A brain tumor is a collection of abnormal cells in the brain. Symptoms depend on the tumor's size, type, and location and may include headaches, nausea, vomiting, vision changes, and more. Diagnosis involves imaging tests like CT scans and MRIs. Treatment options include surgery to remove the tumor, chemotherapy, and radiation therapy. The goals of surgical removal are to confirm diagnosis, remove as much of the tumor as possible, relieve pressure in the brain, and provide access for additional treatments.

1. BRAIN TUMOR
Mrs. A. Sarmila.,Msc (N),
Associate Professor
SRM Trichy College of Nursing

2. Introduction
• Brain
• protected within the skull,the brain is composed of the cerebrum,
cerebellum, and brainstorm.
• The brain controls our thoughts, memory and speech, movement of the arms
and legs, and the function of many organs within our body.
• The central nervous system (CNS) is composed of the brain and spinal cord.
• Tumor
• A tumor is a mass of tissue that’s formed by an accumulation of abnormal
cells.
• Normally the cells in body die,and are replaced by new cells.
• Tumor cells grow, even though the body does not need them, and unlike
normal old cells, they don’t die.

3. Definition of brain tumor
• A brain tumor is a collection, or mass, of
abnormal cells in brain.
• Skull,which enclose the brain, is very
rigid, any growth inside this
restricted place can cause problems.
• when these tumors grow inside the
brain it increase intra cranial pressure
,seizure, hydrocephalus, altered
pituitary function, which can cause
brain damage and may be even life
threatening.

4. Incidence
Acccording to American brain association there are 100 types of brain tumor with
estimate annual occurence of 78,000 new cases.
Developed countries have a higher incidence of primary tumor with rates of 5.1 /
100,000 population compared 3.0/ 100,000 population in developed countries.
In india
• The incidence of CNS tumor in india ranges from 5 to per 100,000 population
with an increasing.
• Brain and central nervous system tumors are also the second most common
cancer in children, about 26% of childhood cancer.
Brain tumour occurs in fifth through seventh decades

5. Cause of brain tumor
• The exact cause is unknown.
• Family history.
• Immuno suppression.
• Exposure to high dose of ionizing radiation.

6. Types of tumor
• The WHO first published a universal classification system for CNS
tumor in 1979.
• Tumors were classified into 2 categories:
1. Primary Brain Tumors .
2. Secondary Brain Tumors.

7. Primary Brain Tumor
• Primary tumor orginates in the CNS.
• These tumors can be Benign or Malignant.
• Benign brain tumors do not contain cancer cells:
• The least aggressive type of brain tumor is often called a Benign brain tumor.
• Usually benign tumor can be removed and the rarely grow back.
• They did not spread to other part of the body.
• Benign brain tumor have an obvious border or edge.
• Some benign tumor can progress to become malignant.

8. • Malignant brain tumor (also called Brain Cancer) contain cancer cell:
• More serious and life threatening because they grow rapidly and
invade surrounding brain tissue.
• Often do not have clear borders.
• Although malignant brain tumor very rarely spread to other areas
of the body, they can spread throughout the brain or to the spine.

9. Types of primary brain tumor
• There are many types of primary brain tumor.
• They are named according to the types of cell or the part of the brain.
• Eg:most primary brain tumors begins in glial cell and are called glioma.
1. Gliomas.
2. Astrocytomas.
3. Glioblastoma multiforme.
4. Oligodendrogliom.
5. Ependymoma.
6. Medulloblastomas.
7. Meningiomas.
8. Pituitary adenomas.
9. Schwannomas.
10. Primary CNS lymphoma.

10. Secondary brain tumor
• Secondary brain tumor also called as Metastatic Brain Tumor .
• It’s orginates from malignancies outside of the CNS and spread to the
brain , typically through arterial circulation .
• It spread from lung, Breast, skin, GI tract, kidney.
• Frontal lobe is the most common site.

