Group2: Brain tumor treatment

Treatment for low grade tumors (To find out more about tumor grading click here !)

 Treatment planning for high grade tumors 

 Higher-grade tumors are more difficult to remove and require additional treatments, beyond surgery, such as radiation, chemotherapy, or a clinical trial if one is available. Microscopic tumor cells can remain after surgery and will eventually grow back. All treatments, therefore, are intended to prolong and improve life for as long as possible. 

 Radiation Therapy

 When surgery is not enough, radiation treatment uses x-rays and other forms of radiation to destroy tumor cells, or delay tumor growth. This can also be used when tumor cells are found in hard-to-reach areas. By planning treatment carefully with brain mapping techniques, radiation oncologists try to avoid killing healthy cells, thereby reducing side effects. Patients may wear a special mask that fits around their head to hold their head in place during radiation treatment. For higher grade gliomas, radiation treatment is often given with low daily doses of chemotherapy (such as temozolomide (Temodar®) to help delay a recurrence and allow patients to live longer. Side effects from radiation may include swelling, fatigue, headaches, nausea, possible hair loss, and changes in your sensations or movement. Damage to normal brain cells is often subtle, but it can affect mental sharpness and the ability to think clearly. Cognitive impairment can worsen to become a long-term problem for some people. 

 There are some different radiation options: 

• External beam fractionated radiation is the standard treatment used for all patients with high grade malignant gliomas, typically given in an outpatient clinic. 
  
• Stereotactic radiosurgery is a technique that focuses high doses of radiation at the tumor from many different angles. This form of radiation, often performed with the Gamma Knife® unit or the newer CyberKnife® unit, can be used to treat both benign and malignant tumors, but is most appropriate for tumors with welldefined edges.
• Proton beam radiation therapy is a type of high-energy, external radiation therapy that kills tumor cells with little damage to nearby tissues. It is most appropriate for tumors located at the base of the skull or behind the eyes.    [1], [3], [4]

Radiation therapy                                                                                                                                                   [6]   

Chemotherapy

  Chemotherapy is the use of drugs to kill cells that rapidly divide, such as cancer cells. It is prescribed when surgery is not enough to remove a tumor – most often for higher-grade tumors. Low doses may reduce the impact of chemotherapy related side effects, such as hair loss, nausea, fatigue, weight loss, and gastrointestinal problems. It becomes a quality of life issue for patients like suffering from glioblastoma, whose median survival is typically between 15 and 18 months.Patients are monitored closely to manage problems that may occur.    [1], [3]

 Chemotherapy is provided in three forms:

• Chemotherapy wafers containing drug called carmustine or BCNU are inserted directly into a high grade glioma during surgery. The wafer, named Gliadel®, slowly dissolves over 2-3 weeks to kill tumor cells. The video shows how these wafers are put into the brain. 

 [7]

• Intravenous chemotherapy is when the chemotherapy is given through a vein, in a clinic setting. Examples for high grade gliomas include: – Nitrosurea: BCNU – Vinca alkaloids: vincristine – Platinum Analogues: carboplatin, cisplatin.

• Oral Chemotherapy is when chemotherapy is given in a pill, by mouth. Examples include: TMZ or temozolomide (Temodar©), lomustine (CCNU), or procarbazine (Matulane®). TMZ plus radiation is the standard treatment for high grade gliomas. Some doctors treat anaplastic oligidendrogliomas with procarbazine, vincristine, and CCNU (known as PVC chemotherapy). Oral chemotherapy is not always effective on brain tumors. This is because of the body’s naturally protective system in the brain and cerebro-spinal fluid. This protective mechanism is known as the blood-brain barrier and it prevents harmful substances from entering the CNS.     [1], [3]

 Surgery

Surgery is used to diagnose and treat brain tumors.Ideally, the brain surgeon (neurosurgeon) can completely remove a brain tumor with surgery. If complete removal is not possible, the surgeon will remove as much as possible (called a resection or debulking) without negatively affecting the brain’s neurologic functions. If a resection is not possible, then a biopsy will be done (removing a small piece of tumor tissue) to diagnose the tumor type and grade so treatment recommendations can be made. [3]

