Surveillance/watching

o Surveillance, observation or watching, with or without surgery, is something that can be utilized in treatment for both benign and malignant brain tumors. 

o For a benign tumor it is often possible to eliminate, or postpone, treatment and instead watch the tumor closely. This may be an option if a tumor is believed to be benign, small, growing slowly, and is not causing symptoms. 

o Surveillance alone may also be recommended for people who are older and/or those who have other serious medical problems making other interventions, such as surgery, too risky. 

o A malignant brain tumor most probably will require further treatment to insure that after the tumor is removed any remnants of the tumor, or tumor cells that might have been unseen, will be exposed to chemotherapy and/or radiation to essentially destroy them and to discourage new growth. Surveillance will be utilized in this case to watch for any signs of tumor recurrence or growth that might require further intervention. 

o Surveillance or monitoring can be in the form of an MRI or CT scan to observe the brain and any changes involving possible tumor growth that may, or may not, occur over time. The time intervals for surveillance imaging will be decided upon by your doctor (neurosurgeon or neuro-oncologist) based on the type of tumor you have and your treatment so far. An example would be: having imaging done three to six months after the first brain scan, then once per year. If the tumor remains stable the interval time may increase. In addition, if the tumor remains unchanged surveillance alone may be all that is required yet if the tumor begins to grow or cause symptoms, treatment may be recommended.

Having Surgery

Having surgery at YNHH begins with a complete evaluation, subsequent detailed discussion and ultimately a mutual decision between patient and physician. Though there are several types of brain surgery that are utilized for various reasons, the most common types used for a known brain tumor are craniotomy and biopsy. A craniotomy involves an incision into the scalp and creating a hole in the skull, known as a bone flap. The incision and bone flap are made closest to the area of the tumor. The goal of a craniotomy is to remove all, or as much of the tumor as possible. When the procedure is complete, the bone flap is usually secured in place with plates and small screws followed by sutures, or staples. In some cases, such as infection or brain swelling, the bone flap may not be replaced before closing the incision. A biopsy is a procedure used to remove a small amount of tumor tissue so it can be examined under a microscope. Similar to a craniotomy, this too requires an incision and hole in the skull, though it is usually smaller. A biopsy may be utilized instead of a craniotomy when it is known that the tumor is not able to be removed completely but information about the tumor is important in determining treatment. Stereotactic radiation such as Gamma Knife, may also be performed. This type of radiation uses narrow beams that are delivered from multiple angles. This allows a very high dose of radiation to be delivered to a small spot. Stereotactic radiosurgery is given as a single or limited number of treatments to small tumors. It is not technically surgery that involves an incision, yet requires placement of a device on the head that allows for very accurate delivery of the radiation with no movement from the patient. With this in mind, some clinicians may use a mild sedative for the procedure. 

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Before Surgery

  • As the process unfolds the patient is scheduled to be seen in Pre-Admission Testing or PAT. PAT is our anesthesia department's way of preparing both the anesthesiologist and the patient for surgery. During the visit Chest X-ray, EKG, blood work and any other testing related to the patient’s tolerance of anesthesia will be performed. The majority of the visit is spent with the patient and an anesthesia doctor or nurse practitioner having a discussion about the patient's past medical history and being told what to expect on the day of surgery. The anesthesiologist may also require a note from the patient's PCP (Primary Care Physician) or any other specialists the patient may see such as cardiologist or pulmonologist. All of the necessary information will be obtained and organized by the PAT department in conjunction with the surgeon. 
  • Patients are usually admitted to the hospital directly to the peri-operative area on the day of surgery. Occasionally a patient may need to be admitted to the hospital before surgery but this is not the usual. Because admission for surgery occurs on the day of the procedure careful attention is paid to giving patients very clear instructions on how to prepare. These instructions range from which medications to stop, which to take (some are even taken on the morning of surgery), when to stop eating and drinking and what time to arrive at the hospital. Each patients needs are different and because of that the instructions they are given are individualized and communicated clearly. 
  • Needless to say, approaching surgery can be daunting and we at YNHH pride ourselves in taking you through the process carefully with clear instructions, plenty of opportunities to ask questions and excellent communication before, during and after. We are also intent upon keeping the patient's family/friends/support team in the loop. 
  • Surgery lengths can last from 2 to 8+ hours depending on the size and location of the tumor. Patients are routinely sent directly to the ICU (intensive care unit) directly after surgery for approximately 24 hours. Hospital stay is usually 2 to 5 days depending on the patient's individual needs. OR (operating room), ICU (intensive care unit) and post ICU floors are staffed with employees who have been specifically trained in neurosurgery medicine. 