11. Classification of Brain tumors
I.Intracerebral tumor
A. gliomas
1. Astrocytomas
2. Glioblastoma
3. Oligodendroglioma
4. Ependymoma
5. Medulloblastoma
II. Tumor arising from supporting structures
A. Menigiomas
B. Neuromas (acoustic Neuroma, schwannoma)
C. Pituitary adenoma
III. Developmental tumor
A. Angiomas
B. Dermoid, epidermois, teratoma, craniopharyngioma
IV. metastatic

12. A. Gliomas – infiltrate any portion of the brain, most common type of brain tumor
A. Astrocytoma – arising from the astrocyte cells, glial cell, supportive tissues.Most
common types of glioma. Can range from low grade to moderate grade
malignancy.
B. Glioblastoma – origin from primitive stem cell. Highly malignant and invasive
among the devastating of primary brain tumors.
C. Oligodendroglioma – arising from Oligodendroglial cells. Represents 10 to 15%
of glioma. It occurs in adults age of 50 to 60 years more found in men. Benign
(encapsulation and calcification.
D. Ependymoma – arises from ependymal epithelium. Range from benign to highly
malignant. Most are benign and encapsulated.
E. Medulablastoma – primitive neuroectodermal cells. Highly malignant and
invasive, metastatic to spinal cord and remote area of brain.
Classification of Brain tumors

13. Menigiomas – are common benign encapsulated tumor of arachnoid cells on the
méningus. They are slow growing, occur most often middle age adults and are
more common in women. It most often occur in area of proximal to the venous
sinuses. Manifestation depends on area of compression rather than invasion of
brain tissue.
Acoustic neuroma (schwannoma) – it is a tumor of eight cranial nerve it is most
responsible for hearing and balance. It usually arise just within the auditory
meatus, where it frequently expand before filling the cerebellopontine recess. It
grow slowly and attain considerable size before it diagnosed. The patient usually
experiences loss of hearing, tinnitus, and episodes of vertigo and staggering gait.
Tumor become larger, painful sensations of the face may occur on the same side
as a result of tumorcompression of fifth cranial nerve.
Classification of Brain tumors

14. Pituitary adenoma – it account for 16% of all brain tumors. It can occur at any age,
but more common in older adults. Women are affected especially during
childbearing years. It rarely malignant. Symptoms are due to pressure or
hormonal changes
Pressure effects – pressure may exerted on the optic nerves, optic chiasm, or optic
tract or on the hypothalamus or third ventricle if tumor invades the cavernous
sinuses or expand into the sphenoid bone. These pressure effects produce
headache, visual dysfunction, hypothalamic disorders (disorder of sleep, appetite,
temperature and emotionals), increased ICP, and enlargement and erosion of
sella turcica.
Hormonal effects – hormonal hyper secretions produced pituitary adenomas. It
secrete an excess amount of hormone including prolactin (prolactinomas),
growth hormone producing acromegaly, adrenocorticotropic hormone resulting
in cushing syndrome. Adenomas that secrete TSH or follicle stimulating hormone
and lutinizing hormone infrequently.
Classification of Brain tumors

15. Hemangioblastoma – origin in the blood vessels of the brain. Rare and benign.
Surgery is curative.
Primary central nervous system lymphoma – arises in lymphocytes. Increase
incidence in transplant recipients and acquired immunodeficiency syndromes
patients.
Metastatic tumors – it is malignant. Metastatic from lungs, breast, kidney, thyroid,
prostate.
Classification of Brain tumors

16. TUMOR GRADING
The World Health Organization (WHO) has created a standard by which
all tumors are classified.
• Lower grade tumors (grades I & II) : are not very aggressive and are
usually associated with long-term survival.
• Higher grade tumors (grade III & IV) : grow more quickly, can cause
more damage, and are often more difficult to treat. These are
considered malignant or cancerous.

17. Grade I Tumor
• Slow-growing cells.
• Almost normal appearance under a microscope.
• Usually not cancer.
• Associated with long-term survival.
• Can potentially be cured with surgery.
Grade II Tumor
• Relatively slow-growing cells.
• Slightly abnormal appearance under a microscope.
• Can invade adjacent normal tissue.
• Can recur as a higher grade tumor.
TUMOR GRADING

18. Grade III Tumor
• Actively reproducing abnormal cells.
• Abnormal appearance under a microscope.
• Infiltrate adjacent normal brain tissue.
• Tumor tends to recur, often as a higher grade.
Grade IV Tumor
• Abnormal cells which reproduce rapidly.
• Very abnormal appearance under a microscope.
• Form new blood vessels to maintain rapid growth.
• Areas of dead cells (necrosis) in center.
TUMOR GRADING

19. Pathophysiology
(Monrokellies Hypothesis)
Fast Growing Tumor
Increased ICP( intracranial pressure)
Reduction in volume of the blood and CSF

20. • Initial compensatory mechanism
Displacement of CSF in to spinal cord and subarachnoid space
Impairment of venous drainage
Venous congestion

21. • Secondary compensatory mechanism
Reduction in blood volum
Hypoxia
Ischemia

22. Tumor growth
Compression of vein increased venous pressure
Dressed absorption Increased capillary
Of CSF permeability
cerbral edema

23. • Last stage of compensation
increased ICP
Displacement of the brain tissue
Death.

