Vital Signs

By Dongwoo John Chang

 

A Bitter Pill

Brain Tumors Often Defy Our Best Treatments

Sept06_VitalSigns

A brain tumor is an abnormal growth that is classified in two broad categories: benign and malignant. This refers to how quickly it grows, spreads, and ultimately, how long people survive after diagnosis and treatment.

Brain tumors can be primary, meaning they arise directly from the brain substance or its supporting cells. There are grades of primary brain tumors, from Grade 1 (the least aggressive) to Grade 4 (the most aggressive). Secondary, or metastatic, brain tumors arise from the spread of tumor cells from other types of cancers elsewhere in the body, such as breast, lung or colon. They typically spread to the junctional zone of the brain, between the "white" and the "gray" matter.

Benign tumors are biologically less aggressive, but still require treatment, which can often involve surgery. Although a surgeon's primary job is to cut, in reality, it's equally important to stay abreast of progress in all of the non-surgical modalities of tumor treatment. In many cases, it's necessary to treat brain tumors with some other form of therapy, or in conjunction with surgery.

If you're diagnosed with a brain tumor, you'll first be referred to a neurosurgeon directly, or you'll consult with a neurosurgeon after speaking with other specialists, perhaps in radiation oncology or in medical oncology.

There's a very good chance that you'll need surgery at some point, either to diagnose or to remove the tumor. With most benign tumors, surgery is often the usual treatment. Surgery will typically involve a craniotomy, or an opening in the skull, although some tumors can be treated through a minimally invasive approach, using a corridor such as the nasal cavities. A benign tumor is effectively "cured" after a total removal, although you must be checked for recurrence through serial brain MRI's, since all tumors eventually grow back.

If a brain tumor originates from a cancer elsewhere in the body, then treatment depends on whether it's single or multiple, or whether the tumor is pressing on the brain enough to cause pressure problems inside the head. If it's a single tumor, then surgery is typically required, although smaller tumors can be treated with direct radiation in the form of "radiosurgery." Even after open-brain surgery for metastatic tumors, the patient often undergoes whole-brain radiotherapy. For multiple metastatic brain tumors, whole-brain radiotherapy is often performed as the main course of management.

Aggressive-tumor cases have spawned the most controversy. Vigorous debate surrounds how much treatment is enough, and whether the discomfort of aggressive treatment is worthwhile for patients who are terminal. Many specialists argue that for highly aggressive malignant tumors, nothing should be done. However, others support treating these tumors with aggressive surgery followed by radiation, followed by chemotherapy. But in the end, each approach only results in a mean survival of about one year.

As a society, we'd all like to believe that receiving "better" neurosurgical care by a "better" neurosurgeon would have a major impact on the overall outcome for brain tumors. However, in reality, your outcome from a brain tumor is often determined by the tumor itself, and not so much by the treatment. While it's true that for particular categories of skull-base brain tumors, neurosurgical experience and skill can make a margin of difference, for most brain tumors, the ultimate outcome depends on the biological behavior of the tumor itself.

In the end, it's oftentimes a crap shoot because surgical technique can only go so far in determining the overall result. And for a physician, that's a bitter pill to swallow.

Dongwoo John Chang, MD, FRCS (C) is the Chief of Cerebro-vascular Neurosurgery, Chief of Epilepsy Surgery, and Co-Director of the Comprehensive Epilepsy Program of the UC Davis School of Medicine and Medical Center in Sacramento, California. A graduate of Stanford University, Chang served his neurosurgery residency at McGill University Faculty of Medicine/Montreal Neurological Institute. Dr. Chang can be contacted via E-Mail at ajschang@aol.com for any questions or comments related to health care and/or neurosurgery.