Brain Tumors

The common types of brain tumours are

• Acoustic Neuroma
  • Information on Brain Tumors
  Dr. Aniruddh Kulkarni
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Brain Tumors

  Acoustic Neuroma (also called “vestibular schwannoma”)

  ---

  Definition: An acoustic neuroma is a benign tumor that grows from the lining of one of the vestibulocochlear nerves, the nerves responsible for hearing and balance.

  

  Symptoms: The most common symptoms of an acoustic neuroma are hearing loss, tinnitus, and vertigo. Hearing loss associated with an acoustic neuroma is usually gradual. It may be preceded by tinnitus, a ringing or other abnormal sound heard in the affected ear. Vertigo is a spinning sensation. Larger acoustic neuromas can compress nerves that lie next to the vestibulocochlear nerve, causing facial weakness.

  Evaluation: The best way to assess an acoustic neuroma is with an MRI of the brain. A CT scan may be recommended to evaluate the skull around the tumor. Audiometry, a test of hearing, may be ordered to assess the extent and progression of a person’s hearing loss.

  Treatment Options:

  1) Continued observation: : Regular MRI’s of the brain will be performed to watch for tumor growth. Audiometry may also be recommended to monitor for worsening hearing loss. If the tumor grows or symptoms attributable to the tumor worsen, then surgical removal may be recommended.

  2) Surgery:: The goal of surgery is to remove or reduce the size of the tumor to prevent it from getting larger and causing further damage to the vestibulocochlear and surrounding nerves. Hearing loss does not usually improve after surgery. Preservation of the level of hearing that is present before surgery is dependent upon the size of the tumor that must be removed.

  3) Radiation: Focal radiation therapy is recommended for recurrent tumors.

  Follow-up: Acoustic neuromas can recur so it is necessary to continue to have regular MRI’s of the brain after removal. If the tumor does not recur, or if it recurs and grows slowly, the time between MRI’s may be increased. If the tumor recurs, repeat surgery or radiation may be recommended. If vestibular problems (problems with vertigo or balance) occur, they can be addressed with vestibular rehabilitation.

  Evaluation and Diagnosis of Brain Tumors

  ---

  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid that flows around the brain and spinal cord. Numbing medicine is given. Then, a needle is inserted between the vertebrae of the lower back to obtain cerebrospinal fluid. The cerebral spinal fluid is sent to a lab to be examined for the presence of tumor cells.

  Audiometry

  Audiometry is a test to evaluate hearing. In cases where a tumor may involve the nerve that carries auditory information from the ear to the brain, audiometry may provide information about whether the tumor has damaged the nerve.

  Visual Field Testing (perimetry)

  Visual field testing is a test to evaluate vision. Certain tumors may result in pressure on the optic nerves or areas of the brain involved with transmitting or processing visual information. In these cases, visual field testing may be very helpful for providing baseline information about the extent and location of visual loss, which will help guide treatment.

  Dr. Aniruddh Kulkarni

  Brain Tumor Treatment

  ---

  Treatment options for a brain tumor depend on the type, location, and size of the tumor and may include surgery, radiation, chemotherapy or often a combination of these options. Treatment can be postponed in some cases if a tumor appears to be growing slowly and is not causing symptoms. Although there are initial standard-of-care treatment plans for most tumors, in some cases, experimental therapies may be recommended if standard therapies are unsuccessful. Dr. Aniruddh Kulkarni

  Surgery

  Surgery is usually the first step in the treatment of brain tumors. The purpose of surgery is to obtain tissue to verify the diagnosis. Additional goals of surgery are to relieve symptoms, decrease pressure on the brain or spinal cord, and minimize the size of the tumor that will need to be treated with radiation or chemotherapy. Importantly, recent data suggests that extensive removal of a brain tumor improves long-term treatment outcomes. Therefore, the goal of surgery is to remove as much of a tumor as possible without damaging healthy brain tissue. Although complete removal of all tumor cells is an ultimate goal, this is often not possible in many brain tumors due to invasion into the brain or microscopic amounts of cells that cannot be seen. Therefore, in many cases patients will need additional therapy after surgery.

  Types of brain tumor surgeries

  Biopsy: If the tumor is in a part of the brain where removal would cause considerable neurological damage, a biopsy may be taken. A biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a sample of tumor cells. The tumor cells are examined under a microscope by a pathologist who establishes a diagnosis so that appropriate treatment can be recommended.

  Resection: A resection is surgical removal of as much of a tumor as possible. This often requires a craniotomy, which is the removal of a piece of the skull so that the neurosurgeon can gain access to the tumor. The piece of skull is replaced after the resection and held in place by thin pieces of titanium. Tumors in the region of the pituitary gland can sometimes be removed through the nose and do not require a craniotomy. A resection is called a “gross total resection” when there is no obvious tumor visible on a brain scan performed soon after surgery. If a portion of the tumor can still be seen on a post-operative brain scan, it is called a “subtotal resection.”

  Stereotactic surgery: A precise computerized map of the brain is made using an MRI or CT scan. The neurosurgeon uses this map during surgery to precisely locate the tumor and to navigate around critical brain structures during resection or biopsy of the tumor, a technique that is known as “intraoperative image guidance.”

  Microscopic surgery: A microscope is used during surgery for detailed evaluation of brain and tumor tissue.

  Radiation Therapy

  Radiation therapy is the use of beams of energy called “ionizing radiation” to slow or stop the growth of tumor cells. Radiation oncologists are the physicians who manage radiation therapy. They determine the most appropriate form and amount of radiation to be delivered according the type, size, and location of the tumor.

  Types of radiation therapy

  Fractionated radiotherapy: A specific dose of radiation is delivered in parts rather than all at once. Radiation is usually delivered in daily sessions five days per week for two to seven weeks. The radiation oncologist determines the treatment schedule.

  Focused radiation = radiation that is directed only at the tumor.

  Whole brain radiation therapy = radiation is directed at the entire brain. This form of radiation is used in cases where there are multiple tumors or a tumor spreads over a large area of the brain.

  Stereotactic radiosurgery = A single high-dose of radiation is delivered precisely to one or more small tumors on an outpatient basis. Novalis BrainLab®, Gamma Knife® and CyberKnife® are brand names of types of stereotactic radiosurgery.

  Chemotherapy

  Chemotherapy is the use of powerful medications to slow or stop the growth of tumors. Oncologists are the physicians who prescribe and manage chemotherapy. Neuro-oncologists are oncologists who specialize in treating nervous system cancers. Chemotherapy can be given by mouth, through an I.V., or directly into the brain during surgery.

  Standard versus Experimental Treatment

  Standard treatment is a commonly accepted form of treatment for a certain medical condition. It is based on either experimental data, expert opinion or both. Experimental treatment is treatment that is currently being tested in clinical trials (research studies). An experimental treatment may become a standard treatment if it is proven to be more effective than current standard treatments.

  Follow-up

  Most people who have been treated for a brain tumor will require long term follow-up with routine brain scans, neurological exams, and visits to one or more of the healthcare providers involved in their treatment. This is to monitor the response to treatment and to watch for tumor recurrence.

  Pituitary

  ---

  About Pituitary Tumors

  Pituitary tumors are abnormal growths that develop in your pituitary gland. Some pituitary Drawing of pituitary glandtumors cause excessive production of hormones that regulate important functions of your body. Other pituitary tumors can restrict normal functions of your pituitary gland, causing it to produce lower levels of hormones.

