrong word is said. This can be extremely frustrating and upsetting for both you and your family. Speech therapy as discussed later can help with this problem.
- Memory Loss Long or short-term memory can be affected. Your short-term memory i.e.: what has happened in the immediate past is normally affected first.
- Weakness/Paralysis You may find that one side of your body has become weaker than the other, similar to having a stroke. The affected limb/limbs often feel heavier or have an altered sensation i.e.: hypersensitive/numb.
- Vomiting Is a common problem especially with patients whose tumour is in their Posterior Fossa (base of the brain). It can be associated with nausea, though normally it isn’t. Vomiting can be sudden and projectile in nature and is usually unrelated to food.
- Seizures About 20-50% of adults with brain tumours develop epilepsy. The term seizure or fit is the same, and more than one episode is known as epilepsy. Seizure activity can vary dramatically from jerking or shaking of one or more limbs for a number of minutes to localised involuntary movements such as lip smacking. Some people can experience absence attacks lasting only a few seconds and this is also known as epilepsy.
- Personality changes These may often be subtle and discreet, noticed only by close contacts or family members initially. Loss of social restraint, inappropriate behaviour, disorientation and confusion may all be noticed.
Members of Our Team
A specialised team of healthcare professionals will be looking after you during your treatment. The team may include a neurosurgeon, radiation oncologist, medical oncologist, neurologist, neuropsychology, nurse specialist, speech and language therapist, dietician, social worker, occupational therapist, physiotherapist, pastoral care, along with many others.
Consultant Neurosurgeon A Doctor who specialises in the surgical treatment of problems within the nervous system.
Our Consultant Neurosurgeons:
- Professor Ciaran Bolger
- Mr John Caird
- Mr Darach Crimmins
- Mr Ben Husien
- Professor Mohsen Javadpour
- Ms Catherine Moran
- Mr Stephen MacNally
- Mr David O’Brien
- Professor Donncha O’Brien
- Mr Daniel Rawluk
- Mr Kieron Sweeney
- Mr Steven Young
Registrars, Senior House Officers (SHO) and Interns are doctors who work with your consultants regarding your condition and treatment plan.
Medical Oncologist A doctor who specialises in treating cancer using chemotherapy and other drugs
Radiation Oncologist A Doctor who specialises in treating cancer with radiotherapy
Neurologist A Doctor who specialises in medical conditions of the nervous system.
Pathologist A Doctor who specialises in the examination of tissues/cells in the laboratory to determine their exact nature.
Endocrinologist A doctor who specialises in monitoring and treating hormone imbalances caused by some brain tumours and or their treatment.
Neuropsychologist a specialist who can help with the diagnosis and assessment of some of the symptoms of the brain tumour, such as behaviour change, memory problems, concentration difficulties or perceptual problems. The overall aim of assessment is to develop rehabilitation strategies to deal with any difficulties that have arisen as a result of the brain tumour. They can also talk to you and your family about emotional and personal matters.
Ophthalmologist A doctor who specialises in the eye and visual system
Clinical Nurse Specialists are specialist nurses who coordinate your care and support your psychological, emotional and relevant educational needs
Epilepsy Nurse A nurse who specialises in giving information and support about seizures, epilepsy and guides management.
A Social worker will advise you on practical, financial and emotional issues that may impact you throughout your treatment journey.
A Dietitian provides advice on optimum nutrition throughout your treatment.
Physio/Occupational Therapists will advise you about functional capacity and physical issues relating to your cancer care if required.
Speech and Language Therapist A specialist trained in treatment , support and care of those who have difficulties with communication, or with eating, drinking or swallowing
Important contact numbers
- Richmond Ward 01 809 2424/2432
- Adams Mc Connell Ward 01 809 2402/2417
- St Brigid’s Ward 01 809 2425/2431
- Richmond Intensive Care 01 809 2420/2418
- Eithne Dunne Tel: 018528455 firstname.lastname@example.org
- Michelle Sheehy Tel: 018528455 email@example.com
- Denise Andrews Tel: 018528854 firstname.lastname@example.org
- Sarah Houston Tel: 018093333 email@example.com
- Eloise Cowie Tel: 018528379 firstname.lastname@example.org
Types of Central Nervous System (CNS) Tumours
Primary Tumours originate from the tissues of the brain or spine or the immediate surroundings and can be Glial or Non Glial
Glial Tumours Also known as Gliomas, originate from the supportive cells within the brain and spine. They may be named after the particular part of the brain or spine in which they’re found e.g.; Brainstem Glioma. They can be low or high grade (malignant). The standard grading system devised by the World Health Organisation is graded from I-4. If the tumour is a low-grade (WHO grades 1& 2) it will tend to be slow growing. However higher grades (WHO grades 3 & 4) are usually highly malignant and grow rapidly.
