Tumor on WebMD

BRAIN TUMORS

Your doctor has told you that you have (or may have) a brain tumor. You have many questions that immediately come to mind. Benign? Malignant? What kind of tumor is it? What caused it? How do I treat it? What alternatives do I have? What is the next step?

Usually the diagnosis of a brain tumor is made after your physician obtains your history of specific complaints and a neurologic examination arises enough suspicion that either a CT or MRI scan is ordered. The tumor is thus seen on these scans. The diagnosis of a tumor often leads to a referral to a neurosurgeon for a consultation. After a neurologic examination the neurosurgeon will review the CT or MRI and enter into an explanation of his thoughts as to the nature or type of tumor and what the next step is in either diagnosing your tumor or treating it.

At this time, several general terms and concepts should be clarified for your better understanding before your visit with us. Tumors that begin within the brain are termed primary. Those that travel to the brain from elsewhere in the body are called metastatic. Tumors may be either malignant (cancerous) or benign (not cancer). All tumors that are metastatic to the brain are malignant; however not all tumors that are primary brain tumors are malignant. In fact only about half are. Metastatic tumors that travel to the brain most commonly come from: lung, breast, kidney, colon or skin (melanoma). Usually patients with these types of tumors already know about their cancers, but occasionally the brain metastasis is the first sign of their disease.

Primary brain tumors can arise from any of the many types of cells within the brain and their name derives from the type of cell that gives rise to the tumor (example, astrocytes=astrocytoma) Meningiomas arise from cells that make up the meninges (or covering of the brain). This type of tumor is almost always benign, grows slowly and is ore likely to occur in women. Gliomas as the most common tumors of the brain and arise from the supporting tissue of the brain. Any of these supporting types of cells can develop into a tumor:astrocytoma, ependymoma, oligodendroglioma. These glioma tumors can all be either benign or cancerous.

The treatment for a brain tumor depends on its type, location and size. The main types of treatment are surgery, radiation, chemotherapy or a combination of these.

Surgery - is the standard treatment for brain tumors. Whenever possible the neurosurgeon tries to removed the entire tumor. If the entire tumor cannot be completely removed without damaging vital areas of the brain, the surgeon will remove as much as safely is possible. Additional treatment such as radiation and/or chemotherapy may then be use.

Radiation - involves an energy beam that is directed at the tumor to stop or slow its growth. The radiation can be used in several different ways (such as stereostactic radiation or conventional radiation). This involves a physician and a radiation oncologist. Radiation may be the first or only treatment you need or may be used after surgery depending upon the type, location or size of tumor.

Chemotherapy -is the use of drugs to kill tumor cells. These drugs can be delivered to the tumors in several ways: by mouth, intravenously or placed within the tumor at the time of surgery.

Stereotactic Biopsy - occasionally your surgeon may suggest this as the next step to treat your brain tumor. This may be suggested if there is a possibility that your tumor can be treated without surgery. In this case, the biopsy will confirm the type of tumor since many tumors look alike on an MRI or CT scan. Your surgeon will discuss the procedure with you if it is recommended.

After your consultation, your surgeon will review his thoughts on the nature of the tumor and recommend the best course of treatment for you. If this involves surgery, arrangements will be made at that visit for you to be admitted to the hospital at the appropriate time. The timing of admission will depend upon many factors and usually will be within one week-rarely the same day. Your surgeon will review details of your planned operation with you at this time.

Pituitary Tumor Surgery
(Transsphenoidal Hypophysectomy)

The pituitary gland is a small structure at the base of the brain whose function is to produce or secrete hormones controlling several organs in the body. The pituitary gland itself is relatively small and measures about the size of a pea. It is located within a bed of bone and is attached to the brain by a stalk of tissue. Some hormones are made in the hypothalamus of the brain and travel to the pituitary gland through this stalk. Other hormones are made directly by the pituitary gland itself. The hormones that are contained within the pituitary gland are then secreted to target organs of the body through the blood stream. The thyroid gland, adrenal glands, breast tissue, and gonads of both male and female are regulated by hormones from the pituitary gland. Tumors involving the pituitary gland could, therefore, affect an individual by creating a disturbance of any one of these organ systems. For example, a woman suffering from abnormal periods and lactation in the absence of childbirth might harbor a small hyper secreting tumor of the pituitary gland. Very large tumors of the pituitary gland can also affect other surrounding structures. There are multiple cranial nerves on either side of the pituitary gland. Near the roof of the pituitary gland is the optic nerve apparatus and with very large pituitary tumors, vision can be compromised.

