Brain tumour (adult), high-grade

Page last reviewed: 13/07/2011

A brain tumour is a growth of cells multiplying in an abnormal, uncontrollable way in the brain.

Brain tumours are graded from 1 to 4 according to their behaviour, such as how fast they grow and how likely they are to spread. A high-grade brain tumour - grade 3 or 4 - is malignant, which means it is cancerous and fast-growing. Malignant tumours invade other cells in the brain.

High-grade brain tumours may be either:

  • Primary tumours - these started in the brain and can spread to other parts of the brain or spine, but rarely to other areas of the body.
  • Secondary tumours (the most common type) - these started as cancer in another part of the body and spread to the brain through the blood.

There are different types of primary high-grade brain tumour, depending on the type of brain cells they have grown from (see box). The most common type is a glioma, which accounts for more than half of all primary brain tumours. About 3,500 new cases of high-grade glioma are currently recorded each year in England and Wales.

Primary brain tumours

The cause of primary high-grade brain tumours is often unknown, although an underlying genetic disease, such as neurofibromatosis, can increase your risk of developing one (see Causes of brain tumour, high-grade). People of any age can be affected.

A primary high-grade brain tumour must be treated as soon as possible, because it can spread to and damage other parts of the brain and spinal cord.

The tumour is usually operated on and as much of it removed as possible. This may be followed with chemotherapy and radiotherapy. However, high-grade tumours will often return.

The outcome for high-grade primary brain tumours depends on many factors, such as the type and location of the tumour and how ill you were when diagnosed.

Secondary brain tumours

Secondary brain tumours are as serious as primary tumours.

In half of patients, a secondary tumour first appears in the brain in one location; in the other half, secondary tumours appear in multiple locations. Treatment aims to improve symptoms and prolong life.

It may be possible to remove single secondary tumours with surgery. Small numbers of secondary tumours may be treated with targeted radiotherapy, whereas multiple tumours may be managed with whole brain radiotherapy (see Treatment of brain tumour, high-grade).

High-grade gliomas

Most high-grade brain tumours develop from the glial tissue, which supports the nerve cells of the brain. These tumours are known as gliomas.

Gliomas can be separated further, depending on the cells they developed from. For example:

  • an ependymoma develops from the cells that line the cavities in the brain,
  • an oligodendroglioma develops from the cells that produce the fatty covering of nerves, and
  • an astrocytoma develops from cells thought to provide the brain's framework.

 

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Page last reviewed: 13/07/2011

A high-grade (malignant) brain tumour causes symptoms either by:

  • putting pressure on the brain, or
  • preventing an area of the brain from functioning properly.

Increased pressure on the brain

If the tumour is causing an increase in pressure inside the skull, it can cause the following symptoms:

  • irritability, drowsiness, apathy or forgetfulness,
  • severe, persistent headache,
  • vomiting, which is sometimes sudden and for no apparent reason,
  • dizziness,
  • epilepsy or fits, which can be either major seizures or local twitching,
  • partial loss of vision or loss of hearing,
  • hallucinations, and
  • personality changes, including abnormal and uncharacteristic behaviour.

It is important to see your GP if you start to have a new, persistent and severe headache that does not appear to have any obvious cause, especially if it is associated with unexpected vomiting.

Loss of brain function

Different areas of the brain control different functions, so any loss of brain function will depend on where the tumour is located. For example:

  • A tumour in the frontal lobe may cause changes in personality, weakness in one side of the body and loss of smell.
  • A tumour in the parietal lobe may cause difficulty in speaking, understanding words, writing, reading and coordinating certain movements. There may also be numbness in one side of the body.
  • A tumour in the occipital lobe may cause loss of vision on one side.
  • A tumour in the temporal lobe may cause fits or blackouts, a sensation of strange smells, and problems with speech and memory.
  • A tumour in the cerebellum may cause a loss of coordination, difficulty walking and speaking, flickering of the eyes, vomiting and neck stiffness.
  • A tumour in the brain stem may cause unsteadiness and difficulty walking, facial weakness, double vision, and difficulty in speaking and swallowing.

Brain tumour grades

  • Grade 1 and 2 (low-grade) brain tumours are slow growing, less likely to come back if they are removed, and unlikely to spread.
  • Grade 3 and 4 (high-grade) brain tumours are malignant (cancerous). They are faster growing and likely to spread.

Page last reviewed: 13/07/2011

Secondary brain tumours (the most common type of high-grade brain tumour) are always caused by a primary cancer somewhere else in the body that has spread to the brain via the bloodstream.

The cause of high-grade primary brain tumours is not fully understood.

Underlying disease

Some people have certain genetic conditions that increase the risk of primary malignant (cancerous) growths in the brain, such as:

  • neurofibromatosis,
  • Turcot syndrome,
  • Li-Fraumeni cancer syndrome, and
  • Gorlin syndrome.

These conditions tend to cause malignant glioma  appearing in childhood or early adulthood, although most cases of glioma arise later in adulthood.