The most common types of glioma are:
- Pilocytic Astrocytoma a WHO grade 1 tumour which is more commonly found in children. This tumour may not grow back is fully removed by surgery.
- Astrocytoma the commonest type of glioma and comes from cells called astrocytes. This can be low or high grade WHO grade 1-4)
- Glioblastoma Multiforme a WHO grade 4 tumour can be called GBM, is fast growing and comes from cells called astrocytes. It can start growing as a low grade tumour that transforms over time (secondary WHO grade 4 Astrocytoma) or can develop quickly (de novo) as a malignant tumour.
- Oligodendroglioma a WHO grade 2 or 3 tumour that come from cells called oligodendrocytes. These cells provide support and insulation for the nerve cells of the brain. They can sometimes be associated with causing seizures.
- Ependymoma is a rare glioma that comes from the ependymal cells lining the fluid-filled spaces of the brain (ventricles) and the spinal cord. Ependymoma can sometimes spread to other parts of the central nervous system, through the fluid that circulates around the brain and spinal cord (cerebrospinal fluid- CSF).
- Mixed glioma a tumour made up of 2 or more types of cells. For example the mixture of a glioblastoma and sarcoma is a gliosarcoma.
Non-Glial tumours Develop on structures such as outer coverings of the brain (meninges), glands such as the pituitary or pineal gland, or individual cranial nerves such as the acoustic nerve.
Types of Non-Glial Primary Brain Tumours:
- Meningioma Arise from the coverings of the brain and spinal cord called the meninges. Most Meningiomas are grade 1 (benign) and rarely infiltrate the brain. However around one third can be grade 2 and are more likely to grow back following surgery. Grade 2 Meningiomas sometimes require further treatment. A very small number are grade 3 and can behave more aggressively. Meningioma can cause symptoms if it grows and causes pressure on the brain or spinal cord.
- Acoustic Neuroma Also can be called Vestibular Schwannoma, these tend to be benign and occur along the auditory (hearing) nerve, which can lead to deafness. They can sometimes be associated with a genetic disease known as Neurofibromatosis.
- Pituitary gland tumours Arising from the pituitary gland which is also known as the ‘master gland’ of the body. Tumours of this can cause hormone imbalances and visual disturbances. Most pituitary tumours are benign and can affect vision and/ or hormone function.
- Primary central nervous system (CNS) lymphoma Is a rare form of lymphoma (cancer that begins in the lymphatic system). CNS Lymphoma starts in the brain and can spread to the spinal fluid and eyes.
- Pineal Tumours Is a tumour in or around the pineal gland in the brain. As the tumour grows it can press on or grow into other parts of the brain causing symptoms to arise. The tumours growth can also cause a build up of cerebro spinal fluid within the skull causing increased intracranial pressure (hydrocephalus). This can be treated with a Shunt or Endoscopic Third Ventriculostomy (ETV). (see Neuro surgical complications)
- Medulloblastoma is a type of cancerous (malignant) tumour. It is always located in the cerebellum and is rarely found in adults. It starts in or near a part of the braincalled the cerebellum and can spread to other parts of the brain or to the spinal cord, usually through the cerebrospinal fluid (CSF). CSF is the fluid that surrounds and protects the brain and the spinal cord. The tumours growth can also cause a build-up pressure (CSF) within the skull causing increased intracranial pressure (hydrocephalus). This can be treated with a Shunt or Endoscopic Third Ventriculostomy (ETV). see treatment with surgery
Secondary CNS Tumours (Metastatic)
These are tumours growing within the brain or spine that have spread from a cancer in another area of the body. These tumours have formed from cells that have broken away from the primary tumour (usually the bowel, kidney, lung, breast or skin) and have travelled to the brain via the bloodstream. These tumours are commonly referred to as metastases or secondary tumours. A secondary brain or spinal tumour is an advanced stage of cancer. Symptoms of secondary brain or spinal tumours are similar to that of primary tumours. The aim of treatment is to slow growth and control symptoms as it may be de difficult to cure them completely
It may not be easy to diagnose a tumour of the Brain or spine, especially if the signs and symptoms are slow to develop or mild. Listed here are some of the tests that your doctor might order for you and will depend on your clinical examination. They will help your Doctors decide how to treat your tumour.