  Most pituitary tumors are noncancerous growths (adenomas). Adenomas remain confined to your pituitary gland or surrounding tissues and don't spread to other parts of your body. If a tumor releases adrenocorticotropic hormone (ACTH), it causes increased cortisol which leads to fat deposits, especially in the shoulders and face. This is usually called Cushing's Disease.

  

  Tumors that secrete excess prolactin are called prolactinomas. Excess prolactin can cause secretion of breast fluids in women and decreased sexual drive in men and women. Men may not experience breast fluid secretation but increased prolactin can certainly cause breast tenderness. It may also cause irregular or absent menstrual periods in women, and difficulty in having an erection or infertility in men. Typically these tumors can be treated with medication alone (bromocriptine).

  For pituitary tumors that do not secrete hormones, the initial symptoms may not occur until the tumor presses on the structures surrounding the normal pituitary gland. Once the tumor is larger than 1 centimeter, it is called a macroadenoma.

  

  Because the pituitary gland is located within the skull, when it becomes large, it may cause headaches that get worse as the tumor grows. Also, since the pituitary gland is located near the eyes, it can press on the nerves to the eyes and cause Dr. Aniruddh Kulkarni of peripheral vision may occur first and be undetected by the patient. This may progress to eventual blindness if the pressure is not removed from the nerve. The tumor may also press on the nerves that move the eye and cause double vision. If the tumor is very large it may press on other parts of the brain and cause problems with memory, weakness, or numbness. If surgery is warranted, the doctors at CU Neurosurgery usually perform a resection using a transnasal approach.

  Some pituitary tumors may be observed without treatment because they may grow very slowly. Pituitary tumors are usually benign. It is rare for them to ever become malignant. If a decision is made to observe the tumor Dr. Aniruddh Kulkarni without treatment, ongoing evaluations by CT or MRI, by an endocrinologist, and by an ophthalmologist are usually done within 3-6 months after the initial diagnosis and every 6-12 months thereafter until the situation has been clarified. This period of observation without treatment provides information that helps the doctors decide whether other treatments that have more risks are needed.

  Observation without treatment may also be recommended if conditions are present that would seriously increase the risk of surgical or other treatments. Because pituitary tumors are slow growing, patients can often be observed without treatment for long periods of time without the tumor causing serious problems. This is often the recommended form of treatment for patients who are age 70 or above or who have a serious medical illness such as heart disease. Close follow-up may be necessary to monitor tumor growth and symptoms.

• Anaplastic Astrocytoma
  • Information on Brain Tumors
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Anaplastic Astrocytoma

  (also called a "grade III astrocytoma" or "malignant astrocytoma")

  ---

  Definition: Astrocytomas are tumors that arise from astrocytes, cells in the brain that support and insulate nerve cells. Anaplastic astrocytomas are classified as grade III by the World Health Organization. They can transform from a grade II astrocytoma or arise from the astrocytes directly as a grade III astrocytoma. They tend to grow more quickly than low-grade astrocytomas. The goal of treatment is to decrease symptoms and slow the progression of the tumor as much as possible. An anaplastic astrocytoma can transform into a grade IV astrocytoma (also called a "glioblastoma multiforme").

  Symptoms: The most common symptoms of an anaplastic astrocytoma are headaches and changes in behavior. Other symptoms depend on the location of the tumor. Seizures may also occur.

  Evaluation: Anaplastic astrocytomas are evaluated with MRI scans.

  Treatment Options:

  1) Surgery: Surgery is recommended to obtain a sample of the tumor to confirm the diagnosis and to remove as much of the tumor as possible without causing significant neurological problems. It is impossible to surgically remove all of the tumor since it mixes in with normal brain tissue. A biopsy may be all that is possible if the tumor is located in a critical part of the brain where removal may cause serious neurological damage.

  2)Radiation: Focal fractionated radiation therapy is usually recommended and started two to four weeks after surgery.

  Chemotherapy: Chemotherapy is usually started at the same time as radiation.

  Follow-up: Long-term close follow-up with regular MRI scans is recommended to watch for tumor growth or transformation to a higher grade.

  Evaluation and Diagnosis of Brain Tumors

  ---

  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid that flows around the brain and spinal cord. Numbing medicine is given. Then, a needle is inserted between the vertebrae of the lower back to obtain cerebrospinal fluid. The cerebral spinal fluid is sent to a lab to be examined for the presence of tumor cells.

  Audiometry

  Audiometry is a test to evaluate hearing. In cases where a tumor may involve the nerve that carries auditory information from the ear to the brain, audiometry may provide information about whether the tumor has damaged the nerve.

  Visual Field Testing (perimetry)

  Dr. Aniruddh Kulkarni

  Visual field testing is a test to evaluate vision. Certain tumors may result in pressure on the optic nerves or areas of the brain involved with transmitting or processing visual information. In these cases, visual field testing may be very helpful for providing baseline information about the extent and location of visual loss, which will help guide treatment.

  Brain Tumor Treatment

  ---

  Dr. Aniruddh Kulkarni

  Treatment options for a brain tumor depend on the type, location, and size of the tumor and may include surgery, radiation, chemotherapy or often a combination of these options. Treatment can be postponed in some cases if a tumor appears to be growing slowly and is not causing symptoms. Although there are initial standard-of-care treatment plans for most tumors, in some cases, experimental therapies may be recommended if standard therapies are unsuccessful.

  Surgery

  Surgery is usually the first step in the treatment of brain tumors. The purpose of surgery is to obtain tissue to verify the diagnosis. Additional goals of surgery are to relieve symptoms, decrease pressure on the brain or spinal cord, and minimize the size of the tumor that will need to be treated with radiation or chemotherapy. Importantly, recent data suggests that extensive removal of a brain tumor improves long-term treatment outcomes. Therefore, the goal of surgery is to remove as much of a tumor as possible without damaging healthy brain tissue. Although complete removal of all tumor cells is an ultimate goal, this is often not possible in many brain tumors due to invasion into the brain or microscopic amounts of cells that cannot be seen. Therefore, in many cases patients will need additional therapy after surgery.

  Types of brain tumor surgeries

  Biopsy: If the tumor is in a part of the brain where removal would cause considerable neurological damage, a biopsy may be taken. A biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a sample of tumor cells. The tumor cells are examined under a microscope by a pathologist who establishes a diagnosis so that appropriate treatment can be recommended.

  Resection: A resection is surgical removal of as much of a tumor as possible. This often requires a craniotomy, which is the removal of a piece of the skull so that the neurosurgeon can gain access to the tumor. The piece of skull is replaced after the resection and held in place by thin pieces of titanium. Tumors in the region of the pituitary gland can sometimes be removed through the nose and do not require a craniotomy. A resection is called a “gross total resection” when there is no obvious tumor visible on a brain scan performed soon after surgery. If a portion of the tumor can still be seen on a post-operative brain scan, it is called a “subtotal resection.”

  Stereotactic surgery: A precise computerized map of the brain is made using an MRI or CT scan. The neurosurgeon uses this map during surgery to precisely locate the tumor and to navigate around critical brain structures during resection or biopsy of the tumor, a technique that is known as “intraoperative image guidance.”

  Microscopic surgery: A microscope is used during surgery for detailed evaluation of brain and tumor tissue.

  Radiation Therapy

  Radiation therapy is the use of beams of energy called “ionizing radiation” to slow or stop the growth of tumor cells. Radiation oncologists are the physicians who manage radiation therapy. They determine the most appropriate form and amount of radiation to be delivered according the type, size, and location of the tumor.