Patients are generally discovered to have a pituitary tumor either as a result of a hormonal abnormality that was discovered or neurological abnormality. These in turn will lead to an MRI that demonstrates the tumor. At this point, the patient is referred to an endocrinologist and/or a neurosurgeon for formal evaluation of the pituitary tumor. If seen by a neurosurgeon primarily, the patient is generally also referred to a consulting endocrinologist. This is done because if one hormone is affected by the pituitary tumor, other hormones can also be affected and yet not recognized as impairment by the patient. In addition, there are some forms of hormones that can be actively treated with medication alone, and in fact, decrease in size as a result of the medication. Many of these patients then do not require surgery.

The patients in our office who require surgery are then referred to yet another specialist in anticipation of the operation. One specialist might be an ophthalmologist who would perform visual field testing in the cases of patients with very large pituitary tumors. This is done to formally document whether or not the pituitary tumor has affected areas of vision. The other specialist that the patients are sent to is an otolaryngologist familiar with skull base surgery to the pituitary gland. It is this otolaryngologist along with the neurosurgeon who will make the approach for the transsphenoidal procedure and access the tumor at the base of the skull.

The transsphenoidal procedure itself is an approach to the pituitary gland that allows the neurosurgeon access to the pituitary tumor without resorting to a craniotomy. With the patient under general anesthesia, the otolaryngologist makes an incision above the teeth and in the gum of the upper lip. Dissection is then carried at the base of the nose to the base of the skull under magnified vision and microscope. Once there, the small shell of bone at the base of the pituitary gland is opened, and the pituitary tumor is resected from underneath. Following the completion of this, some fatty tissue from either the abdomen or the side of the leg is taken using a separate incision during the same operation, and it is used to tack this area so that it will seal. Further packing is placed by the otolaryngologist. Postoperatively the patient is seen by the neurosurgeon, the otolaryngologist, and the endocrinologist. The postoperative length of stay is generally from three to five days.

Alternative forms of surgery can be used around the nose to access the base of the pituitary gland. However, for many small pituitary tumors the transsphenoidal approach is the procedure of choice. At times, an endoscopic form of surgery can be used along with this approach or independently in specific cases. Another alternative to the transsphenoidal approach is a craniotomy. With a craniotomy, the brain tissue itself is reflected back after removal of a portion of bone above the eyes. With this approach, the pituitary tumor can be directly observed along with the optic nerves and their connection. This type of surgery is reserved for those patients whose tumor has grown so large that a transsphenoidal approach cannot adequately resect enough of the pituitary tumor, or in those patients in whom the pituitary tumor has grown so large as to involve surrounding blood vessels and the optic nerves and portions of the brain. The craniotomy allows the surgeon to directly observe these areas and therefore better protect them. In the cases of these very large tumors, with either approach, the goal of the surgery is two-fold; resecting as much tumor tissue as possible, and also identifying what kind of tumor has occurred by analyzing the surgical tissue pathologically. Based upon the kind of resection that has been performed and the type of pituitary tumor, further hormonal therapy or radiation therapy might be recommended.

The recuperation from surgery depends upon the individual patient working with his or her physicians postoperatively and the type of tumor. As mentioned, further therapy may be required for a particular tumor after surgery. Return to fully normal activity can take as little as a few weeks to several weeks or even a few months. Postoperatively the patients are followed by both the endocrinologist and the neurosurgeon for some time. Postoperatively hormone levels are monitored and supplemental medications are monitored by the endocrinologist. The postoperative patient will have to undergo follow-up postoperative MRI's over several months and even, at times, on a yearly basis to make absolutely sure that no recurrence occurs. This can be requested by the physicians even if they feel that a tumor was completely excised and that it was totally benign.

This brief discussion on pituitary tumors and their surgery is only meant to be an outline for the patient reading it. At each point in a patient's workup and care, it never hurts to write a list of questions regarding his or her problem. This list can be generated after speaking with the primary care physician and the family. Once discussion has been undertaken with the operating surgeon and the endocrinologist, further questions can be generated. The patient should always feel free to call or revisit the surgeon and/or endocrinologist with any further questions regarding his or her problem.