24. Signs and symptoms
• The symptoms of the brain tumor depend on tumor size, type and location.
• Common symptoms
Increased intracranial pressure
Headache
Nausea and vomiting.
Papilledema.
Personality changes and variety if focal defictsincluding motor, sensory, and
cranial nerve dysfunction
Headache
 usually worse in the morning ) and is made worse by coughing, straining, or
sudden movement.
Deep, expanding, dull but unrelenting
Frontal tumor – bilateral frontal hedaache
Pituitary gland tumors produce radiating pain between two temples
Cerebellar tumor – suboccipital region at the back of head

25. • Vomiting
• – projectile vomiting, headache relieved after vomiting
• Visual disturbances – diplopia, hemianopia, papilledema, blindness
• Changes in mood , personality, or ability to concentrate.
• Problems with memory.
• Numbness or tingling in the arms or legs.
• Problems in coordination (balancing or walking).
• Changes in speech, vision or hearing.
• Changes in Mental status.
• Seizures – result of structural or metabolic cause. It may be focal or general.
Signs and symptoms

26. Based on tumor locations
Frontal lobe – unilateral hemiplegia, seizures, memory deficit, personality and
adjustment changes, visual disturbances, ataxic gait.
Parietal lobe – speech disturbances, inability to write, spatial disorders
Occipital lobe – vision disturbances, seizure
Temporal lobe- seizure, dysphagia
Subcortical – hemiplegia
Menigeal tumors- symptoms associated with compression of brain and depends on
tumor location
Signs and symptoms

27. Based on tumor locations
Metastatic – headache, nausea, vomiting, of increased ICP
Thalamus and sellar tumors – headache, nausea, visiual disturbances,
papillaedma, nystagmus occurs from increased ICP, diabetes insipidus
Fourth ventricle and cerebellar tumor – headache, nausea, papilledema, ataxic
gait,change in co ordination
Cerebellopontine tumors – tinitus, and vertigo, deafness
Brainstem tumors – headache on awakening drowsiness, vomiting, ataxic gait,
fascial muscle weakness, hearing loss, dysphagia, dysarthria, “crossed eye” or
other visual changes, hemiparesis.
Signs and symptoms

28. Diagnostic examination
• History collection
• Medical history including the specific signs and symptoms.
• Physical examination
• Neurological examination – Testing of reflexes , asses visual, sensory ,
and motor function.
• Computed Axial Tomography (CAT or CT Scan)
• It is a computerized x-ray that can show a combination of soft tissue,
bone, and blood vessels. Number , size, density of lesions and cerebral
edema

29. • Magnetic Resonance Imaging (MRI)
• It can create clear and detailed three-dimensional images of a brain tumor. To
detect the brain tumors particularly smaller lesions, tumors of the brainstem
and pituitary lesions.
• Magnetic Resonance Spectroscopy(MRI Spect or MRS),
• measures the levels of metabolites in the body.
• An MRS can detect irregular patterns of activity to help diagnose the type of
tumor, evaluate its response to therapies, or determine aggressiveness of a
tumor.
Diagnostic examination

30. • Perfusion MRI examines
• The flow of blood into the tisues to help assess the grade/aggressiveness of
tumors and differentiate a recurrent tumor from dead tumor tissue.
• Functional MRI (fMRI) tracks
• The use of oxygen and blood flow in the brain as patients perform tasks.
• An fMRI can identify the motor, sensory, visual and language centers of the
brain which helps your doctor carefully plan for surgery.
Diagnostic examination

31. • Positron Emission Tomography(PET)
• scan uses a radioactive substance to visualize hypermetabolic
activity such as with malignant cells, or abnormalities from a
tumor or scar tissue. PET is also used during brain mapping
procedures.
• Spinal tap (also called a lumbarpuncture),
• It uses a special needle placed into the lower back to measure
pressure in the spinal canal and brain and determine if there is an
infection or tumor cells.
Diagnostic examination