- Clinical exam Your Doctor will ask you about your symptoms and perform a physical examination to help guide further tests and scans.
- CT Scan (Computerised Axial Tomagraphy) This is a sophisticated x-ray that is carried out without any risk to the patient. It is obtained by the patient lying on a table which then moves the head into a doughnut shaped scanner. It normally takes about 10 minutes.
- MRI Scan (Magnetic Resonance Imagining) This provides more detailed information than a CT scan and is only required for some tumours. In this case the table slides into a tunnel. It takes about 20 minutes to complete. This scanner is quite noisy and is often described as sounding like a washing machine. As this is based on magnetic fields, all metal objects clips are removed before entering the MRI room.
- Blood Tests For certain types of brain tumour, blood may be drawn to test for tumour marker levels or hormone levels.
- EEG This test is sometimes performed before CT scanning for patients who present initially with fits. It involves placement of a series of small electrodes on the scalp which are used to record electrical brain wave signals.
- Wada A test that can help your doctor evaluate how important each side of the brain is in respect to language and memory functions. This test may be done to aid maximal safe resection.
- Angiogram This is a test performed in the x-ray department whereby a dye is injected into the groin and a series of x-rays are taken of the head or spine whilst the dye is circulating in the blood vessels. It is sometimes necessary before surgery to provide more information on tumours which are close to major blood vessels. Occasionally, such tumours may be treated with a technique called embolization at the same sitting to reduce their blood supply before surgery. When this is planned, the radiologist visits the ward and explains the procedure to the patient beforehand.
- Vision/Hearing/Balance Tests These special tests are performed as part of the routine work-up for certain tumours in locations that may affect your senses.
- Lumbar Puncture Sometimes a sample of Cerebrospinal fluid (CSF) is required to help diagnose or stage your tumour. A sample is obtained by inserting a needle under local anaesthetic into your spinal canal.
Tumours of the brain and spinal cord can be managed with a combination of surgery (maximal safe resection), radiotherapy and chemotherapy. However in some cases if the tumour is not causing symptoms and has the characteristics of a benign or low grade (slow growing) tumour then observation alone might be recommended
The vast majority of patients with brain tumours undergo some form of surgery during the course of their management.
Your Neuro Surgeon will discuss with you the best surgical options. Taking into account the size and location of the tumour along with other considerations like your age, level of fitness and medical history.
- Biopsy This involves taking a specimen under anaesthetic by passing a fine needle into the tumour and bringing it to the laboratory for examination and diagnosis. This surgery is performed through a small hole in the skull (called a burr hole), by open biopsy (via mini craniotomy) or by using a small flexible telescope (endoscopic).
- Excision/Debulking The surgeon will remove as much of the tumour as is safely possible, without harming normal brain structures. The amount of tissue or tumour which can be removed will be different with each patient and is discussed before surgery. This surgery is performed through a trap door in the skull (called a craniotomy).
- Awake Craniotomy Some people can have their tumour resected/debulked while they are aware. This will allow for the surgeon to talk to you and do checks during the operation to make sure the surgery isn’t affecting your brain functions, like speech and movement. A Speech therapist and a neurophysiologist may also be in the room to monitor you during the surgery.
- Fluorescence Guided Surgery (5-ALA) A treatment called 5-ALA can be used in adults who are having surgery for a high grade tumour. It helps guide the surgeon during surgery by causing the tumour tissue to glow pink under a special light. It is taken by mouth in a small drink that you will be asked to take approximately four hours before your operation.
- Transphenoidal Surgery Certain types of brain tumours, notably pituitary tumours, are sometimes removed through the nose, a procedure known as transphenoidal surgery. The particular implications of this technique are discussed prior to surgery.
