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— Archie, patientUnderstanding Brain TumorsC H A P T E R T W O / U N D E R S TA N D I N G B R A I N T U M O R SBe patient. Give yourselftime to absorb what’shappening and don’timmediately dive intothe internet.

C H A P T E R T W O / U N D E R S TA N D I N G B R A I N T U M O R SC H A P T E R 2 / U N D E R S TA N D I N G B R A I N T U M O R S . . . . . . . . . . . . . . . . . . . . . . . . . . . 5What is a brain tumor?. 7Defining brain tumors. 7Diagnosing a brain tumor. 9Scans and imaging techniques. 10 Tumor grading. . 11Tumor types. 12Diagnostic surgery. 13Pathology report. . 13The treatment team. 14Specialists. 15

2Understanding Brain TumorsThe brain, its structure, and the role that each part plays in our everyday thoughtsand behaviors is remarkable. These are only some of the reasons why a tumor in thebrain is so complex. THINGS TO REMEMBERThere are over 120 types of brain andcentral nervous system tumors. Whendiagnosed, it is important to understand: 1. The type and grade (how aggressive it is)2. Whether it is a primary or a secondarytumor 3. If it is cancerous (malignant) or not (benign)4. Where in the brain the tumor is located It helps to get a second or even thirdopinion to confirm your diagnosis andtreatment plan.Keep a list with phone numbers for allof the doctors, specialists, nurses, etc.on your team (collect business cards). You can bring someone to doctors’appointments to help you sort throughinformation, ask questions, remembernext steps, and keep notes.Keep copies of your medical records,current medication list, and diagnostic testresults. This can help you as you meet newdoctors and work with insurance.Take one step at a time. You can learnabout your diagnosis, treatment options,and what to expect after treatment, thendecide the best next-steps for you andyour family.C H A P T E R 2 / U N D E R S TA N D I N G B R A I N T U M O R S5

Brain and Spinal CordBRAIN STRUCTURES AND THEIR FUNCTIONSTogether, the brain and spinal cord (thecentral nervous system (CNS)) control thephysiological and psychological functionsof our body. Generally our brain includesthree major parts: The cerebrum controls thinking,learning, problem solving, emotions,speech, reading, writing, and voluntarymovement. The cerebellum controls movement,FRON TA L L OB E movement reasoning behavior memory decision making personality planning judgment initiative inhibition moodPAR I ETAL LO BE telling rightfrom left calculations sensations reading writingO C C I PI TALLO BE visionbalance, and posture. The brain stem connects the brainto the spinal cord, and controlsbreathing, heart rate, and the nervesand muscles that we use to see, hear,walk, talk, and eat.For more information aboutthe brain, view the NationalCancer Institute’s brain tumor tbrain/PatientTEMPORA LL OB E languagecomprehension behavior memory hearing emotionsPITU ITA RYGL A N D hormones growth fertilityC ER EBELLUM balance coordination fine musclecontrolBR AI N STEM breathing blood pressure heartbeat swallowingBased on an illustration from National Brain Tumor Society’s The Essential Guide to Brain Tumors6F R A N K LY S P E A K I N G A B O U T B R A I N T U M O R S

W H AT I S A B R A I N T U M O R ?DEFINING BRAIN TUMORSA brain tumor is an abnormal growthBenignspread to other areas of the body, theyof tissue in the brain or central spineThe least aggressive type of brain tumorcan spread throughout the brain or to thethat can disrupt proper brain function.is often called a benign brain tumor.spine. These tumors can be treated withDoctors refer to a tumor based on whereThey originate from cells within orsurgery, chemotherapy and radiation, butthe tumor cells began, and whethersurrounding the brain, do not containthey may recur after treatment.they are cancerous (malignant) or notcancer cells, grow slowly, and typically(benign).have clear borders that do not spreadPrimaryinto other tissue. They may become quiteWhether cancerous or benign, tumorsAll brain tumors can grow to damageareas of normal brain tissue if leftuntreated, which could be disabling andpossibly fatal.large before causing any symptoms. Ifthese tumors can be removed entirely,they tend not to return. Still, they cancause significant neurological symptomsBrain and spinal cord tumors are differentdepending on their size, and locationfor everyone. They form in different areas,near other structures in the brain. Somedevelop from different cell types, and maybenign tumors can progress to becomehave different treatment options. In thismalignant.primary brain tumors. Primary braintumors may spread to other parts ofthe brain or to the spine, but rarely toother organs.Metastatic or SecondaryMetastatic or secondary brain tumorsbook, we try to offer general guidance forbegin in another part of the body andboth low grade (benign) and high gradeMalignant(malignant) primary brain tumors forMalignant brain tumors contain canceradults.that start in cells of the brain are calledcells and often do not have clear borders.They are considered to be life-threateningbecause they grow rapidly and invadesurrounding brain tissue. Althoughmalignant brain tumors very rarelythen spread to the brain. These tumorsare more common than primary braintumors and are named by the location inwhich they begin. They are treated basedon where they originate, such as the lung,breast, colon or skin.C H A P T E R 2 / U N D E R S TA N D I N G B R A I N T U M O R S7