32. • Biopsy
• Surgical biopsy is performed to obtain tumor tissue as part of tumor
resection or as a separate diagnostic procedure.
• Sterotatctic biopsy is a computer – directed needle biopsy.
• This technique is frequently used with deep – seated tumor in
functionally important or inaccessible areas of the brain in oder to
preserve function.
• Laboratory examination
• ECG. Abnormal waves, to evaluate the temporal lobe seizure.
• Complete blood count.
• Audiometry and vestibular test.
• Endocrine test.

33. Management
• Medical management.
• Surgical management.
• Chemotherapy.
• Radiation therapy.

34. Medical management
Medical treatment only help to control the symptoms.
Antiseizure/Antiepileptic Drugs (AEDs)
• Antiseizure drugs treat and prevent seizures associated with pressure in
the brain from a tumor, from surgery, or from an irritating treatment.
Eg: phenytoin. 5 mg/kg/day orally in 2-3 divided doses, initially may
make dose adjustments no sooner than 7-10 day intervals. Maintenance
4-8 mg/kg/day orally not to exceed 300 mg/day
Valproic 10-15 mg/kg/day PO initially; may increase by 5-10
mg/kg/week to achieve optimal clinical response; not to exceed 60
mg/kg/day

35. Steroids.
• It’s used to reduce swelling and fluid build up (edema) around the tumor.
Eg :dexamethasone - 10 mg IV, then 4 mg IM q6hr until clinical improvement
is observed; may be reduced after 2-4 days and gradually discontinued over 5-
7 days
 Furosemide and Mannitol- Mannitol 0.5mg/kg and furosemide 0.5mg/kg IV
Medical management

36. The goals of surgical treatment for brain tumors are multiple and may
include one or more of the following:
• Confirm diagnosis by obtaining tissue that is examined under a microscope.
• Remove all or as much of the tumor as possible.
• Reduce symptoms and improve quality of life by relieving intracranial
pressure caused by the cancer.
• Provide access for implantation of internal chemotherapy or radiation.
• Provide access for delivering intra-surgical treatments, including
hypertherapy or laser surgery.
Surgical management

37. Surgical management
Craniotomy :
• To open the skull and remove the tumor .
• Sometimes only part of the tumor is removed if
it is near critical areas of the brain.
• A partial removal can still relieve symptoms .
• In case of menigioma, acoustic neuroma, cystic
astrocytomas of cerebellum, colloid cyst of
vebtricle, congenital tumor of dermoid cyst,
and some of granulomas.
• With improved imaging technology and
availability of microscope and microsurgical
instruments even large tumors can removed by
small craniotomy.

38. Craniotomy cont..
For patient with malignant glioma complete removal is not possible, but the
rational resection include relief of ICP, removal of any necrotic tissues, and
reduction of bulk tumor, which theoretical leave behind fewer cells to become
resistant to radiation or chemotherapy.
Types of Craniotomy
• Extended bifrontal craniotomy
• "Eyebrow" craniotomy (supra-orbital craniotomy)
• "Keyhole" craniotomy (retro-sigmoid craniotomy)
• Orbitozygomatic craniotomy
• Translabyrinthine craniotomy
Surgical management

39. Extended bifrontal craniotomy is a traditional skull base approach used to target
difficult tumors towards the front of the brain. It is based on the concept that it is
safer to remove extra bone than to unnecessarily manipulate the brain.
The extended bifrontal craniotomy involves making an incision in the scalp
behind the hairline and removing the bone that forms the contour of the orbits
and the forehead. This bone is replaced at the end of surgery. Temporarily
removing this bone allows surgeons to work in the space between and right
behind the eyes without having to unnecessarily manipulate the brain.
Brain tumors that may be treated
• Meningiomas
• Esthesioneurblastomas
• Malignant skull base tumors
Surgical management