- Shunting Procedures Tumours which cause an obstruction to the normal flow of fluid (C S F) through the brain (called hydrocephalus) may require the placement of some form of shunting device. This can take the form of a temporary tube which drains fluid into a bag situated at the bedside or a permanent tube which is implanted under the skin and drains fluid from the head usually into the stomach. Some tumours which continue to accumulate cystic fluid are treated by inserting a tube into the cyst which leads to a reservoir under the scalp from which fluid can be taken off easily. This is called an Ommaya reservoir.
- Endoscopic Third Ventriculostomy (ETV) An alternative surgical procedure that creates a bypass to the cerebrospinal fluid in the head that eliminates the need for a shunt. see shunting procedures
- Pseudomeningocele can occur following surgery and refers to an abnormal collection of cerebrospinal fluid that occurs due to leakage from the CSF- filled spaces surrounding the brain and or spinal cord. Few patients need to undergo an operative procedure to achieve resolution of symptoms. Most will be managed conservatively however some may require an operation or procedure to drain the fluid. Your Consultant will discuss the options with you.
Radiotherapy is the use of very powerful X-Rays to kill tumour cells. Not all patients require radiotherapy for their tumour. If your consultant feels that you would benefit from radiotherapy you will be referred to a Consultant Radiation Oncologist.
Radiotherapy must be planned carefully to ensure the highest dose is given to the tumour area and as little as possible to the nearby cells. Planning your treatment and preparing for it can take several weeks. During this time your wound will be healing and you will have time to recover from surgery.
You will need a plastic mould or mask fitted prior to your treatment. The mask can be made from a thermoplastic mesh. All markings will go on the mask and not your skin to show where treatment will be given and it will prevent you from moving during treatment.
There are different types and ways of delivering radiotherapy and can be given as a single treatment or may be given five days a week (Monday to Friday) for up to six weeks. Your Doctor with discuss with you which is the best option for you.
- External Beam Radiotherapy is the gold standard treatment for most Gliomas and targets the tumour cavity following surgery, any remaining tumour and a 1-2 centimetre margin. This option may be used following a biopsy only if it is considered to be too unsafe to remove with surgery.
- Whole Brain Radiotherapy is when the whole brain is treated with radiotherapy to treat the tumour and help prevent new tumours from growing. This is a treatment option that is sometimes used for secondary (metastatic) tumours.
- Craniospinal Radiotherapy treatment is delivered to the brain and spine when a tumour involves both or there is concern that it may spread from one area to the other via the cerebrospinal fluid (CSF). One type of tumour that this option can be used for is a
- Stereotactic Radiosurgery (SRS) is a type of Radiotherapy allows Doctors to give high doses of radiation very accurately directly to brain tumours. This special machine gives concentrated beams of radiation to the tumour from different angles. It is sometimes given after the standard external beam radiotherapy. Usually 1-5 sessions of radiosurgery are required and can take from 30 minutes to a few hours to deliver.
- Proton Beam Radiotherapy Is a special way of delivering treatment with protons rather than x-rays to tumours that are too close to important structures in the brain or spine for standard treatment, like the optic nerves, the brain stem or spinal cord. This treatment is used more often for children and for some tumours of the spinal cord. If your Doctor recommends this option you will be referred to a specialist centre abroad that has the specialised equipment required to deliver the treatment.
For more information about Radiotherapy click here
Treatment for a brain or spinal tumour is influenced by a variety of factors including type, location, size of tumour as well as the patient’s age and general health. Chemotherapy is the use of drugs designed to kill cancer cells. Therapy is usually given in a defined schedule by a specialised team led by a Medical Oncologist.
The Doctor may use one drug or a combination of drugs usually given by mouth or injection or both. If the chemotherapy drugs are given by injection they are usually given into a vein.
Intrathecal Chemotherapy A minority of patients may require administering chemotherapy drugs directly into the cerebral spinal fluid. This may be done via a special catheter called an ommaya reservoir. See more under surgery- shunting procedures for brain tumours
Stupp Protocol A regime of treatment that combines 6 weeks of radiotherapy with a chemotherapy tablet (Temozolomide). Followed by a 4 week break and then taking the chemotherapy only for up to six cycles (each cycle= 5 days of treatment and a 23 day break).This protocol is usually used to treat High grade brain tumours.