During Surgery

During
  • If a tumor is suspected to be malignant, or benign yet large, symptomatic or fast growing, then surgery is preferred and usually recommended. Removing as much of the tumor as possible is optimal, however, it is not always possible. Some tumors cannot be totally removed if it is too close to or involved with blood vessels, nerves or parts of the brain that control important body functions. In these cases, the tumor may be removed partially. 
  • After surgery, it is also possible that the tumor may come back. This is largely dependent on how much tumor was removed and whether it was benign, atypical, or malignant. If the tumor is not removed completely with surgery, radiation therapy is often recommended after surgery to diminish the risk of it coming back 
  • Complications of surgery include bleeding, damage to normal brain tissue and infection. Potentially serious complications can include: 
  • Cerebral edema or fluid accumulation in the brain can occur and is usually temporary. Steroids are usually given intravenously, before, during and after surgery to avoid this problem. 
  • Some people enter into surgery having already had a seizure and about 20 percent of people who did not have seizures before surgery will develop them afterward. Anti-seizure medication is often recommended after surgery, and is slowly discontinued afterward if seizures do not occur. 
  • Some people may develop neurologic symptoms after surgery, such as muscle weakness, hearing or speech problems, dizziness or difficulty with coordination. These symptoms depend on where the tumor was located. They will often resolve after a few weeks 
  • People who have brain tumors, and brain surgery itself, are at an increased risk of forming blood clots in the veins (deep venous thrombosis (DVT)) and/or lungs (pulmonary embolism(PE)). As a result, treatments to prevent blood clots are recommended during and after surgery. Certainly people who have had blood clots prior to the diagnosis of a brain tumor will receive specialized pre and post-operative treatment in this area. 

After Surgery

  • Brain surgery, as with any type of surgery, requires time to recover. Recovery is different for everyone and depends on: the location of the tumor within the brain, areas of the brain affected by the surgery, the patient’s age and overall health 
  • Prior to Discharge from the Hospital you will be seen by the following: 
  • Physical therapists will assess and, if necessary, help the patient to improve their ability to walk safely and climb stairs before being released from the hospital. They may also help the patient improve strength and balance. 
  • Occupational therapists will assess the patient’s ability to perform more detailed activities involved in "real life" such as getting dressed, using the bathroom and daily personal hygiene. 
  • Speech language pathologists will assess and, if necessary, help improve problems with speech, language or thinking. They are also able to assess patients who may have problems with swallowing. 
  • While care delivered by physical therapists, occupational therapists, speech pathologist and nurses are available in all in-patient rehabilitation facilities they can also be arranged for home visits as well. 
  • All inpatient units at YNHH have a care coordinator who will assist the patient and their caregivers with OT, PT, VNA, rehabilitation or any other special needs the patient may require for their recovery. 
  • Most patients are discharged to home and in some cases may require additional care. Brain tumors as well as surgery for brain tumors can occasionally result in problems with thoughts, behavior and physical abilities. OT (occupational therapy), PT (physical therapy), speech therapists, VNA (visiting nurses) are available to assist them in transitioning to healing after discharge. 
  • Occasionally some patients may require additional care that is unable to be accomplished at home. If this is necessary, the patient can be admitted to an in-patient rehabilitation facility for a short time to insure their safe and effective recuperation. 
  • At the time of discharge from the hospital, the patient and his/her caregivers will be provided with detailed written and verbal instructions about the transition to care at home. The instructions include care of their incision, prescriptions for medications, appointment for a post-operative examination with the surgeon and telephone numbers for any questions or concerns that may emerge after discharge.

Radiation

Radiation therapy may be utilized in conjunction with surgery or alone. 

When utilized with surgery it is typically done after surgery if the tumor is not able to be completely removed. It’s purpose is not to remove the tumor, or tumor remnant, but to stop it from growing. Radiation therapy after surgery is usually started after the person has fully recovered. 