Craniotomy

 A surgical procedure that involves removing a piece of the skull to access the brain. After the tumor is resected and tested, the bone is usually put back and held in place with plates and screws. All tissue obtained during the procedure is evaluated by a pathologist, the doctor who examines the tissue to identify the tumor type and grade. [8]

Biopsy 

A surgical procedure to remove a small sample of tissue from the tumor so the cells can be examined under a microscope. There are two kinds of biopsy procedures: 

•  Open Biopsy: done during a craniotomy. 
• Closed Biopsy (also called stereotactic or needle biopsy): when a needle is used to access and remove a small selection of tumor tissue from an area that is difficult to reach. A pathology report 
  contains the analysis of brain tissue taken from a biopsy. Sometimes the pathologist can’t make an exact diagnosis, so the tissue may be sent to another pathologist for a second opinion.  [9]

The treatments listed down below are those kind of treatments classified as new treatments which are still nowadays being proved and experimented. Others  are promising treatments still in development (yet not proved on real patients): 

Clinical Trials

Clinical trials are studies designed to test the most promising new treatments. People participate in a clinical trial for a variety of reasons: to try a new and promising treatment method, to contribute to the development of future treatments, or to help find a cure. Most clinical trials require a patient to qualify with certain medical criteria. Some trials can be joined before your first surgery, others during radiation, others at the point of recurrence. Patients can ask their doctor if they are eligible for a trial, or get a second opinion at any time. Though participants may be among the first people to benefit from a new treatment, there can be unexpected side effects, or the new treatment may not be better than or even as effective as the standard treatment. Patients are provided with very clear information about the treatment under investigation before they decide to participate. If they do wish to participate, they are monitored closely.   [11]

Clinical Trial Phases:

• Phase I: Determine maximum tolerated dose…how much, how safe, how often?

• Phase II: Evaluate effectiveness…does it do any good?

• Phase III: Compares a new treatment to the standard treatment to determine which is more effective…is the new treatment better?

If you want to know more about this clinical trials please click here.

Electric Field Treatments

Electric field treatments are a new strategy to kill brain tumor cells, utilizing a device called NovoTTF™ (by Novicure), that is placed along the scalp. It provides a mild electric current (electrodes) that may stop the growth of tumor cells without harming normal brain cells. There is some controversy about the efficacy of this therapy but we still managed to find the success story of a patient who was treated at John Theurer Cancer Center at Hackensack University Medical Center  for his brain cancer, glioblastoma also known as one of the most dangerous and deadly brain tumor. Right after his first times using the NovoTTF™ device, doctors noticed a big difference on tumor size, tumors had started to shrink considerably. Within a month of starting his care with the new device, Townsend (the patient) was able to stop chemotherapy and radiation treatments altogether. Patients are urged to wear the device for 75 percent of the time. The NovoTTF-100A is FDA approved for recurrent glioblastoma, but the company who makes the device, Novocure, is working to speed approval for newly diagnosed patients as well. In fact, a clinical trial looking at newly diagnosed glioblastoma patients receiving standard chemotherapy and radiation versus those receiving standard therapy with the addition of the device was cut short when an independent monitoring committee observed a survival benefit of those using the device was so evident, it seemed unethical to deprive the standard therapy group of the combination treatment. A potential side effect of using the NovoTTF-100A is skin irritation where the device adheres to the scalp, but doctors closely monitor patients and educate their families and caregivers on how prevent it. Down below you have the video of the patient and doctors talking about patients story and this new treatment which in this case was a success. If you want to read more about his story click here. If you want to learn more about the device you can click here.

Other promising treatments still in development are:

 Vaccine Therapy 

 Vaccine therapy uses the patient’s immune system to recognize and then attack cancer cells. Substances made with brain tissue or made in a laboratory are used to boost, direct, or restore the body’s natural defenses against cancer – similar to the way a flu vaccine helps the body fight the flu. To learn more about vaccine therapy click here!

  Gene Therapy

 Gene therapy uses engineered genes that can selectively kill cancer cells, stop their growth, or stimulate the immune system to fight them. This is done with the introduction of engineered genes that can enter into cells for treatment because they affect the way cancer cells behave. Gene therapy can be introduced to cancer cells by inserting them into viruses, stem cells, liposomes, or other immune cells. Gene therapy has been very promising in pre-clinical trials.  [13]

Advanced way of treatments

You can find more information about new ways and discoveries regarding brain tumor treatment here!