For information about Chemotherapy click here
Also known as Active Observation or Watch and Wait and can be used for some low grade, slow growing tumours that are unlikely to spread. The most common types of brain tumour to receive a watch and wait approach are newly diagnosed low grade gliomas or grade 1 meningiomas.
A common steroid used for the treatment of symptoms caused by a brain or spinal tumour. Steroids do not treat the tumour itself but are given to reduce swelling around the tumour. These help to improve headaches and any other symptoms caused by swelling, such as nausea, seizures or limb weakness. It is important to take the correct dose and do not stop taking these drugs suddenly as you may become unwell. Steroids are often reduced slowly over time by your doctor.
Side effects: steroids can cause side effects such as increased appetite, weight gain, difficulty sleeping, indigestion, mood changes, irritability/restlessness, skin thinning, increased risk of infection or changes to taste. Long term use can cause other side effects such as diabetes, bone thinning or muscle wasting.
Your doctor and nurse will discuss your steroid treatment with you and it is important that you follow the advice given. Most side effects will go away after you have finished your treatment. However it is important to discuss any side effects with your doctor or nurse if they are troubling you.
Seizure Management and Advice
Not everyone diagnosed with a brain tumour will have a seizure (fit). However because it is hard to predict if you will have a seizure it is important for you and your family to familiarise yourself with seizures and the management of them. There are different types of seizures and can differ in severity and how they affect you. Symptoms can include:
- Shaking in one part of the body, such as an arm or leg, or shaking of th whole body.
- Feeling a bit strange, being unaware of what’s going on around you or staring blankly (absence)
- Feeling of gastric upset, odd smells and sensations
- A feeling of déjà vu
- Getting confused or behaving oddly
- Becoming unresponsive or unconscious (sometimes causing loss of bowel or bladder control)
If your tumour causes you to have seizures, you may be given medication (anticonvulsants) to try and stop this from happening. A seizure is caused by a burst of electrical activity in the brain.
There are many different types of anti seizure medications and your doctor will advise and monitor this medication to ensure good levels of control with the least side effects.
Sometimes your medication might have a different name and it is important to familiarise yourself with the brand name and drug (generic) name. For example the medication Levetiracetam has the brand name of Keppra.
Side effects of anticonvulsants vary depending on the type of drug and dose. They can include difficulty concentrating, drowsiness, feeling, sick, dry mouth, dizziness, mood changes, diarrhoea or constipation.
It is important to take your medication regularly as directed and not stop it or miss a dose unless advised to by your doctor. Poor compliance, fatigue, dehydration and alcohol consumption can all contribute to lowering your seizure control.
You should contact the hospital or your GP if your seizures are not well controlled of you are experiencing any of these side effects.
If you develop a skin rash it may mean that you are allergic to the drug. You should seek medical attention straight away if you develop a rash while you are taking an anti-convulsant medication.
Seizure Management: Advice for carers
It can be quite upsetting to witness a seizure however they usually pass quite quickly. It can take some time for the person to feel back to normal again and they may need to be allowed to rest until fully recovered. It is important that you familiarise yourself with what to do if a seizure occurs.
In the case of a Convulsant Seizure (shaking with loss of consciousness):
- Keep calm
- Stay with the person
- Ensure a safe environment by moving hard objects away from the person
- Protect the head by placing something soft underneath if possible
- Reassure the person throughout and after the seizure
- Stay with the person until fully recovered and turn onto their side once the shaking has ended (recovery position)
Do not try to restrain the person or put anything in their mouth
In the case of a Partial Seizure (may stare blankly, chew, fumble, wander or be confused without full awareness):
- Keep calm and reassure the person
- Protect the person from hazards without physical restraint if safe
- Explain to others what is happening
- Stay with the person until they are fully aware of their surrounds and behaving normally
Call an ambulance (112) or seek urgent medical advice:
- if the seizure lasts more than five minutes
- if the person has sustained an injury
- if the frequency or severity of seizures has changed
- if the person has more than one seizure after the other
- if the seizure occurs in the sea or a swimming pool
- if the person is unusually slow to regain consciousness or does not fully recover
- if this is a first time seizure event