  Types of radiation therapy

  Fractionated radiotherapy: A specific dose of radiation is delivered in parts rather than all at once. Radiation is usually delivered in daily sessions five days per week for two to seven weeks. The radiation oncologist determines the treatment schedule.

  Focused radiation = radiation that is directed only at the tumor.

  Whole brain radiation therapy = radiation is directed at the entire brain. This form of radiation is used in cases where there are multiple tumors or a tumor spreads over a large area of the brain.

  Stereotactic radiosurgery = A single high-dose of radiation is delivered precisely to one or more small tumors on an outpatient basis. Novalis BrainLab®, Gamma Knife® and CyberKnife® are brand names of types of stereotactic radiosurgery.

  Chemotherapy

  Chemotherapy is the use of powerful medications to slow or stop the growth of tumors. Oncologists are the physicians who prescribe and manage chemotherapy. Neuro-oncologists are oncologists who specialize in treating nervous system cancers. Chemotherapy can be given by mouth, through an I.V., or directly into the brain during surgery.

  Standard versus Experimental Treatment

  Standard treatment is a commonly accepted form of treatment for a certain medical condition. It is based on either experimental data, expert opinion or both. Experimental treatment is treatment that is currently being tested in clinical trials (research studies). An experimental treatment may become a standard treatment if it is proven to be more effective than current standard treatments.

  Follow-up

  Most people who have been treated for a brain tumor will require long term follow-up with routine brain scans, neurological exams, and visits to one or more of the healthcare providers involved in their treatment. This is to monitor the response to treatment and to watch for tumor recurrence.

  Pituitary

  ---

  About Pituitary Tumors

  Pituitary tumors are abnormal growths that develop in your pituitary gland. Some pituitary Drawing of pituitary glandtumors cause excessive production of hormones that regulate important functions of your body. Other pituitary tumors can restrict normal functions of your pituitary gland, causing it to produce lower levels of hormones.

  Most pituitary tumors are noncancerous growths (adenomas). Adenomas remain confined to your pituitary gland or surrounding tissues and don't spread to other parts of your body. If a tumor releases adrenocorticotropic hormone (ACTH), it causes increased cortisol which leads to fat deposits, especially in the shoulders and face. This is usually called Cushing's Disease.

  

  Tumors that secrete excess prolactin are called prolactinomas. Excess prolactin can cause secretion of breast fluids in women and decreased sexual drive in men and women. Men may not experience breast fluid secretation but increased prolactin can certainly cause breast tenderness. It may also cause irregular or absent menstrual periods in women, and difficulty in having an erection or infertility in men. Typically these tumors can be treated with medication alone (bromocriptine).

  For pituitary tumors that do not secrete hormones, the initial symptoms may not occur until the tumor presses on the structures surrounding the normal pituitary gland. Once the tumor is larger than 1 centimeter, it is called a macroadenoma. Dr. Aniruddh Kulkarni

  

  Because the pituitary gland is located within the skull, when it becomes large, it may cause headaches that get worse as the tumor grows. Also, since theDr. Aniruddh Kulkarnilocated near the eyes, it can press on the nerves to the eyes and cause loss of vision. Loss of peripheral vision may occur first and be undetected by the patient. This may progress to eventual blindness if the pressure is not removed from the nerve. The tumor may also press on the nerves that move the eye and cause double vision. If the tumor is very large it may press on other parts of the brain and cause problems with memory, weakness, or numbness. If surgery is warranted, the doctors at CU Neurosurgery usually perform a resection using a transnasal approach.

  Some pituitary tumors may be observed without treatment because they may grow very slowly. Pituitary tumors are usually benign. It is rare for them to ever become malignant. If a decision is made to observe the tumor without treatment, ongoing evaluations by CT or MRI, by an endocrinologist, and by an ophthalmologist are usually done within 3-6 months after the initial diagnosis and every 6-12 months thereafter until the situation has been clarified. This period of observation without treatment provides information that helps the doctors decide whether other treatments that have more risks are needed.

  Observation without treatment may also be recommended if conditions are present that would seriously increase the risk of surgical or other treatments. Because pituitary tumors are slow growing, patients can often be observed without treatment for long periods of time without the tumor causing serious problems. This is often the recommended form of treatment for patients who are age 70 or above or who have a serious medical illness such as heart disease. Close follow-up may be necessary to monitor tumor growth and symptoms.

• Central Neurocytoma
  • Information on Brain Tumors
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Central Neurocytoma

  ---

  Definition: A central neurocytoma is a rare, low-grade tumor. The World Health Organization classifies this tumor as a grade II. Central neurocytomas grow into the ventricles, spaces in the brain where cerebrospinal fluid is secreted and flows. The tumor often blocks the flow of cerebrospinal fluid, causing hydrocephalus, a build-up of fluid in the brain.

  Symptoms: The most common symptoms of a central neurocytoma are due to increased intracranial pressure from hydrocephalus. Symptoms of increased intracranial pressure are headaches, nausea, vomiting, visual changes, and changes in behavior.

  Evaluation: Central neurocytomas are evaluated with MRI and CT scans.

  Treatment Options:

  1) Surgery: Surgical removal of as much of the tumor as possible is the preferred treatment of central neurocytomas.

  2)Radiation: Fractionated radiation is recommended for recurrent tumors.

  3) Chemotherapy: Chemotherapy is recommended for recurrent tumors.

  Follow-up: Long-term follow-up with regular brain scans is recommended to watch for tumor recurrence.

  Evaluation and Diagnosis of Brain Tumors

  ---

  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid that flows around the brain and spinal cord. Numbing medicine is given. Then, a needle is inserted between the vertebrae of the lower back to obtain cerebrospinal fluid. The cerebral spinal fluid is sent to a lab to be examined for the presence of tumor cells.

  Audiometry

  Audiometry is a test to evaluate hearing. In cases where a tumor may involve the nerve that carries auditory information from the ear to the brain, audiometry may provide information about whether the tumor has damaged the nerve.

  Visual Field Testing (perimetry)

  Visual field testing is a test to evaluate vision. Certain tumors may result in pressure on the optic nerves or areas of the brain involved with transmitting or processing visual information. In these cases, visual field testing may be very helpful for pDr. Aniruddh Kulkarniformation about the extent and location of visual loss, which will help guide treatment.

  Brain Tumor Treatment

  ---

  Treatment options for a brain tumor depend on the type, location, and size of the tumor and may include surgery, radiation, chemotherapy or often a combination of these options. Treatment can be postponed Dr. Aniruddh Kulkarni in some cases if a tumor appears to be growing slowly and is not causing symptoms. Although there are initial standard-of-care treatment plans for most tumors, in some cases, experimental therapies may be recommended if standard therapies are unsuccessful.

  Surgery

  Surgery is usually the first step in the treatment of brain tumors. The purpose of surgery is to obtain tissue to verify the diagnosis. Additional goals of surgery are to relieve symptoms, decrease pressure on the brain or spinal cord, and minimize the size of the tumor that will need to be treated with radiation or chemotherapy. Importantly, recent data suggests that extensive removal of a brain tumor improves long-term treatment outcomes. Therefore, the goal of surgery is to remove as much of a tumor as possible without damaging healthy brain tissue. Although complete removal of all tumor cells is an ultimate goal, this is often not possible in many brain tumors due to invasion into the brain or microscopic amounts of cells that cannot be seen. Therefore, in many cases patients will need additional therapy after surgery.

  Types of brain tumor surgeries

  Biopsy: If the tumor is in a part of the brain where removal would cause considerable neurological damage, a biopsy may be taken. A biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a sample of tumor cells. The tumor cells are examined under a microscope by a pathologist who establishes a diagnosis so that appropriate treatment can be recommended.