40. Extended bifrontal craniotomy

41. • Supra-orbital craniotomy (often called "eyebrow" craniotomy) is a procedure
used to remove brain tumors. In this procedure, make a small incision within the
eyebrow to access tumors in the front of the brain or around the pituitary gland.
This approach is used instead of endonasal endoscopic surgery when a tumor is
very large or close to the optic nerves or vital arteries.
Benefits of supra-orbital “eyebrow”
• Less pain than open craniotomy
• Faster recovery than open craniotomy
• Minimal scarring
Brain tumors that may be treated
• Rathke's cleft cysts
• Skull base tumors
• Some types of pituitary tumors
Surgical management

42. Supra-orbital craniotomy ("eyebrow" craniotomy)

43. Retro-sigmoid craniotomy (often called "keyhole" craniotomy) is a minimally-
invasive surgical procedure performed to remove brain tumors. This procedure
allows for the removal of skull base tumors through a small incision behind the
ear, providing access to the cerebellum and brainstem. This approach to reach
certain tumors, such as meningiomas and acoustic neuromas (vestibular
schwannomas).
Benefits of "keyhole" craniotomy:
• Retro-sigmoid craniotomy results in:
• Less pain than an open craniotomy
• Faster recovery than an open craniotomy
• Minimal scarring
Surgical management

44. Retro-sigmoid craniotomy

45. Orbitozygomatic craniotomy is a traditional skull base approach used to target
difficult tumors and aneurysms. It is based on the concept that it is safer to
remove extra bone than to unnecessarily manipulate the brain.
The orbitozygomatic craniotomy involves making an incision in the scalp
behind the hairline and removing the bone that forms the contour of the orbit
and cheek. This bone is replaced at the end of surgery. Temporarily removing this
bone allows to reach deeper and difficult parts of the brain while minimizing
severe damage to the brain.
Brain tumors that may be treated with orbitozygomatic craniotomy include:
• Craniopharyngiomas
• Pituitary tumors
• Meningiomas
Surgical management

46. Orbitozygomatic craniotomy

47. Translabyrinthine craniotomy is a procedure that involves making an incision in the
scalp behind the ear, then removing the mastoid bone and some of the inner ear
bone (specifically, the semicircular canals which contain receptors for balance).
Finds and removes the tumor, or as much of the tumor as possible without risk of
severe damage to the brain.
When there is no useful hearing or hearing is to be sacrificed, the
translabyrinthine approach is often considered. During the translabyrinthine
craniotomy, the semicircular canals of the ear are removed in order to access the
tumor. Complete hearing loss occurs as a result of the removal of the semicircular
canals.
Although hearing is lost with the translabyrinthine craniotomy, the risk of
facial nerve injury may be reduced.
Surgical management

48. Translabyrinthine craniotomy

49. • Transphenoidal microsurgery This is the most common way to remove
pituitary tumors. Transsphenoidal means that the surgery is done through
the sphenoid sinus, a hollow space in the skull behind the nasal passages
and below the brain. The back wall of the sinus covers the pituitary gland.
Surgical management

50. Transphenoidal microsurgery
• A small incision (cut) along the nasal septum (the cartilage between the 2 sides of
the nose) or under the upper lip (above the teeth). To reach the pituitary, the
surgeon opens the boney walls of the sphenoid sinus with small surgical chisels,
drills, or other instruments depending on the thickness of the bone and sinus.
Small tools and a microscope are used to remove the tumor.
• Another approach is to use an endoscope, a thin fiber-optic tube with a tiny
camera at the tip. This way, the incision under the upper lip or along the nasal
septum isn't needed, because the endoscope allows the surgeon to see through a
small incision that's made in the back of the nasal septum. The surgeon passes
instruments through the nose and opens the sphenoid sinus to reach the
pituitary gland and take out the tumor. Whether this technique can be used
depends on the tumor’s position and the shape of the sphenoid sinus.

51. Transphenoidal microsurgery

52. TumorGlow: Surgical resection—whether it's a full or partial resection of a brain
tumor is now being aided by TumorGlow, a new form of intraoperative molecular
imaging (IMI) that uses a fluorescent dye that causes cancerous cells to glow
during surgery.
Hours before surgery, the patient receives an intravenous fluorescent dye
which moves through the patient’s system in and into the brain. Later, during
surgery, the tumors located by the dye take on a bright neon hue when exposed
to infrared lights. The malignant tissues therefore become more clearly
identifiable, ensuring that identify and remove as much of the tumor as possible.
TumorGlow is a great and safe alternative to ionizing radiation. TumorGlow
clinical trials are now enrolling.
Surgical management