Other causes

Radiotherapy to the brain increases the risk of brain tumour, but this accounts for only a small fraction of new cases.

It is also thought that family history and exposure to chemicals (such as formaldehyde) may be risk factors.

 

Can mobile phones cause brain tumours?

There has been some publicity in the media about a possible connection between brain tumours and the radiofrequency (RF) energy emitted by mobile phones. RF energy produces heat, which can increase body temperature and damage tissue exposed to it.

It is thought that the amount of RF energy we are exposed to by the use of mobile phones is too low to produce significant tissue heating or an increase in body temperature.

However, research is underway to establish whether RF energy has any effects on our health in the long term, and no definitive conclusions have yet been reached. 

Page last reviewed: 13/07/2011

If you start to develop some of the symptoms of a brain tumour, such as a persistent and severe headache, see your GP, who will be able to examine you and refer you to a specialist if necessary.

Your GP will examine the back of your eye and look for changes to the optic disc (the inside of the back of the eye) caused by raised pressure inside the skull. A raised pressure inside the skull may indicate the presence of a tumour.

If a growth is suspected, you will be referred to a brain and nerve specialist called a neurologist.

Referral to a specialist

The specialist will ask you about your medical history and symptoms. Then they will examine your nervous system, which may include tests of your:

  • reflexes, such as your swallow reflex and knee jerk reflex,
  • facial muscles (testing whether you can smile or grimace, for example),
  • hearing and vision,
  • limb strength,
  • balance and coordination,
  • skin sensitivity to pinpricks, heat and cold, and
  • mental agility - simple questions or arithmetic.

A brain tumour diagnosis is made on the basis of your symptoms, the above examinations and the findings of certain tests (see below).

Tests

You may have some of the following tests to help diagnose a brain tumour:

  • computerised tomography (CT) scan - this produces a detailed picture of your brain using a series of X-rays,
  • magnetic resonance imaging (MRI) scan - this produces a detailed picture of your brain using a strong magnetic field and radio waves,
  • X-ray of the skull,
  • positron emission tomography (PET) scan - this produces an image of your brain by detecting radiation inside your head (after radiation is introduced into your body), and
  • electroencephalogram (EEG) - electrodes record your brain activity.

If a tumour is suspected, a biopsy (surgical removal of a small piece of tissue) may be taken to establish the type of tumour and the most effective treatment.

A biopsy involves making a small hole in the skull and using a fine needle to obtain the sample of tumour tissue. It requires a few days in hospital.

Page last reviewed: 13/07/2011

People with high-grade brain tumours will usually have surgery to remove as much of the tumour as possible. Radiotherapy and chemotherapy is then used to treat any remaining tumour tissue.

However, the majority of high-grade brain tumours return after they have been treated. At this point, the aim of treatment is to extend life for as long as possible and treat any symptoms (see below). 

Primary tumours

Surgery

Most primary tumours will be removed using surgery, and are often treated with radiotherapy and/or chemotherapy afterwards (see below), to reduce the risk of the tumour coming back.

Surgery aims to remove as much of the tumour as possible, without damaging the surrounding tissue.

You are given a general anaesthetic (put to sleep) and an area of your scalp is shaved. A section of the skull is then cut out as a flap, to reveal the brain and tumour underneath. This is known as a craniotomy. The surgeon can then remove the tumour tissue.

You may then be given photodynamic therapy, where the surgeon injects a light-sensitive drug into your veins, which is taken up by the remaining cancer cells. When a laser is focused on these cancer cells, the drug becomes active and kills them.

Chemotherapy and radiotherapy

Some tumours that are situated deep inside the brain are difficult to remove without damaging surrounding tissue. In this case, the tumour may just be treated with chemotherapy or radiotherapy (or both).

Radiotherapy is where controlled doses of radiation (usually X-rays) are beamed at the tissue to stop the cancer cells multiplying. The radiation is a lower intensity than that used in radiosurgery (see below), and is given over a period of time.

Radiotherapy can cause tiredness, headaches, hair loss, nausea and reddening of your skin.

Chemotherapy is medication used to kill any cancerous cells, and may be given as tablets, an injection or implants. Carmustine and temozolomide are both chemotherapy drugs used in the treatment of high-grade brain tumours, and are described below.

Carmustine implants are small wafers placed at the tumour site when the tissue has been surgically removed. As they dissolve, they release carmustine to slow or stop the growth of cancerous cells.

Carmustine implants may be used to treat gliomas that are in an advanced stage of growth.

Carmustine implants need to be implanted immediately following surgery, and before surgery is complete, so your surgical team must be prepared to use them in advance if the removal of 90% of the tumour looks possible.

Possible side effects of carmustine implants are brain oedema (fluid in the brain), fits and infection in the brain.

Temozolomide is a chemotherapy drug that is given to some patients with a high-grade glioma to slow down progression after initial treatment, or if the tumour has returned.

Possible side effects of temozolomide include anorexia, constipation, fatigue, headache, nausea and vomiting.