  Resection: A resection is surgical removal of as much of a tumor as possible. This often requires a craniotomy, which is the removal of a piece of the skull so that the neurosurgeon can gain access to the tumor. The piece of skull is replaced after the resection and held in place by thin pieces of titanium. Tumors in the region of the pituitary gland can sometimes be removed through the nose and do not require a craniotomy. A resection is called a “gross total resection” when there is no obvious tumor visible on a brain scan performed soon after surgery. If a portion of the tumor can still be seen on a post-operative brain scan, it is called a “subtotal resection.”

  Stereotactic surgery: A precise computerized map of the brain is made using an MRI or CT scan. The neurosurgeon uses this map during surgery to precisely locate the tumor and to navigate around critical brain structures during resection or biopsy of the tumor, a technique that is known as “intraoperative image guidance.”

  Microscopic surgery: A microscope is used during surgery for detailed evaluation of brain and tumor tissue.

  Radiation Therapy

  Radiation therapy is the use of beams of energy called “ionizing radiation” to slow or stop the growth of tumor cells. Radiation oncologists are the physicians who manage radiation therapy. They determine the most appropriate form and amount of radiation to be delivered according the type, size, and location of the tumor.

  Types of radiation therapy

  Fractionated radiotherapy: A specific dose of radiation is delivered in parts rather than all at once. Radiation is usually delivered in daily sessions five days per week for two to seven weeks. The radiation oncologist determines the treatment schedule.

  Focused radiation = radiation that is directed only at the tumor.

  Whole brain radiation therapy = radiation is directed at the entire brain. This form of radiation is used in cases where there are multiple tumors or a tumor spreads over a large area of the brain.

  Stereotactic radiosurgery = A single high-dose of radiation is delivered precisely to one or more small tumors on an outpatient basis. Novalis BrainLab®, Gamma Knife® and CyberKnife® are brand names of types of stereotactic radiosurgery.

  Chemotherapy

  Chemotherapy is the use of powerful medications to slow or stop the growth of tumors. Oncologists are the physicians who prescribe and manage chemotherapy. Neuro-oncologists are oncologists who specialize in treating nervous system cancers. Chemotherapy can be given by mouth, through an I.V., or directly into the brain during surgery.

  Standard versus Experimental Treatment

  Standard treatment is a commonly accepted form of treatment for a certain medical condition. It is based on either experimental data, expert opinion or both. Experimental treatment is treatment that is currently being tested in clinical trials (research studies). An experimental treatment may become a standard treatment if it is proven to be more effective than current standard treatments.

  Follow-up

  Most people who have been treated for a brain tumor will require long term follow-up with routine brain scans, neurological exams, and visits to one or more of the healthcare providers involved in their treatment. This is to monitor the response to treatment and to watch for tumor recurrence.

  Pituitary

  ---

  About Pituitary Tumors

  Pituitary tumors are abnormal growths that develop in your pituitary gland. Some pituitary Drawing of pituitary glandtumors cause excessive production of hormones that regulate important functions of your body. Other pituitary tumors can restrict normal functions of your pituitary gland, causing it to produce lower levels of hormones.

  Most pituitary tumors are noncancerous growths (adenomas). Adenomas remain confined to your pituitary gland or surrounding tissues and don't spread to other parts of your body. If a tumor releases adrenocorticotropic hormone (ACTH), it causes increased cortisol which leads to fat deposits, especially in the shoulders and face. This is usually called Cushing's Disease.

  

  Tumors that secrete excess prolactin are called prolactinomas. Excess prolactin can cause secretion of breast fluids in women and decreased sexual drive in men and women. Men may not experience breast fluid secretation but increased prolactin can certainly cause breast tenderness. It may also cause irregular or absent menstrual periods in women, and difficulty in having an erection or infertility in men. Typically these tumors can be treated with medication alone (bromocriptine).

  For pituitary tumors that do not secrete hormones, the initial symptoms may not occur until the tumor presses on the structures surrounding the normal pituitary gland. Once the tumor is larger than 1 centimeter, it is called a macroadenoma.

  

  Dr. Aniruddh Kulkarni

  Because the pituitary gland is located within the skull, when it becomes large, it may cause headaches that get worse as the tumor grows. Also, since the pituitary gland is located near the eyes, it can press on the nerves to the eyes and cause loss of vision. Loss of peripheral vision may occur first and be undetected by the patient. This may progress to eventual blindness if the pressure is not removed from the nerve. The tumor may also press on the nerves that move the eye and cause double vision. If the tumor is very large it may press on other parts of the brain and cause problems with memory, weakness, or numbness. If surgery is warranted, the doctors at CU Neurosurgery usuDr. Aniruddh Kulkarnition using a transnasal approach.

  Some pituitary tumors may be observed without treatment because they may grow very slowly. Pituitary tumors are usually benign. It is rare for them to ever become malignant. If a decision is made to observe the tumor without treatment, ongoing evaluations by CT or MRI, by an endocrinologist, and by an ophthalmologist are usually done within 3-6 months after the initial diagnosis and every 6-12 months thereafter until the situation has been clarified. This period of observation without treatment provides information that helps the doctors decide whether other treatments that have more risks are needed.

  Observation without treatment may also be recommended if conditions are present that would seriously increase the risk of surgical or other treatments. Because pituitary tumors are slow growing, patients can often be observed without treatment for long periods of time without the tumor causing serious problems. This is often the recommended form of treatment for patients who are age 70 or above or who have a serious medical illness such as heart disease. Close follow-up may be necessary to monitor tumor growth and symptoms.

• Chordoma
  • Information on Brain Tumors
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Chordoma

  ---

  Definition: A chordoma is a benign, slow-growing tumor that occurs at the base of the skull or in the spine. These tumors arise from cells present before birth that were supposed to develop into a part of the spinal cord. The World Health Organization does not assign a grade to chordomas.

  Symptoms: Common symptoms of a chordoma at the base of the skull are headache and inability to move the eyes appropriately causing double vision. A chordoma in the spine can cause pain, numbness, tingling, weakness in the arms and legs, or urinary problems.

  Evaluation: Chordomas are evaluated with CT or MRI scans. X-rays may be done to show the amount of bone affected by the tumor.

  Treatment Options:

  The preferred treatment of a chordoma is surgical removal of as much of the tumor as possible without causing significant neurological damage followed by radiation therapy to prevent recurrence.

  Follow-up: Long-term close follow-up with regular MRI scans is recommended due to the high rate of recurrence of this type of tumor and the possibility of metastasis (spread) to other parts of the body.

  Evaluation and Diagnosis of Brain Tumors

  ---

  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid that flows around the brain and spinal cord. Numbing medicine is given. Then, a needle is inserted between the vertebrae of the lower back to obtain cerebrospinal fluid. The cerebral spinal fluid is sent to a lab to be examined for the presence of tumor cells.

  Audiometry

  Audiometry is a test to evaluate hearing. In cases where a tumor may involve the nerve that carries auditory information from the ear to the brain, audiometry may provide information about whether the tumor has damaged the nerve.

  Visual Field Testing (perimetry)

  Visual field testing is a test to evaluate vision. Certain tumors may result in pressure on the optic nerves or areas of the brain involved with transmitting or processing visual information. In these cases, visual field testing may be very helpful for providing baseline information about the extent and location of visual loss, which will help guide treatment.