53. Tumor Glow

54. Stereotactic surgery: The use of computers to create a three-dimensional image is called stereotaxy.
The purpose of this technique is to provide precise information about the location of a tumor and
its position relative to the many structures in the brain. Stereotaxy can be used to map out the
surgical procedure beforehand so that the they can “rehearse” the procedure or to allow the
radiation specialist to plan radiation therapy.
While conventional X-ray pictures depict tumors in two dimensions, stereotaxy provides
the third dimension—depth—by obtaining readings in both left to right and front to rear
directions, and then using a computer to analyze the information. It is the third dimension that
allows to accurately insert the needle for biopsy, the laser beam for vaporization, the scalpel for
cutting, or the suction device for aspiration.
Stereotactic surgical techniques are used to perform biopsies, remove tumors, implant
radiation pellets or other local treatments, or to provide a navigational system during surgery
(frameless stereotaxy). These techniques are particularly useful for reaching a tumor located deep
within the brain, such as the brain stem or thalamus. Stereotaxy can also help limit the extent of
surgery.
Surgical management

55. Stereotactic surgery

56. • Steriotaxy with a head frame involves placing the patient’s head in a rigid frame so the attached
scanning devices can accurately pinpoint the tumor location in three-dimensional space. The rigid
frame holds the patient’s head in place during the pre-surgical scans and the surgery itself. The
information from the CT and/or MRI scans, along with coordinate information from the
headframe, is entered into a computer system. The images produced, with their relational
coordinates, are used to plan the surgery and guide the surgeon’s tools during the procedure.
• Frameless steriotaxy utilizes an imaging hand-held device rather than CT or MRI. With this
approach, the head must be stabilized in a frame. Touches structures in the patient’s brain with
an imaging “wand” that superimposes that location in the brain on a computer monitor showing
a recent scan or three-dimensional image of the brain. This tool is used to orient the surgeon as
to the exact location of the tumor as compared to a specific point on the exterior of the brain.
The wand provides quick and continuous “real-time” information about its location during
surgery. This tool is particularly useful during skull base surgery, which is an especially
complicated area. It is also of value when multiple tumors are to be removed. The viewing wand
can shorten the surgical time by quickly identifying parts of the brain and localizing the tumor.
Surgical management

57. Stereotactic surgery
Steriotaxy with a head frame Frameless steriotaxy

58. Embolization: Embolization is used to reduce the amount of blood supply to a
tumor by blocking the flow of blood in selected arteries. This procedure is
conducted prior to surgery. Results from an arteriography, which is an X-ray taken
after radiolabeled dye has been injected into the circulatory system, help
determine whether embolization is necessary and which blood vessel or vessels
may need to be blocked. Surgery follows as soon as possible to avoid re-growth of
blood vessels. This technique might be used with vascular tumors such as
meningiomas, meningeal hemangiopericytomas, and glomus jugulare tumors.
Surgical management

59. Neuro Endoscopy: Endoscopes are long, narrow, flexible lighted tubes that are
inserted into the surgical area. They provide the surgeon with light and visual
access. Preoperative scans help determine the location of tumors and enable to
plan surgery using relatively small openings. These small openings (sometimes
called keyhole approaches) make it difficult to see. The endoscope helps solve
that problem. The neuro-endoscope is particularly useful for surgery that involves
correcting a malfunctioning shunt, removing scar tissue blocking a shunt, or
removing intra-ventricular tumors. It can also be useful for removing brain cysts.
Surgical management

60. Neuro Endoscopy:

61. Laser surgery: Using a laser during brain surgery is a relatively routine practice. The
aim of laser surgery is to direct the laser beams at the cancer and destroy it with
heat. Because the light beams cannot penetrate bone, the laser can be used only
during surgery. Lasers are used in addition to, or in place of, a scalpel. Lasers are
capable of immense heat and power when focused at close range. Lasers destroy
tumor cells by vaporizing them. Stereotactic, or computer-assisted techniques,
are frequently used to direct the laser. Lasers are chiefly used in the treatment of
tumors that have invaded the skull base or are deep within the brain, with hard
tumors that cannot be removed by suction, or with tumors that break apart
easily.
Surgical management

