Brain tumor

Ricarda Schwarz studied medicine in Würzburg, where she also completed her doctorate.After a wide range of tasks in practical medical training (PJ) in Flensburg, Hamburg and New Zealand, she is now working in neuroradiology and radiology at the Tübingen University Hospital.

More about the experts All content is checked by medical journalists.

A brain tumor is a very rare disease for which usually no cause can be found. People mainly get it in childhood or around the age of 70. There are many types of brain tumors - benign and malignant. Your treatment and prognosis will vary widely. In general, a brain tumor can be operated on, irradiated or treated with chemotherapeutic agents. Here you can read everything you need to know about brain tumors.

ICD codes for this disease: ICD codes are internationally recognized codes for medical diagnoses. They can be found, for example, in doctor's letters or on certificates of incapacity for work. D43C71D33

Brain tumor: description

The term brain tumor refers to any benign and malignant growth within the skull. In comparison to colon, lung, breast cancer or other cancers, brain tumors are relatively rare. In 2010, according to cancer registry data from the Robert Koch Institute, around 2,900 women and 3,800 men in Germany developed a brain tumor. In both sexes, most illnesses were recorded between the ages of 70 and 75. About 100 female and 200 male patients were under 20 years of age.

When compared to other cancers, a brain tumor is relatively common in children. According to the Children's Cancer Registry, around a quarter of childhood cancers can be traced back to tumors of the central nervous system.

Not all brain tumors are created equal. On the one hand, as mentioned, there are both benign and malignant forms of brain tumors (“brain cancer”). In addition, a distinction is made between primary and secondary brain tumors: Primary brain tumors

Primary is a brain tumor that develops directly from cells of the brain substance or the meninges. Such tumors are also known as the brain's own tumors.

Often, primary brain tumors also include tumors that originate from a cranial nerve. Most of the cranial nerves are located in the skull, but they are not part of the central nervous system (CNS: brain and spinal cord), but rather the peripheral nervous system. If a tumor in the head originates from a cranial nerve, it is actually a new formation in the peripheral nervous system.

The primary brain tumors are further subdivided according to various criteria. The World Health Organization (WHO) divides the individual tumors according to the tissue from which they originate and the extent to which the brain tumor is malignant or benign. This distinction influences both brain tumor treatment and prognosis. Interestingly, only a small fraction of brain tumors originate from nerve cells (neurons). More than every second primary brain tumor develops from the supporting tissue of the brain and thus belongs to the group of gliomas. The following table gives an overview of the most important brain tumors:

Gliomas	They originate from the supporting cells of the CNS. These include, for example, astrocytoma, oligodendroglioma and glioblastoma.
Ependyoma	This brain tumor is formed from cells that line the inner chambers of the brain.
Medulloblastoma	The medulloblastoma forms in the cerebellum. It is the main brain tumor in children.
Neurinoma	This tumor originates from cranial nerves. It is also known as a schwannoma.
Meningioma	This brain tumor develops from the meninges.
CNS lymphoma	CNS lymphoma is formed from a group of white blood cells.
Germ cell tumors	Germ cell tumors include germinoma and chorionic carcinoma.
Sella region brain tumor	These tumors are found in a specific place in the brain, the sella turcica. This is usually where the pituitary gland is located. They include the pituitary adenoma and the craniopharyngioma.

Individual brain tumors are more common than others in each age group. Among the primary brain tumors in adults, the most common are gliomas, meningiomas, and pituitary tumors. If a child develops a brain tumor, it is usually a medulloblastoma or a glioma.

Secondary brain tumors

Secondary brain tumors are much more common than primary brain tumors. They arise when cells from other organ tumors (for example lung cancer, skin cancer, breast cancer) get into the brain and form a daughter tumor here. So these are brain metastases. Some experts do not even consider you to be a “real” brain tumor.

In the case of brain metastases, a distinction is made between settlements in the brain tissue (parenchymal metastases) and those in the meninges (meningiosis carcinomatosa).

Brain tumor: symptoms

You can read everything you need to know about possible signs of a brain tumor in the article Brain tumor - symptoms.

Brain tumor: causes and risk factors

So far it is largely unknown why a primary brain tumor forms. For most of those affected, no triggering factor can be found. If the causes of a brain tumor are not known, experts also speak of a sporadic brain tumor.

In contrast, there is also a hereditary brain tumor. It can develop in certain hereditary diseases such as neurofibromatosis, tuberous sclerosis, von Hippel-Lindau syndrome or Li-Fraumeni syndrome. However, these diseases are extremely rare. Only a small proportion of brain tumors can be traced back to one of these clinical pictures.

CNS lymphomas are more likely to develop in people with a severely weakened immune system, for example due to HIV or the use of immunosuppressants to prevent rejection reactions after an organ transplant.

Otherwise, the only known risk factor for a brain tumor is radiation to the nervous system. It is used for life-threatening diseases such as acute leukemia. Overall, however, very few people develop a brain tumor after brain radiation. By the way, ordinary X-ray examinations do not cause a brain tumor.