  Brain Tumor Treatment

  ---

  Dr. Aniruddh Kulkarni

  Treatment options for a brain tumor depend on the type, location, and size of the tumor and may include surgery, radiation, chemotherapy or often a combination of these options. Treatment can be postponed in some cases if a tumor appears to be growing slowly and is not causing symptoms. Although there are initial standard-of-care treatment plans for most tumors, in some cases, experimental therapies may be recommended if standard therapies are unsuccessful.

  Surgery

  Dr. Aniruddh Kulkarni Surgery is usually the first step in the treatment of brain tumors. The purpose of surgery is to obtain tissue to verify the diagnosis. Additional goals of surgery are to relieve symptoms, decrease pressure on the brain or spinal cord, and minimize the size of the tumor that will need to be treated with radiation or chemotherapy. Importantly, recent data suggests that extensive removal of a brain tumor improves long-term treatment outcomes. Therefore, the goal of surgery is to remove as much of a tumor as possible without damaging healthy brain tissue. Although complete removal of all tumor cells is an ultimate goal, this is often not possible in many brain tumors due to invasion into the brain or microscopic amounts of cells that cannot be seen. Therefore, in many cases patients will need additional therapy after surgery.

  Types of brain tumor surgeries

  Biopsy: If the tumor is in a part of the brain where removal would cause considerable neurological damage, a biopsy may be taken. A biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a sample of tumor cells. The tumor cells are examined under a microscope by a pathologist who establishes a diagnosis so that appropriate treatment can be recommended.

  Resection: A resection is surgical removal of as much of a tumor as possible. This often requires a craniotomy, which is the removal of a piece of the skull so that the neurosurgeon can gain access to the tumor. The piece of skull is replaced after the resection and held in place by thin pieces of titanium. Tumors in the region of the pituitary gland can sometimes be removed through the nose and do not require a craniotomy. A resection is called a “gross total resection” when there is no obvious tumor visible on a brain scan performed soon after surgery. If a portion of the tumor can still be seen on a post-operative brain scan, it is called a “subtotal resection.”

  Stereotactic surgery: A precise computerized map of the brain is made using an MRI or CT scan. The neurosurgeon uses this map during surgery to precisely locate the tumor and to navigate around critical brain structures during resection or biopsy of the tumor, a technique that is known as “intraoperative image guidance.”

  Microscopic surgery: A microscope is used during surgery for detailed evaluation of brain and tumor tissue.

  Radiation Therapy

  Radiation therapy is the use of beams of energy called “ionizing radiation” to slow or stop the growth of tumor cells. Radiation oncologists are the physicians who manage radiation therapy. They determine the most appropriate form and amount of radiation to be delivered according the type, size, and location of the tumor.

  Types of radiation therapy

  Fractionated radiotherapy: A specific dose of radiation is delivered in parts rather than all at once. Radiation is usually delivered in daily sessions five days per week for two to seven weeks. The radiation oncologist determines the treatment schedule.

  Focused radiation = radiation that is directed only at the tumor.

  Whole brain radiation therapy = radiation is directed at the entire brain. This form of radiation is used in cases where there are multiple tumors or a tumor spreads over a large area of the brain.

  Stereotactic radiosurgery = A single high-dose of radiation is delivered precisely to one or more small tumors on an outpatient basis. Novalis BrainLab®, Gamma Knife® and CyberKnife® are brand names of types of stereotactic radiosurgery.

  Chemotherapy

  Chemotherapy is the use of powerful medications to slow or stop the growth of tumors. Oncologists are the physicians who prescribe and manage chemotherapy. Neuro-oncologists are oncologists who specialize in treating nervous system cancers. Chemotherapy can be given by mouth, through an I.V., or directly into the brain during surgery.

  Standard versus Experimental Treatment

  Standard treatment is a commonly accepted form of treatment for a certain medical condition. It is based on either experimental data, expert opinion or both. Experimental treatment is treatment that is currently being tested in clinical trials (research studies). An experimental treatment may become a standard treatment if it is proven to be more effective than current standard treatments.

  Follow-up

  Most people who have been treated for a brain tumor will require long term follow-up with routine brain scans, neurological exams, and visits to one or more of the healthcare providers involved in their treatment. This is to monitor the response to treatment and to watch for tumor recurrence.

  Pituitary

  ---

  About Pituitary Tumors

  Pituitary tumors are abnormal growths that develop in your pituitary gland. Some pituitary Drawing of pituitary glandtumors cause excessive production of hormones that regulate important functions of your body. Other pituitary tumors can restrict normal functions of your pituitary gland, causing it to produce lower levels of hormones.

  Most pituitary tumors are noncancerous growths (adenomas). Adenomas remain confined to your pituitary gland or surrounding tissues and don't spread to other parts of your body. If a tumor releases adrenocorticotropic hormone (ACTH), it causes increased cortisol which leads to fat deposits, especially in the shoulders and face. This is usually called Cushing's Disease.

  

  Tumors that secrete excess prolactin are called prolactinomas. Excess prolactin can cause secretion of breast fluids in women and decreased sexual drive in men and women. Men may not experience breast fluid secretation but increased prolactin can certainly cause breast tenderness. It may also cause irregular or absent menstrual periods in women, and difficulty in having an erection or infertility in men. Typically these tumors can be treated with medication alone (bromocriptine).

  For pituitary tumors that do not secrete hormones, the initial symptoms may not occur until the tumor presses on the structures surrounding the normal pituitary gland. Once the tumor is larger than 1 centimeter, it is called a macroadenoma.

  

  Because the pituitary gland is located within the skull, when it becomes large, it may cause headaches that get worse as the tumor grows. Also, since the pituitary gland is located near the eyes, it can press on the nerves to the eyes and cause loss of vision. Loss of peripheral vision may occur first and be undetected by the patient. This may progress to eventual blindness if the pressure is not removed from the nerve. The tumor may also press on the nerves that move the eye and cause double vision. If the tumor is very large it may press on other parts of the brain and cause problems with memory, weakness, or numbness. If surgery is warranted, the doctors at CU Neurosurgery usually perform a resection using a transnasal approach. Dr. Aniruddh Kulkarni

  Some pituitary tumors may be observed without treatment because they may grow very slowly. Pituitary tumors are usually benign. It is rare for them to ever become malignant. If a decision is made to observe the tumor without treatment, ongoing evaluations by CT or MRI, by an endocrinologist, and by an ophthalmologist are usually done within 3-6 months after the initial diagnosis and every 6-12 months thereafter until the situation has been clarified. This period of observation without treatment provides information that helps the doctors decide whether other treatments that have more risks are needed.

  Dr. Aniruddh Kulkarni

  Observation without treatment may also be recommended if conditions are present that would seriously increase the risk of surgical or other treatments. Because pituitary tumors are slow growing, patients can often be observed without treatment for long periods of time without the tumor causing serious problems. This is often the recommended form of treatment for patients who are age 70 or above or who have a serious medical illness such as heart disease. Close follow-up may be necessary to monitor tumor growth and symptoms.

• Craniopharyngioma
  • Information on Brain Tumors
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Craniopharyngioma

  ---

  Definition: A craniopharyngioma is a benign tumor that occurs at the base of the brain near the pituitary gland, optic nerves and third ventricle. This type of tumor grows slowly and can become quite large before it causes symptoms.

