The treatment options for brain and spinal cord tumors depend on several factors, including the type and location of the tumor and how far it has grown or spread.
Non-infiltrating astrocytomas
These tumors include juvenile pilocytic astrocytomas, which most commonly occur in the cerebellum in young people, and the subependymal giant cell astrocytomas, which are almost always associated with tuberous sclerosis. Many doctors consider these benign tumors.
In most cases, these astrocytomas are cured by surgery alone. But older patients are less likely to be cured. Radiation therapy may be given after surgery, particularly if the tumor is not completely removed, although many doctors will wait until there are signs the tumor has grown back before considering it. Even then, repeat surgery may be the first option.
The outlook is not as good if the astrocytoma occurs in a place that does not allow it to be removed surgically, such as the hypothalamus or brain stem. In these cases, radiation therapy is usually the best option.
For subependymal giant cell astrocytomas that can't be removed completely by surgery, treatment with a newer drug called everolimus (Afinitor) may shrink the tumor or slow its growth for some time.
Low-grade astrocytomas
(Infiltrating or diffuse astrocytomas)
The initial treatment for these tumors is surgery when possible. These tumors are hard to cure by surgery because they often grow into (infiltrate) nearby normal brain tissue. Usually the surgeon will try to remove as much of the tumor as safely possible. If the surgeon is able to remove it all this may be curative.
Radiation therapy may be given after surgery, especially if large amounts of tumor remain. In younger adults, radiation may not be given unless the tumor shows signs of regrowth. (In some cases, a second surgery may be tried before giving radiation.) In those over age 40, radiation may be added after surgery because of the chance of recurrence. Chemotherapy may also be given after surgery in some cases. Some doctors may use genetic tests of the tumor to help determine if chemotherapy should be given
Radiation or chemotherapy may also be used as the main treatment if surgery is not a good option for some reason.
Intermediate- and high-grade astrocytomas
(Anaplastic astrocytomas, glioblastomas)
Surgery is often the first treatment when it can be done, but these tumors are not curable by surgery. As much of the tumor is removed as is safely possible. Chemotherapy wafers may be placed in or near any remaining tumor at this time. Radiation therapy is then given, usually along with or followed by chemotherapy if the person's health allows. For tumors that cannot be treated with surgery, radiation therapy — with or without chemotherapy — is usually the best option.
Temozolomide is the chemotherapy drug most commonly used to treat these tumors. It is often given along with radiation therapy, as it appears to make it more effective. It is then continued after the radiation is completed. Temozolomide is the drug used first by most doctors because it crosses the blood-brain barrier, it's a pill, it's convenient to give, and it has been shown to help prolong life.
Cisplatin, carmustine (BCNU), and lomustine (CCNU) are other commonly used drugs. Combinations of drugs may also be used, such as the PCV regimen (procarbazine, CCNU, and vincristine). All of these treatments may shrink or slow tumor growth for some time, but they are not expected to be curative.
If standard chemotherapy drugs are no longer effective, the targeted drug bevacizumab (Avastin) may be helpful for some people, either alone or along with chemotherapy.
In general, these tumors are very hard to treat effectively for extended periods of time. Because these tumors are so hard to cure with current treatments, clinical trials of promising new treatments may be a good option.
Oligodendrogliomas and anaplastic oligodendrogliomas
If possible, surgery is the first option for oligodendrogliomas. Surgery usually doesn't cure them, but it can relieve symptoms and prolong survival. Many oligodendrogliomas grow slowly, especially in younger people, and may not need further treatment right away. Surgery may be repeated in many cases if the tumor grows back in the same spot. Radiation therapy and/or chemotherapy (most often with temozolomide or the PCV regimen) may also be options after surgery.
Oligodendrogliomas may respond to chemotherapy better than other brain tumors if certain chromosome changes are present in the tumor cells. You can ask your doctor about testing for these changes.
For tumors in which surgery is not an option radiation therapy or chemotherapy may be helpful.
Anaplastic oligodendrogliomas tend to be more aggressive. They are treated the same way as anaplastic astrocytomas (see above).
Ependymomas and anaplastic ependymomas
These tumors usually do not infiltrate normal brain tissue. They may be cured in some cases by surgery alone if the entire tumor can be removed, but often this is not possible. If only part of the tumor is removed with surgery (or if it is an anaplastic ependymoma), radiation therapy is given after surgery. If surgery cannot be done, radiation therapy is the main treatment.
Patients typically get an MRI of the brain and spine (and possibly a lumbar puncture) a few weeks after surgery if it is done. If either of these tests shows that the cancer may have spread through the cerebrospinal fluid, radiation therapy is given to the entire brain and spinal cord.
It is not clear how helpful chemotherapy is for these tumors — this is still being studied. Chemotherapy is usually not given unless the tumor can no longer be treated with surgery or radiation.
Meningiomas
Most meningiomas tend to grow slowly, so small tumors that aren't causing symptoms can often be watched rather than treated, particularly in the elderly.
If treatment is needed, these tumors can usually be cured if they are completely removed with surgery. Radiation therapy may be used along with, or instead of, surgery for tumors that can't be completely removed. If the tumor is an atypical (grade II) or anaplastic (grade III) meningioma (which tend to recur after treatment), radiation therapy is given after surgery even if all of the tumor has been removed.
For meningiomas that recur after initial treatment, further surgery (if possible) or radiation therapy may be used. If surgery and radiation aren't options, drug treatments (chemotherapy, immunotherapy, or hormone-like drugs) may be used, but it's not clear how much benefit they may offer.
Schwannomas (including acoustic neuromas)
These slow-growing tumors are usually benign and are cured by surgical removal. In some centers, small acoustic neuromas are treated by stereotactic radiosurgery (see the section "Radiation therapy"). For large schwannomas where complete removal is likely to cause problems, tumors may be operated on first to decrease their size and then the remainder is treated with radiosurgery. For the rare malignant schwannomas, radiation therapy is often given after surgery.
Spinal cord tumors
These tumors are treated in a manner similar to those in the brain. Astrocytomas of the spinal cord usually cannot be completely removed. They may be treated with surgery to remove as much tumor as possible, followed by radiation therapy, or with radiation therapy alone. Meningiomas of the spinal canal are often cured by surgical removal, as are some ependymomas. If surgery doesn't completely remove an ependymoma, radiation therapy is often given.
Lymphomas
Treatment of central nervous system lymphomas generally consists of chemotherapy and/or radiation therapy. Treatment is discussed in more detail in our document, Non-Hodgkin Lymphoma.
Brain tumors that occur more often in children
Some brain tumors occur more commonly in children but do occur occasionally in adults. These include brain stem gliomas, germ cell tumors, craniopharyngiomas, choroid plexus tumors, medulloblastomas, primitive neuroectodermal tumors, and some others. Treatment of these cancers is described in our document, Brain and Spinal Cord Tumors in Children.
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