Radiation therapy may also be recommended alone if surgery is not possible or in specific cases when surgery is not desired. 

Radiation therapy uses high energy x-rays to damage tumor cells thus causing them to stop or slow growth. The radiation is carefully aimed at the area of the brain where only tumor tissue is located. If surrounding normal brain cells are exposed to radiation they are more likely than tumor, or abnormal cells, to recover because they are able to repair themselves after radiation exposure. The area of the brain to be treated is very carefully calculated to expose the largest amount of tumor cells to radiation and subsequent damage while minimizing radiation exposure to the normal brain tissue. 

There are different ways to deliver radiation therapy and decisions regarding the type of treatment should be made by a radiation oncologist. Decision making is based on aspects of the tumor such as size, location, symptoms, potential side effects of treatment, the patient's general health, and prior treatments if any. 

o Types of radiation treatments: 

  • Fractionated radiation therapy treatment is given in multiple small doses. It is performed five days per week for five to six weeks, and each treatment lasts only several seconds. Receiving radiation is not felt by the recipients, much like having an x-ray. 
  • Stereotactic radiation such as Gamma Knife may also be performed. This type of radiation uses narrow beams that are delivered from multiple angles. This allows a very high dose of radiation to be delivered to a small spot. Stereotactic radiosurgery is given as a single or limited number of treatments to small tumors. It is not technically surgery that involves an incision, yet requires placement of a device on the head that allows for very accurate delivery of the radiation with no movement from the patient. With this in mind, some clinicians may use a mild sedative for the procedure. 

o Side effects of radiotherapy: 

  • Radiation therapy cannot stop all tumor cells from growing without the possibility of damaging nearby normal brain tissue. Fortunately, side effects are not usually serious or life-threatening. 
  • During fractionated radiation treatment, hair loss will occur and it usually occurs only in areas that are treated; this may be temporary or permanent. 
  • Mild fatigue is common and often does not develop until the last few weeks of radiation treatment; this is temporary. Mild skin redness or irritation may occur and is temporary. Headaches and nausea occur infrequently during radiation therapy, and can be treated if needed. 
  • Stereotactic radiosurgery is usually tolerated with minimal or no symptoms. The most common possible symptoms are mild fatigue and mild headaches, both of which are temporary.

Chemotherapy

Chemotherapy is a name for chemical substances that come in the form of pills or injections which can be placed into an artery, vein, muscle, or the skin. It is used to treat many diseases, especially cancer. The goal of chemotherapy is to stop the growth of a tumor. It is typically used to treat malignant or higher grade tumors, but may also be used to treat low grade and benign tumors anywhere in the body. 

Chemotherapy may occasionally be recommended for the treatment of a brain tumor. It is only effective in treating some types of brain tumors and, as with any decision made about your care, your doctor will decide which methods are available and appropriate for you in particular. He/she will then discuss your options so you will be able to make the best decision for your care. 

Types: there are two main types of chemotherapy drugs: 

  • Drugs that kill cancer cells (cytotoxic drugs) are the most commonly used. They are called systemic therapy because the drug travels throughout the body and usually reaches all cells, both cancer and normal. 
  • Drugs that prevent cancer cells from reproducing (cytostatic drugs) are a newer type of chemotherapy. They are called targeted therapy because they identify and attack cancer cells with the smallest amount of harm to normal cells. 

The type of chemotherapy, the doses and timeframe for your treatment depends on the type of tumor being treated as well as your overall health. This will be decided by your doctor. 

Chemotherapy can be given alone and without any other treatment, along with radiation therapy, or before or after surgery. This decision is based on the type of tumor and its location. 

Side Effects: 

  • Chemotherapy drugs have the greatest effect on cells that reproduce rapidly. Tumor cells reproduce rapidly, as do some other cells in the body, therefore the drugs cannot always tell the difference between tumor cells and healthy cells. The side effects that might be noticed from chemotherapy are directly related to rapidly reproducing cells. Some of them include: vomiting, diarrhea, fatigue and harm to a pregnancy 

After your doctor has decided your type and dose of chemotherapy he/she will provide more information about what you in particular might expect.