  Symptoms: Initial symptoms of a craniopharyngioma often involve visual loss due to compression of the optic nerves. This type of tumor can also affect the pituitary gland, a small structure attached to the brain that secretes chemicals (hormones) that influence the functioning of organs throughout the body. Compression of the pituitary gland can cause a myriad of symptoms such as obesity, lethargy, and problems with growth and development. Symptoms such as headache, nausea, vomiting, vision problems, and changes in behavior can occur and are usually due to increased intracranial pressure from hydrocephalus, a build-up of cerebrospinal fluid in the brain due to blockage of its flow.

  Evaluation: Craniopharyngiomas are evaluated with MRI or CT scans. Visual field testing (perimetry) may be recommended to assess for and monitor vision loss. Blood tests may be ordered to evaluate the functioning of the pituitary gland.

  Treatment Options:

  1) Surgery: Surgical removal is the treatment of choice for craniopharyngiomas.

  2) Radiation: Fractionated radiation or radiosurgery may be recommended if complete surgical removal of the visible tumor is not possible or for recurrent tumors.

  Follow-up: Long-term follow-up with regular brain scans is recommended to watch for tumor recurrence.

  Evaluation and Diagnosis of Brain Tumors

  ---

  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid that flows around the brain and spinal cord. Numbing medicine is given. Then, a needle is inserted between the vertebrae of the lower back to obtain cerebrospinal fluid. The cerebral spinal fluid is sent to a lab to be examined for the presence of tumor cells.

  Audiometry

  Audiometry is a test to evaluate hearing. In cases where a tumor may involve the nerve that carries auditory information from the ear to the brain, audiometry may provide information about whether the tumor has damaged the nerve.

  Visual Field Testing (perimetry)

  Visual field testing is a test to evaluate vision. Certain tumors may result in pressure on the optic nerves or areas of the brain involved with transmitting or processing visual information. In these cases, visual field testing may be very helpful for providing baseline information about the extent and location of visual loss, which will help guide treatment.

  Brain Tumor Treatment

  ---

  Treatment options for a brain tumor depend on the type, location, and size of the tumor and may include surgery, radiation, cDr. Aniruddh Kulkarni a combination of these options. Treatment can be postponed in some cases if a tumor appears to be growing slowly and is not causing symptoms. Although there are initial standard-of-care treatment plans for most tumors, in some cases, experimental therapies may be recommended if standard therapies are unsuccessful.

  Surgery

  Surgery is usually the first step in the treatment of brain tumors. The purpose of surgery is to obtain tissue to verify the diagnosis. Additional goals of surgery are to relieve symptoms, decrease pressure on the brain or Dr. Aniruddh Kulkarni spinal cord, and minimize the size of the tumor that will need to be treated with radiation or chemotherapy. Importantly, recent data suggests that extensive removal of a brain tumor improves long-term treatment outcomes. Therefore, the goal of surgery is to remove as much of a tumor as possible without damaging healthy brain tissue. Although complete removal of all tumor cells is an ultimate goal, this is often not possible in many brain tumors due to invasion into the brain or microscopic amounts of cells that cannot be seen. Therefore, in many cases patients will need additional therapy after surgery.

  Types of brain tumor surgeries

  Biopsy: If the tumor is in a part of the brain where removal would cause considerable neurological damage, a biopsy may be taken. A biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a sample of tumor cells. The tumor cells are examined under a microscope by a pathologist who establishes a diagnosis so that appropriate treatment can be recommended.

  Resection: A resection is surgical removal of as much of a tumor as possible. This often requires a craniotomy, which is the removal of a piece of the skull so that the neurosurgeon can gain access to the tumor. The piece of skull is replaced after the resection and held in place by thin pieces of titanium. Tumors in the region of the pituitary gland can sometimes be removed through the nose and do not require a craniotomy. A resection is called a “gross total resection” when there is no obvious tumor visible on a brain scan performed soon after surgery. If a portion of the tumor can still be seen on a post-operative brain scan, it is called a “subtotal resection.”

  Stereotactic surgery: A precise computerized map of the brain is made using an MRI or CT scan. The neurosurgeon uses this map during surgery to precisely locate the tumor and to navigate around critical brain structures during resection or biopsy of the tumor, a technique that is known as “intraoperative image guidance.”

  Microscopic surgery: A microscope is used during surgery for detailed evaluation of brain and tumor tissue.

  Radiation Therapy

  Radiation therapy is the use of beams of energy called “ionizing radiation” to slow or stop the growth of tumor cells. Radiation oncologists are the physicians who manage radiation therapy. They determine the most appropriate form and amount of radiation to be delivered according the type, size, and location of the tumor.

  Types of radiation therapy

  Fractionated radiotherapy: A specific dose of radiation is delivered in parts rather than all at once. Radiation is usually delivered in daily sessions five days per week for two to seven weeks. The radiation oncologist determines the treatment schedule.

  Focused radiation = radiation that is directed only at the tumor.

  Whole brain radiation therapy = radiation is directed at the entire brain. This form of radiation is used in cases where there are multiple tumors or a tumor spreads over a large area of the brain.

  Stereotactic radiosurgery = A single high-dose of radiation is delivered precisely to one or more small tumors on an outpatient basis. Novalis BrainLab®, Gamma Knife® and CyberKnife® are brand names of types of stereotactic radiosurgery.

  Chemotherapy

  Chemotherapy is the use of powerful medications to slow or stop the growth of tumors. Oncologists are the physicians who prescribe and manage chemotherapy. Neuro-oncologists are oncologists who specialize in treating nervous system cancers. Chemotherapy can be given by mouth, through an I.V., or directly into the brain during surgery.

  Standard versus Experimental Treatment

  Standard treatment is a commonly accepted form of treatment for a certain medical condition. It is based on either experimental data, expert opinion or both. Experimental treatment is treatment that is currently being tested in clinical trials (research studies). An experimental treatment may become a standard treatment if it is proven to be more effective than current standard treatments.

  Follow-up

  Most people who have been treated for a brain tumor will require long term follow-up with routine brain scans, neurological exams, and visits to one or more of the healthcare providers involved in their treatment. This is to monitor the response to treatment and to watch for tumor recurrence.

  Pituitary

  ---

  About Pituitary Tumors

  Pituitary tumors are abnormal growths that develop in your pituitary gland. Some pituitary Drawing of pituitary glandtumors cause excessive production of hormones that regulate important functions of your body. Other pituitary tumors can restrict normal functions of your pituitary gland, causing it to produce lower levels of hormones.

  Most pituitary tumors are noncancerous growths (adenomas). Adenomas remain confined to your pituitary gland or surrounding tissues and don't spread to other parts of your body. If a tumor releases adrenocorticotropic hormone (ACTH), it causes increased cortisol which leads to fat deposits, especially in the shoulders and face. This is usually called Cushing's Disease.

  

  Tumors that secrete excess prolactin are called prolactinomas. Excess prolactin can cause secretion of breast fluids in women and decreased sexual drive in men and women. Men may not experience breast fluid secretation but increased prolactin can certainly cause breast tenderness. It may also cause irregular or absent menstrual periods in women, and difficulty in having an erection or infertility in men. Typically these tumors can be treated with medication alone (bromocriptine).

  For pituitary tumors that do not secrete hormones, the initial symptoms may not occur until the tumor presses on the structures surrounding the normal pituitary gland. Once the tumor is larger than 1 centimeter, it is called a macroadenoma.

  

  Because the pituitary gland is located within the skull, when it becomes large, it may cause headaches that get worse as the tumor grows. Also, since the pituitary gland is located near the eyes, it can press on the nerves to the eyes and cause loss of vision. Loss of peripheral vision may occur first and be undetected by the patient. This may progress to eventual blindness if the pressure is not removed from the nerve. The Dr. Aniruddh Kulkarni tumor may also press on the nerves that move the eye and cause double vision. If the tumor is very large it may press on other parts of the brain and cause problems with memory, weakness, or numbness. If surgery is warranted, the doctors at CU Neurosurgery usually perform a resection using a transnasal approach.

