Treatment options

Surgery alone is the treatment of choice for most benign lesions though additional radiotherapy is appropriate after incomplete resection in some (e.g. pituitary adenoma or meningioma). Low-grade astrocytomas presenting with epilepsy alone and without mass effect on scan can often be managed medically; the development of other neurological symptoms or imaging evidence of growth or transformation are indications for surgery. The role of radiotherapy for these tumours remains controversial though treatment is frequently given following partial resection.

Suspected high-grade gliomas require surgery for histological confirmation. This may be with stereotactic biopsy or, where possible, by craniotomy and debulking of tumour. Whilst resection is often valuable for relief of pressure symptoms its value in tumour control is more contentious. 'Blind' burr-hole biopsy carries a high risk of morbidity. Without further treatment the median survival for patients with anaplastic astrocytoma or glioblastoma is approximately one year and three months respectively. Radiotherapy improves median survival to three years for anaplastic tumours and one year for glioblastoma.

Post-operative radiotherapy is normally given, except in elderly patients or those with low performance status when the prognosis is too poor irrespective of treatment. The area irradiated is usually limited to tumour-bearing brain and doses of 30-60 Gy are given over 2-6 weeks depending on prognostic factors.

Chemotherapy adds little, if any, advantage in the adjuvant setting and is usually reserved for relapse. The nitrosoureas (BCNU, CCNU) are the most common agents used. Procarbazine and the platinum compounds and Temozolomide may also have some value.

Medulloblastoma is managed by resection followed by cranio-spinal radiotherapy; the role of chemotherapy is currently being explored. Overall, 50% of patients are disease-free at five years. Similar approaches are required for ependymomas and supratentorial primitive neuro-ectodermal tumours.

Patients with brain tumours suffer a wide variety of related physical, cognitive, and emotional problems. Prominent are:

♦ Movement disorders

♦ Tumour-associated epilepsy

♦ Speech disorders

♦ Intellectual decline

These are best managed jointly by the GP and a specialized unit with access to a dedicated tumour surgeon, a neuro-oncologist, a neurologist, a nurse specialist, and rehabilitation team, whose intentions are to maximize the quality of life as well as delivering optimal therapy to improve survival. Early involvement of the palliative care team can be valuable.

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