Secondary brain tumors, i.e. brain metastases, form when cancer is present in the body. If there are risk factors for a specific cancer, the risk of brain metastases also increases. However, not every malignant tumor spreads to the brain.

Brain metastases

You can read more information on the subject in the article Brain Metastases.

Brain tumor: examinations and diagnosis

The right contact person for a brain tumor is a specialist in neurology (neurologist). In order to be able to carry out the correct diagnostic steps, he must collect your medical history precisely (anamnesis). He asks about your exact complaints, any previous illnesses and medical treatments. Possible questions are, for example:

• Do you suffer from new headaches (especially at night and in the morning)?
• Does the headache increase while lying down?
• Can conventional headache relievers help you?
• Do you suffer from nausea and vomiting (especially in the morning)?
• Do you have visual disturbances?
• Have you had a seizure? Did one half of your body twitch involuntarily?
• Did or do you have problems moving or coordinating a part of the body?
• Did you have or do you have trouble speaking?
• Do you notice limitations when trying to concentrate, memorize, or understand something?
• Have new hormonal disorders occurred?
• Do your family members or friends think that your personality has changed?

After that, the doctor will conduct a neurological exam. It tests muscle reflexes, muscle strength and coordination. He also tests whether the cranial nerves are working properly, for example by asking you to frown or by shining your eyes in order to test the pupillary reflex. He also checks your field of vision and examines the fundus with an examination light.

This can be followed by further examinations such as computed tomography (CT), magnetic resonance imaging (magnetic resonance imaging, MRI), electroencephalography (EEG) and nerve fluid examination. If these examinations indicate a brain tumor, it may be necessary to take a tissue sample (biopsy) for more detailed clarification.

If your neurologist suspects that your symptoms are caused by brain metastases, the underlying cancer must be diagnosed. To do this, depending on your suspicion, you may be referred to another specialist (such as a gynecologist or gastroenterologist).

CT and MRI

With CT, the patient is pushed into the examination tube on a couch, where the brain is x-rayed. On the computer you can then see the brain structures on individual cross-sectional images. This procedure is particularly good for recognizing bleeding and calcification.

In the past few years, an MRI has been performed more and more frequently if a brain tumor is suspected. This examination is also carried out in an examination tube. It takes longer than a CT scan, but does not use X-rays. Instead, images of the body are made using magnetic fields and electromagnetic waves. The representation is often even more detailed than with the CT.

Sometimes both procedures are carried out one after the other. Both examinations are not painful. However, some patients find the narrow tube and the high noise level uncomfortable.

Measurement of electrical brain waves (EEG)

If you have a brain tumor, the electrical currents in the brain may be changed. So an electroencephalogram (EEG) that records these currents can be very insightful. To do this, small metal electrodes are attached to the scalp and connected to a special measuring device with cables. Now the brain waves can be diverted at rest, during sleep or under light stimuli. Based on the results, a brain tumor can be differentiated from a convulsive disorder, for example. In addition, the EEG can often be used to determine the origin of a brain change. This procedure is neither painful nor harmful, making it particularly popular for examining children.

Nerve fluid examination (liquor puncture)

A nerve water puncture may be necessary to rule out changes in the cerebral water pressure (CSF pressure) or meningitis. In addition, cells that have been changed by a brain tumor can be detected in the nerve water.

Before this examination, the patient is usually given a sedative or light sleeping pill. General anesthesia is usually performed on children. Then the lumbar area on the back is first disinfected and covered with sterile cloths. A local anesthetic is first injected under the skin so that the patient does not experience any pain during the puncture. The doctor can then push a hollow needle into a CSF reservoir in the spinal canal. In this way, he can determine the CSF pressure and take some CSF for a laboratory test.

The spinal cord cannot be injured during this examination because a point below the end of the spinal cord is chosen as the puncture site. Most people find the examination uncomfortable but bearable, especially since the CSF puncture usually only takes a few minutes.

Taking a tissue sample

To classify a brain tumor, a sample of tissue must be taken and examined under a microscope. This can be done either through open brain tumor surgery or a stereotactic surgical technique.

In open brain tumor surgery, the patient is placed under general anesthesia. The roof of the skull is opened and the tumor structures are visited. This procedure is usually chosen when the brain tumor is to be completely removed in the same operation. Then the entire tumor tissue can be examined under the microscope. Further treatment often depends on the result.

Stereotactic surgery, on the other hand, is almost always performed under local anesthesia so that the patient does not feel any pain. Its head is fixed in a scaffold for taking samples. An imaging procedure is used to determine exactly where the tumor is in the head. A small hole is then drilled into the skull at a suitable point (trephination), through which the surgical tools can be inserted: the biopsy forceps can be guided to the brain tumor under computer control and a tissue sample can be removed in a targeted manner.

Brain tumor: treatment

Not every brain tumor is treated the same. Basically, a brain tumor can be operated on, irradiated or given chemotherapy. But these three options can also be implemented in very different ways or combined with one another.