  Some pituitary tumors may be observed without treatment because they may grow very slowly. Pituitary tumors are usually benign. It is rare for them to ever become malignant. If a decision is made to observe the tumor without treatment, ongoing evaluations by CT or MRI, by an endocrinologist, and by an ophthalmologist are usually done within 3-6 months after the initDr. Aniruddh Kulkarniery 6-12 months thereafter until the situation has been clarified. This period of observation without treatment provides information that helps the doctors decide whether other treatments that have more risks are needed.

  Observation without treatment may also be recommended if conditions are present that would seriously increase the risk of surgical or other treatments. Because pituitary tumors are slow growing, patients can often be observed without treatment for long periods of time without the tumor causing serious problems. This is often the recommended form of treatment for patients who are age 70 or above or who have a serious medical illness such as heart disease. Close follow-up may be necessary to monitor tumor growth and symptoms.

• Epidermoid Tumor
  • Information on Brain Tumors
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Epidermoid Tumor

  (Also called an "epidermoid cyst")

  ---

  Definition: An epidermoid tumor is a benign, slow-growing tumor that arises from skin cells that get trapped in the brain and spinal cord during development. This type of tumor is often referred to as a “cyst” because it has a thin wall that secretes a soft material into the center. This type of tumor most often occurs near the brainstem, cerebellum, or pituitary gland.

  Symptoms: Common symptoms of an epidermoid tumor are headache, imbalance, or visual changes depending on the location of the tumor. Rarely, an epidermoid cyst will rupture causing meningitis, an inflammation of the lining of the brain. Symptoms of meningitis are fever, chills, severe headache, and neck stiffness.

  Evaluation: Epidermoid tumors are evaluated with an MRI or CT scan.

  Treatment Options:

  Maximal surgical removal is the treatment of choice for epidermoid tumors. Radiation and chemotherapy are not usually treatment options for this type of tumor.

  Follow-up: Long-term follow-up with regular brain scans is recommended to watch for tumor recurrence.

  Evaluation and Diagnosis of Brain Tumors

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  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid that flows around the brain and spinal cord. Numbing medicine is given. Then, a needle is inserted between the vertebrae of the lower back to obtain cerebrospinal fluid. The cerebral spinal fluid is sent to a lab to be examined for the presence of tumor cells.

  Audiometry

  Audiometry is a test to evaluate hearing. In cases where a tumor may involve the nerve that carries auditory information from the ear to the brain, audiometry may provide information about whether the tumor has damaged the nerve.

  Visual Field Testing (perimetry)

  Visual field testing is a test to evaluate vision. Certain tumors may result in pressure on the optic nerves or areas of the brain involved with transmitting or processing visual information. In these cases, visual field testing may be very helpful for providing baseline information about the extent and location of visual loss, which will help guide treatment.

  Brain Tumor Treatment

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  Treatment options for a brain tumor depend on the type, location, and size of the tumor and may include surgery, radiation, chemotherapy or often a combination of these options. Treatment can be postponed in some cases if a tumor appears to be growing slowly and is not causing symptoms. Although there are initial standard-of-care treatment plans for most tumors, in some cases, experimental therapies may be recommended if Dr. Aniruddh Kulkarni standard therapies are unsuccessful.

  Surgery

  Surgery is usually the first step in the treatment of brain tumors. The purpose of surgery is to obtain tissue to verify the diagnosis. Additional goals of surgery are to relieve symptoms, decrease pressure on the brain or spinal cord, and minimize the size of the tumor that will need to be treated with radiation or chemotherapy. Importantly, recent data suggests that extensive removal of a brain tumor improves long-term treatment outcomes. Therefore, the goal of surgery is to remove as muDr. Aniruddh Kulkarnisible without damaging healthy brain tissue. Although complete removal of all tumor cells is an ultimate goal, this is often not possible in many brain tumors due to invasion into the brain or microscopic amounts of cells that cannot be seen. Therefore, in many cases patients will need additional therapy after surgery.

  Types of brain tumor surgeries

  Biopsy: If the tumor is in a part of the brain where removal would cause considerable neurological damage, a biopsy may be taken. A biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a sample of tumor cells. The tumor cells are examined under a microscope by a pathologist who establishes a diagnosis so that appropriate treatment can be recommended.

  Resection: A resection is surgical removal of as much of a tumor as possible. This often requires a craniotomy, which is the removal of a piece of the skull so that the neurosurgeon can gain access to the tumor. The piece of skull is replaced after the resection and held in place by thin pieces of titanium. Tumors in the region of the pituitary gland can sometimes be removed through the nose and do not require a craniotomy. A resection is called a “gross total resection” when there is no obvious tumor visible on a brain scan performed soon after surgery. If a portion of the tumor can still be seen on a post-operative brain scan, it is called a “subtotal resection.”

  Stereotactic surgery: A precise computerized map of the brain is made using an MRI or CT scan. The neurosurgeon uses this map during surgery to precisely locate the tumor and to navigate around critical brain structures during resection or biopsy of the tumor, a technique that is known as “intraoperative image guidance.”

  Microscopic surgery: A microscope is used during surgery for detailed evaluation of brain and tumor tissue.

  Radiation Therapy

  Radiation therapy is the use of beams of energy called “ionizing radiation” to slow or stop the growth of tumor cells. Radiation oncologists are the physicians who manage radiation therapy. They determine the most appropriate form and amount of radiation to be delivered according the type, size, and location of the tumor.

  Types of radiation therapy

  Fractionated radiotherapy: A specific dose of radiation is delivered in parts rather than all at once. Radiation is usually delivered in daily sessions five days per week for two to seven weeks. The radiation oncologist determines the treatment schedule.

  Focused radiation = radiation that is directed only at the tumor.

  Whole brain radiation therapy = radiation is directed at the entire brain. This form of radiation is used in cases where there are multiple tumors or a tumor spreads over a large area of the brain.

  Stereotactic radiosurgery = A single high-dose of radiation is delivered precisely to one or more small tumors on an outpatient basis. Novalis BrainLab®, Gamma Knife® and CyberKnife® are brand names of types of stereotactic radiosurgery.

  Chemotherapy

  Chemotherapy is the use of powerful medications to slow or stop the growth of tumors. Oncologists are the physicians who prescribe and manage chemotherapy. Neuro-oncologists are oncologists who specialize in treating nervous system cancers. Chemotherapy can be given by mouth, through an I.V., or directly into the brain during surgery.

  Standard versus Experimental Treatment

  Standard treatment is a commonly accepted form of treatment for a certain medical condition. It is based on either experimental data, expert opinion or both. Experimental treatment is treatment that is currently being tested in clinical trials (research studies). An experimental treatment may become a standard treatment if it is proven to be more effective than current standard treatments.

  Follow-up

  Most people who have been treated for a brain tumor will require long term follow-up with routine brain scans, neurological exams, and visits to one or more of the healthcare providers involved in their treatment. This is to monitor the response to treatment and to watch for tumor recurrence.

  Pituitary

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  About Pituitary Tumors

  Pituitary tumors are abnormal growths that develop in your pituitary gland. Some pituitary Drawing of pituitary glandtumors cause excessive production of hormones that regulate important functions of your body. Other pituitary tumors can restrict normal functions of your pituitary gland, causing it to produce lower levels of hormones.

