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14

Brain Tumours

Epidemiology

There are 5-15 primary brain tumours

per 100,000 population.This accounts for

5-10% of cancers in all age groups and

30-40% of tumours in children.Tumours

may also spread to the brain from distant

sites (secondary tumours).The commonest

tumours which spread to the brain are

lung (44%), breast (10%), kidney (7%)

and bowel (4%). Brain tumours themselves

almost never spread out from the central

nervous system.

Presentation

Tumours usually present in one of three

ways: headaches (54%), progressive

neurological deficit (68%) or seizures

(26%).

The

headache

is related to raised

pressure inside the brain.The classical

description is of early morning headaches

over the forehead, which usually settle

by the afternoon. Many patients also

complain of nausea.

Any

neurological deficit

will depend

on the site of the tumour. The common

deficits seen are weakness (frontal),

numbness (parietal), speech problems

(temporal), visual problems (temporal,

parietal or occipital) or a change in

personality (frontal). Certain tumours

present in a very specific fashion, i.e.

endocrine problems with a pituitary

tumour.

Seizures

occurring for the first time in

an adult must be investigated with an

urgent scan. Seizures vary from classical

grand mal seizures to focal seizures.

Investigations

An urgent CT or MRI of the brain is

mandatory; CT chest, abdomen and

pelvis where a secondary is suspected.

Treatment options

The treatment of brain tumours depends

on the location, size and extent of the

tumour. Younger patients and those who

are self-caring, have a better outcome

than older patients or those who have

neurological deficits.

Each patient’s treatment is individually

tailored to his or her needs.The rationale

for surgery may vary from one patient to

another, as may the use of radiotherapy

or chemotherapy.

There are no cures for astrocytomas

(other than some pilocytic tumours);

however, a combination of surgery,

radiotherapy and chemotherapy may

increase survival in some instances.

The aim of any treatment must be to

improve quality of survival.

Surgery

The role of surgery may be diagnostic

or therapeutic. Some patients may not

be suitable for surgery.The location

and extent of a tumour may make it

unsuitable for a debulking, in which case

a biopsy may be performed to confirm

the diagnosis.

The options for a biopsy are:

• To locate the tumour using an image

guidance system and to remove a piece.

• Stereotactically locate the tumour and

perform a biopsy using a fixed frame.

Image guidance systems are safe, but

locating a small tumour may be difficult.

Stereotactic biopsy is the safest and most

accurate method in which to biopsy most

brain tumours.The mortality rate is 1% and

the rate of a non-diagnostic sample is <1%.

If the tumour is in a relatively ‘silent’ part of

the brain, or is causing symptoms of raised

pressure, it may be debulked.The aim is to

safely reduce the volume of the tumour. A

craniotomy is performed, either freehand

with image guidance or with the help of

the stereotactic frame.

Tumours spread in such a way that they

cannot be cured by simply removing them.

In some cases, intra-tumoral chemotherapy

may be left in place (gliadel wafer).

All patients MUST be referred for a

neuro-oncological opinion.The neuro-

oncologist will decide on whether

radiotherapy, chemotherapy or palliation

is the most appropriate option.

Mr Sanj Bassi FRCS

(Neuro Surg) – Neurosurgeon, King’s College Hospital

Contact Mr Bassi’s secretary, Michelle Salton:

Tel: +44 (0) 20 7234 2939