62. Laser surgery:

63. Photodynamic laser surgery: A laser is also used in photodynamic therapy.
Photodynamic therapy combines a drug that increases a tissue’s sensitivity to
light and laser surgery. Prior to surgery, the photosensitizing drug is injected into
a vein or artery. It travels through the blood system to the tumor, accumulating in
the cells of the tumor. The patient is then taken to surgery for removal of the
tumor. During the operation, the treated tumor cells appear fluorescent. The
physician aims a laser at the tumor cells, activating the drug. The activated drug
then kills the tumor cells. Only operable tumors can be treated with this
procedure. Tumor cells not or not sensitive to the drug are not affected by this
treatment. This is a local form of therapy because some parts of the tumor might
not be exposed to the light. Because of the danger of swelling, tumors near the
brain stem cannot be treated with this technique.
Surgical management

64. Photodynamic laser surgery

65. Ultrasonic aspiration: Ultrasonic aspiration uses ultrasonic sound waves to
fragment and break the tumor into small pieces, which are then aspirated, or
suctioned out. This technique causes fewer disturbances to adjacent tissue than
other types of suction devices because it causes less heat and destruction of
normal tissue. This is particularly helpful with tumors that would be difficult to
remove with cautery and suction because of their firmness and location. As with
the laser, the use of ultrasound has permitted the removal of tumors that would
otherwise have been inoperable.
Surgical management

66. Ultrasonic aspiration:

67. Immunotherapy (or CAR-T cell therapy)
• Immunotherapy (or CAR-T cell therapy) is the future of brain tumor treatment,
and, though it’s still in clinical trials for aggressive cancers like glioblastoma, it’s
no overstatement to say the results have been beyond promising.
This new and developing form of cancer therapy recruits your immune
system in the fight against brain tumors. As a cancer develops in the body, it
suppresses immune responses, which means the T-cells—the cells that act on
behalf of the immune system—fail to activate in the presence of cancer cells. The
immune system is stymied and significantly less effective

68. 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.
• Chemotherapy is provided in three forms:
• Chemotherapy wafers containing drug called carmustine or BCNU are
inserted directly into a high grade glioma during surgery. wafer is a
biodegradable polymer loaded with the chemotherapeutic agent BCNU (bis-
chloroethylnitrosourea) used for the treatment of recurrent gliomas. It was
approved by the FDA in 1995.
• The wafer, named Gliadel, slowly dissolves over 2-3 weeks to kill tumor cells.

69. • Intravenous chemotherapy is when the chemotherapy is given
through a vein, in a clinic setting.
• Examples for high grade gliomas include:
• Nitrosurea: BCNU previously untreated patients is 150 to 200 mg/m²
intravenously every 6 weeks. Administer as a single dose or divided into
daily injections such as 75 to 100 mg/m² on two successive days. Lower
the dose when BiCNU is used with other myelosuppressive drugs or in
patients in whom bone marrow reserve is depleted. Administer BiCNU for
the duration according to the established regimen. Premedicate each
dose with anti-emetics.
• Vinca alkaloids: vincristine 1.4 mg/m2 IV over one minute once a week
• Platinum Analogues: carboplatin injection300 mg/m² IV on day 1 every 4
weeks for 6 cycles
• cisplatin -135 mg/m2 cisplatin intravenously every month for 5 courses.
Chemotherapy

70. • Oral Chemotherapy is when chemotherapy is given in a pill, by mouth. Examples
include: TMZ or temozolomide (Along with radiation therapy 6 weeks followed by
6 to 12 months for glioama.
Side effects of chemotherapy :
• such as hair loss, nausea, fatigue, weight loss, and gastrointestinal problems
Autologus bone marrow transplantation is used for Chemotherapy patient or
radiation therapy patients, because it can “resue” the patient from bone marrow
suppression. A fraction of bone marrow from patient is aspirated usually from
illiac crest and stored. The marrow is then rein fused intravenously after
treatment is completed.
Chemotherapy

71. Radiation therapy
• The cornerstone of treatment for many brain tumor
• Decrease the incidences of recurrence of incompletely resected tumors
• 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.
• Gamma radiation is delivered via an external beam to the tumor in multiple
fraction.
Radiation therapy options:
Internal Beam Radiation
External Beam Radiation

72. Internal Beam Radiation
Brachytherapy
The surgical implantation of radiation sources to delivery high doses at short
distance is an option for some types of tumors depending on their location. It is
usually used as an adjunct to conventional radiation therapy or as a rescue
measure for recurrent disease. Radioisotopes such as iodine131 are used to
minimize effects on surrounding brain tissue.
Radiation therapy