  Most pituitary tumors are noncancerous growths (adenomas). Adenomas remain confined to your pituitary gland or surrounding tissues and don't spread to other parts of your body. If a tumor releases adrenocorticotropic hormone (ACTH), it causes increased cortisol which leads to fat deposits, especially in the shoulders and face. This is usually called Cushing's Disease.

  

  Tumors that secrete excess prolactin are called prolactinomas. Excess prolactin can cause secretion of breast fluids in women and decreased sexual drive in men and women. Men may not experience breast fluid secretation but increased prolactin can certainly cause breast tenderness. It may also cause irregular or absent menstrual periods in women, and difficulty in having an erection or infertility in men. Typically these tumors can be treated with medication alone (bromocriptine).

  For pituitary tumors that do not secrete hormones, the initial symptoms may not occur until the tumor presses on the structures surrounding the normal pituitary gland. Once the tumor is larger than 1 centimeter, it is called a macroadenoma.

  

  Because the pituitary gland is located within the skull, when it becomes large, it may cause headaches that get worse as the tumor grows. Also, since the pituitary gland is located near the eyes, it can press on the nerves to the eyes and cause loss of vision. Loss of peripheral vision may occur first and be undetected by the patient. This may progress to eventual blindness if the pressure is not removed from the nerve. The tumor may also press on the nerves that move the eye and cause double vision. If the tumor is very large it may press on other parts of the brain and cause problems with memory, weakness, or numbness. If surgery is warranted, the doctors at CU Neurosurgery usually perform a resection using a transnasal approach.

  Some pituitary tumors may be observed without treatment because they may grow very slowly. Pituitary tumors are usually benign. It is rarDr. Aniruddh Kulkarniecome malignant. If a decision is made to observe the tumor without treatment, ongoing evaluations by CT or MRI, by an endocrinologist, and by an ophthalmologist are usually done within 3-6 months after the initial diagnosis and every 6-12 months thereafter until the situation has been clarified. This period of observation without treatment provides information that helps the doctors decide whether other treatments that have more risks are needed.

  Observation without treatment may also be recommended if conditions are present that would seriously increase the risk of surgical or other treatments. Because pituitary tumors are slow growing, patients can often be observed without treatment for long periods of time without the tumor causing serious problems. This is often the recommended form of treatment for patients who are age 70 or above or who have a serious medical illness such as heart disease. Close follow-up may be necessary to monitor tumor growth and symptoms.

• Ependymoma
  • Information on Brain Tumors
  • Evaluation and Diagnosis of Brain Tumors
  • Brain Tumor Treatment
  • Pituitary

  Ependymoma

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  Definition: Ependymomas are tumors that arise from ependymal cells that line the venticles in the brain and the center of the spinal cord where cerebrospinal fluid flows. The World Health Organization classifies ependymomas as grade I (myxopapillary ependymoma and subependymoma), grade II (ependymoma), or grade III (anaplastic ependymoma) based on the aggressiveness of the tumor. Ependymomas can occur in the brain and spread to the spinal cord through the cerebrospinal fluid. The majority of ependymomas are benign (grade I).

  Symptoms: Many ependymomas occur in the fourth ventricle and can block the flow of cerebrospinal fluid leading to hydrocephalus, a build-up of cerebrospinal fluid in the brain. Increased intracranial pressure from hydrocephalus can cause headaches, nausea, vomiting, visual changes, and changes in behavior. Ependymomas in the spine can cause back pain, weakness in the arms or legs, or bladder problems.

  Evaluation: Ependymomas are evaluated with an MRI or CT scan. A lumbar puncture (spinal tap) may be performed to see if there are ependymoma cells in the cerebrospinal fluid.

  Treatment Options:

  1) Surgery: Surgical biopsy and removal of as much of the tumor as possible without causing significant neurological damage is the first step in the treatment of an ependymoma.

  2) Radiation: Ependymomas are very sensitive to radiation so fractionated radiation is usually recommended after surgery to prevent tumor re-growth.

  3) Chemotherapy: Chemotherapy is occasionally used in the treatment of ependymomas.

  Follow-up: Long-term follow-up with regular scans and neurological exams is recommended to watch for tumor recurrence.

  Evaluation and Diagnosis of Brain Tumors

  ---

  Medical History and Exam

  Brain tumors cause the same symptoms as many other health problems. A history and exam conducted by a healthcare provider can help determine what might be causing certain symptoms and if further testing is needed. A medical history consists of questions regarding a person’s past and present state of health and detailed questions about their current symptoms. A neurological exam is performed to test the functioning of the nervous system and often includes testing of vision, hearing, speech, cognition, strength, sensation, coordination, balance, and reflexes. If specific abnormalities are discovered during the history and physical, the health care provider will send a patient for a brain scan.

  Imaging

  Medical imaging is the creation of a picture (scan) of the internal structures of the body. A radiologist is a physician who interprets the images. Magnetic resonance imaging (MRI) and computed tomography (CT) are the types of medical imaging most commonly used to evaluate brain tumors. Contrast is often given during MRI or CT scans. Contrast is a substance that is swallowed or injected into the veins before imaging to illuminate tumors. In fact, it is difficult or impossible to see many tumors without contrast. People with certain medical conditions will be asked to have a blood test to evaluate their kidney function before receiving contrast. This is to make certain that their kidneys are working well enough to filter the contrast out of the body after the scan. Scans other than MRI or CT scans may be performed to obtain specific information about a tumor.

  The most common types of scans used for the evaluation of brain tumors are the following:

  1. Magnetic resonance imaging (MRI): Magnetic fields, radio waves, and computer technology are used to create images of the soft tissues of the brain in great detail.
  2. Computed tomography (CT): X-rays and computer technology are used to visualize bone, collections of calcium within tumors, bleeding, and swelling.
  3. Functional MRI (fMRI): MRI technology is used to generate an image of brain activity according to changes of blood flow in the brain. The purpose of this test is to determine which areas of the brain control certain functions so that these areas can be avoided during surgery.
  4. Positron Emission Tomography (PET): A type of scan that helps distinguish between tumor cells, necrosis (dead tumor cells), and scar tissue.
  5. Magnetic Resonance Angiogram/Venography (MRA or MRV): MRI technology is used to create an image of blood vessels in the brain.
  6. Magnetic Resonance Spectroscopy/Perfusion: These are specialized MRI-based tests that give information about the metabolic activity of specific areas of the brain, which can help in providing evidence for the presence of a tumor.

  Biopsy

  Medical imaging can verify the presence and show certain features of different types of brain tumors but a biopsy is required to know the tumor type for certain. Knowing the tumor type is essential for initiating treatment of brain tumors, as therapies can be significantly different for different tumor types. In cases where removal of large portions of a tumor may not be possible, a biopsy is a surgical procedure in which a small opening is made in the skull and a needle is inserted into the tumor to obtain a small sample of tumor cells. Alternatively, tumor specimens (“biopsy”) can be taken during surgery that is intended to remove larger portions of the tumor. During the surgery, an initial evaluation of the biopsy material is performed under a microscope by a pathologist who can often provide a preliminary diagnosis. However, final pathological identification of the tumor often takes up to a week, which is critical for providing an accurate diagnosis so that appropriate treatment can be given.

  Lumbar Puncture (spinal tap)

  In rare cases, a diagnosis can be made for particular tumors if the tumor cells are found within the cerebrospinal fluid (CSF). A lumbar puncture is a procedure that is occasionally performed to obtain a sample of cerebrospinal fluid, the fluid t