Radiosurgery

Radiosurgery involves focusing a high-energy dose of radiation on the tumour to kill it. It is different to radiotherapy in that the radiation is:

  • a higher intensity,
  • focused on a smaller area of the brain, and
  • given in one session (rather than over a period of time).

This means you will usually not experience any of the usual side effects of radiotherapy, such as skin reddening and hair loss. Recovery is good and an overnight stay is usually not required.

However, radiosurgery is only available in a few specialised centres across the UK. 

Secondary tumours

A secondary brain tumour indicates serious, widespread cancer that usually cannot be cured.
Treatment aims to improve symptoms and to prolong life by shrinking and controlling the tumour. This may include:

  • corticosteroids - these tablets reduce the swelling and pressure in the brain,
  • chemotherapy (see above),
  • radiotherapy (see above),
  • anticonvulsant medicines, which prevent epileptic fits,
  • painkillers, which can reduce headaches, and
  • anti-nausea drugs, which can help to alleviate sickness caused by increased pressure inside the skull.

Your healthcare team

You will be cared for by a team of healthcare professionals that may include:

  • a neurosurgeon, who will operate on your brain,
  • a neurologist, who will treat your illness from the tumour,
  • an oncologist, who will treat you with chemotherapy, if necessary,
  • a radiologist, who will administer your radiotherapy, and 
  • a specialist nurse, who will give you information and support

You should be given the name and contact details of a key worker, who will support you during your brain tumour journey.

What if I choose not to have treatment?

If your tumour is at an advanced stage or in a difficult place in the brain, a cure may not be possible and treatment may only be able to control the cancer for a period of time. This means you will be getting the side effects of treatment without getting rid of the tumour.

In this sort of situation, it may be difficult to decide whether or not to go ahead with treatment. Talk to your doctor about what will happen if you choose not to be treated, so you can make an informed decision.

If you decide not to have treatment, you will still be given palliative care, which will control your symptoms and make you as comfortable as possible.

Page last reviewed: 13/07/2011

After being treated for a high-grade brain tumour, you may be offered physiotherapy, speech therapy and/or occupational therapy. These therapies aim to speed up your recovery and help you cope with any problems that the tumour caused:

  • an occupational therapist will recommend any equipment or alterations to your home that may help you carry out daily activities,
  • a speech therapist will help you with any speech or swallowing problems, and
  • a physiotherapist will help you to use parts of the body that have been affected by the tumour.

Epilepsy may effect some patients for up to six months or rarely longer after surgery.

Sports and activities

After you have been treated for a brain tumour you should permanently avoid contact sports, such as rugby and boxing. However, other activities may be resumed once you have recovered, with the agreement of your doctor.

Swimming unsupervised is not recommended for approximately one year after treatment, to avoid the risk of epileptic fit.

Sex

Having sex after a brain tumour is safe, although women should avoid pregnancy for six months and discuss with their specialist the implications of any ongoing medication.

Going back to work

You will become tired more easily following treatment for a brain tumour. Although you may wish to return to work and normal life as soon as possible, it is a good idea to return part time to begin with and to go back full time when you feel capable.

If you have experienced seizures, you should not work with machinery or at heights.

Help and support

A brain tumour is often a life-changing event. You may feel angry, frightened, and emotionally drained. Your doctor or specialist should be able to refer you to the social worker and counsellor on the team for help with the practical and emotional aspects of your diagnosis.

Can I drive or travel after a brain tumour?

If you have a brain tumour, it could affect your ability to drive. It is important that you inform your doctor and the Road Safety Authority (RSA) about a medical condition that could have an impact on your driving ability.

Based on up-to-date scans and advice from your medical team, you may be allowed to drive again once an agreed period has passed and you have successfully completed a medical test to determine your ability to control a vehicle.

If you wish to travel, flying is usually possible after three months.

Page last reviewed: 13/07/2011

Living with a brain tumour is not easy. The future can look very unpredictable and the unknown can be frightening.  

As well as medical worries about tests, treatments and side effects, it is also common for patients to worry about life's practicalities, such as 'who will care for my family when I feel too ill to do so?' 
 
This panic and anxiety is a natural response and one that will affect everyone concerned. Changes in daily routines and responsibilities are often necessary and this is something that involves the whole family. Try to ensure everyone knows what is happening and has an idea of what to expect. 

The following are just a few of the ways that can help you, your family and close friends deal with the changes in your lives:

  • Seek accurate medical information about the disease and your treatment options.
  • Involve yourself in decisions about your care and treatment. This can help dispel the fear of the unknown and the feeling that you do not have any control in what is happening to you.
  • Take a notepad with you if you find it difficult to remember questions and the answers, and write things down to refer to later. 
  • Set your own limits according to how you feel. Do not push yourself to perform at the level you were before the diagnosis and think you have to continue as before. 

Content provided by NHS Choices www.nhs.uk and adapted for Ireland by the Health A-Z.

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