73. External beam fractionated radiation is the standard treatment
used for all patients with high grade malignant gliomas, typically
given in an outpatient clinic.
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.
Radiation therapy

74. Conventional radiation therapy. The treatment location is determined based on
anatomic landmarks and x-rays. In certain situations, such as whole brain
radiation therapy for brain metastases, this technique is appropriate. For more
precise targeting, different techniques are needed. The amount of radiation given
depends on the tumor’s grade
3-dimensional conformal radiation therapy (3D-CRT). Using images from CT and
MRI scans a 3-dimensional model of the tumor and healthy tissue surrounding
the tumor is created on a computer. This model can be used to aim the radiation
beams directly at the tumor, sparing the healthy tissue from high doses of
radiation therapy.
Radiation therapy

75. Intensity modulated radiation therapy (IMRT). IMRT is a type of 3D-CRT (see
above) that can more directly target a tumor. It can deliver higher doses of
radiation to the tumor while giving less to the surrounding healthy tissue. In
IMRT, the radiation beams are broken up into smaller beams and the intensity of
each of these smaller beams can be changed. This means that the more intense
beams, or the beams giving more radiation, can be directed only at the tumor.
Fractionated stereotactic radiation therapy. Radiation therapy is delivered with
stereotactic precision but divided into small daily doses called fractions and given
over several days or weeks, in contrast to the 1-day radiosurgery. This technique
is used for tumors located close to sensitive structures, such as the optic nerves
or brain stem.
Radiation therapy

76. Side effects.
• Side effects from radiation may include swelling, fatigue,
headaches, nausea, possible hair loss, and changes in your
sensations or movement.
Radiation therapy

77. Targeted therapy
• Bevacizumab (Avastin, Mvasi) is an anti-angiogenesis therapy used to treat
glioblastoma multiforme when prior treatment has not worked. Anti-
angiogenesis therapy is focused on stopping angiogenesis, which is the process of
making new blood vessels. Because a tumor needs the nutrients delivered by
blood vessels to grow and spread, the goal of anti-angiogenesis therapy is to
“starve” the tumor.
• Larotrectinib (Vitrakvi) is a type of targeted therapy that is not specific to a
certain type of tumor but focuses on a specific genetic change called
an NTRK fusion. This type of genetic change is found in a range of tumors,
including some brain tumors. It is approved as a treatment for some brain tumors
that are metastatic or cannot be removed with surgery and have worsened with
other treatments

78. Nursing management
Nursing diagnosis
Impaired tissue perfusion related to (cerebral) related to cerebral edema
Acute pain related to (headache) related to cerebral edema and increased ICP
Self care deficit related to altered neuromuscular function, loss or impairment of
motor and sensory functions
Imbalance nutrition less than body requirement related to cachexia due to
treatment and tumor effects
Anxiety related to fear of dying, uncertainty
Potential complication seizure related to abnormal electrical activity of brain
Potential complication increased ICP related to presence of tumor and failure of
normal compensatory mechanisms
Interrupted family processes related to anticipatory grief and the burden
imposed by the care of the person with a terminal illness

79. Role of nurse in brain tumor
• Providing support for parents or caregiver.
• Frequent monitoring for post op increased intracranial pressure.
• Monitor fluid and electrolytes .
• Administer medication such as steroids.
• Prevent patient from self harm at the time of suffering with seizure.
• Encourage self care , mobility with supervision.
• Establish communication system.
• Check the vitals for sudden variation.
• Provide individual ,family support and education .
• Explain about home care like rehabilitation and home evaluation for neuro
deficits.

80. Rehabilitation
• Rehabilitation care for post-surgical or other treatment to help you
regain lost motor skills and muscle strength.
• Speech, physical, and occupational therapists may be involved in this
aspect of care, based on rehabilitative needs.
• Physical therapists help patients improve their walking, balance and
strength.
• Occupational therapists teach patients how to manage their side
effects so that they can go about their lives and perform daily
activities, such as cooking, writing, and driving.

81. • Speech therapists help people overcome problems understanding
and producing language.They teach patients how to improve their
speech process and adjust how they verbalize or otherwise express
themselves.
Rehabilitation