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?
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.
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.
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.
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.
- 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.
- 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.
-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
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.
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 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.
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.
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.
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.
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.
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.
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.