Which brain tumor treatment is suitable in each individual case depends on the type of tissue, the cell change and molecular biological characteristics. Of course, it is also taken into account how advanced the clinical picture is and what wishes the person concerned expresses. Not all therapy options are suitable for every patient, but there are usually alternative treatment measures.

Brain tumor: surgery

A brain tumor operation can have different goals. Some brain tumors can be completely removed by surgery. In other cases, surgery can only shrink the tumor. However, this can sometimes alleviate the symptoms and improve the prognosis, because the tumor reduction creates better conditions for subsequent treatments (radiation therapy, chemotherapy).

Surgical intervention in brain tumor patients can also aim to compensate for a tumor-related disturbance of the drainage of the nerve water. Because if the liquor cannot flow away undisturbed, the pressure in the brain increases, which results in serious complaints. In an operation, a shunt can then be implanted, for example, which drains the cerebral fluid into the abdominal cavity, for example.

Most of the time, an open brain tumor operation is performed under general anesthesia: the head is fixed to a metal frame. After the skin has been severed, the skull bone can be sawed open and the hard meninges opened. The brain tumor is found and operated under a special microscope. Some patients are given a fluorescent agent that is absorbed by the brain tumor before surgery. During the operation, the tumor then glows under a special light. This makes it easier to distinguish it from the surrounding healthy tissue.

If the tumor is in the vicinity of important brain centers, these are monitored by special examinations. For example, sensitive and motor functions or the auditory pathway should be protected. The language center can only be monitored if the operation is performed under local anesthesia. Sometimes the operation is interrupted in order to check the success of the operation using imaging (CT, MRI).

After the operation, bleeding is stopped and the wound closed. The patient is first transferred to a monitoring station until his condition is stable. In the further course of the procedure, imaging is usually initiated again in order to check the result of the operation. In addition, patients usually receive a cortisone preparation for a few days after the operation. It is supposed to prevent the brain from swelling too much.

Brain tumor: radiation

Some brain tumors are treated with radiation therapy only. For others, this is just one of several treatment measures.

During irradiation, brain tumor cells should be destroyed, but neighboring healthy cells should be spared as far as possible. In general, it is not possible to determine only the brain tumor. Thanks to good technical possibilities, however, it can be calculated very well with prior imaging which area is to be irradiated. The irradiation takes place in several individual sessions because this improves the result. In order not to have to redefine the tumor area for each session, individual face masks are made. This means that the patient's head can be brought into exactly the same position each time for the irradiation.

Side effects can occur with radiation therapy. For example, the skin over the irradiated area can redden. Headaches and nausea also occur. The doctor will explain possible side effects and how to deal with them before radiotherapy.

Brain tumor: chemotherapy

Special cancer drugs (chemotherapeutic agents) are used to kill brain tumor cells or stop them from multiplying. If chemotherapy is carried out before the operation (to shrink the tumor), it is called neoadjuvant chemotherapy. If, on the other hand, it follows the surgical removal of the brain tumor (to kill remaining tumor cells), experts refer to it as adjuvant.

Different drugs are suitable for the different types of brain tumors. Some brain tumors also do not respond to chemotherapy drugs at all and must therefore be treated with another therapy.

In contrast to other cancers, with a brain tumor, chemotherapeutic agents first have to cross the blood-brain barrier in order to reach their destination. In individual cases, the chemotherapeutic agents can also be injected directly into the spinal canal. They then enter the brain with the nerve water.

As with radiation therapy, chemotherapy drugs also target healthy cells. This can cause certain side effects, such as a disorder of blood formation. The side effects that are typical of the medication used in each case are discussed in a doctor's consultation prior to treatment.

Brain tumor: supportive therapy

The term “supportive therapy” summarizes all measures that support the patient during his illness. It does not fight the tumor directly, only the symptoms caused by it or the treatment (such as chemotherapy). For example, headaches, increased intracranial pressure, vomiting, nausea, pain, infections or blood changes can be treated with medication. Psycho-oncological care can also be part of supportive therapy: It is intended to support patients and their relatives in dealing with the serious illness.

Brain tumor: disease course and prognosis

Each brain tumor has a different prognosis. The course of the disease and the chances of a cure for a brain tumor depend very much on how the tissue of the tumor is structured and how quickly it grows. As a guide for doctors and patients, the WHO has developed a severity classification for tumors. There are a total of four degrees of severity, which are mainly defined by the tissue examination:

• Grade I: Benign brain tumor with slow growth and a very good prognosis
• Grade II: Benign brain tumor, which can turn into a malignant one
• Grade III: Malignant brain tumor
• Grade IV: Very malignant brain tumor with rapid growth and poor prognosis

This classification is not only used to estimate the personal chances of a cure for a brain tumor. It also determines how a brain tumor is treated. For example, a first-degree brain tumor can usually be cured with brain tumor surgery. A second-degree brain tumor can return after surgery. With WHO grade III or IV, the chances of a cure for a brain tumor are so poor that radiation and / or chemotherapy is always recommended after an operation.

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