FA C T S A B O U T B R A I N T U M O R S I N T H E U N I T E D S TAT E SAn estimated 688,000 PEOPLEin the U.S. are living witha primary brain or central nervous system (CNS) tumor diagnosis:PRIMARY BRAINTUMOR TYPES138,000 WITH MALIGNANT TUMORS550,000 WITH BENIGN TUMORSAPPROXIMATELY20-40%OF ALL OTHER CANCERS LATERDEVELOP A BRAIN METASTASESIN 2012, NEW PRIMARY BRAIN TUMORDIAGNOSES INCLUDED:63%B E NI G NTUM ORS(41,980 Cases)37%This accounts for 98,000 to 170,000 newmetastatic brain tumor cases each year.M AL I G NAN TTUM iomaPituitaryNerve mbryonal, etc.)(24,300 Cases)Source: CBTRUS Statistical Report (2012)8F R A N K LY S P E A K I N G A B O U T B R A I N T U M O R S

DIAGNOSING A BRAIN TUMORWhat a crazy ride this has been. I went to bed after watching amovie and woke up in an ambulance on the way to the hospital.I didn’t know my name, didn’t recognize my wife or kids andcouldn’t understand why I was in the back of this ambulance.— Mike (from the National Brain Tumor Society’s Story Corner)Some people may have symptoms thatNeurological Examinationsuggest there is a brain tumor, othersAs part of the diagnostic testing, a doctorhave no obvious symptoms.will measure nervous system functions,Commonly, people experience longterm headaches, seizures or convulsions,difficulty thinking and speaking/findingwords, personality changes, tingling orphysical and mental alertness, andinclude the examination of normal brainfunctions from reflexes to judgment,smell and taste.stiffness in one side of the body, a loss ofIf responses are not normal, a brainbalance, vision changes, nausea, and/orscan will be ordered, or a patient will bedisorientation (see Chapter 4).referred to a neurologist or neurosurgicalIf these symptoms are occurring, a doctoroncologist for more tests.will ask questions about a person’smedical history and overall health, andprescribe a variety of diagnostic teststo determine what is causing theseproblems, and then seek remedies.C H A P T E R 2 / U N D E R S TA N D I N G B R A I N T U M O R S9

SCANS AND IMAGING TECHNIQUESMagnetic Resonance Spectroscopytissue. PET is also used during braintumor is present, and to locate exactly where(MRI Spect or MRS), measures themapping procedures.it is growing. A scan creates computerizedlevels of metabolites in the body. Animages of the brain and spinal cord byMRS can detect irregular patternspuncture), uses a special needleexamining it from different angles. Someof activity to help diagnose the typeplaced into the lower back to measurescans use a contrast agent (or a dye) toof tumor, evaluate its response topressure in the spinal canal and brainallow the doctor to see the differencetherapies, or determine aggressivenessand determine if there is an infectionbetween normal and abnormal tissue.of a tumor.or tumor cells.A scan is the first step to identify if a brainA patient may need more than one type Spinal tap (also called a lumbarPerfusion MRI examines the flow ofof scan to diagnose a tumor, dependingblood into the tissues to help assessThings to Know about Scanson its type and location.the grade/aggressiveness of tumorsAsk your neurosurgeon or nurse whatand differentiate a recurrent tumoryou have to do for a scan, where to gofrom dead tumor tissue.and how the scan works, so you can feelCommonly used scanning and imagingtechniques: 10Functional MRI (fMRI) tracks theprepared. Keep a record of your scanComputed Axial Tomography (CATuse of oxygen and blood flow inand x-ray history. This information canor CT Scan) is a computerized x-ray thatthe brain as patients perform tasks.help doctors make informed treatmentcan show a combination of soft tissue,An fMRI can identify the motor,decisions and minimize your over-bone, and blood vessels. This is oftensensory, visual and language centersexposure to radiation.the first test a person will receive in anof the brain which helps your doctoremergency room (i.e. after a seizure).carefully plan for surgery.Magnetic Resonance Imaging (MRI) Be prepared to receive multiple scansover time: first to detect the tumor; thenPositron Emission Tomographycan create clear and detailed three-to observe the site after surgery; later,(PET) scan uses a radioactivedimensional images of a brain tumor. Anwith follow-up care, to see if the tumorsubstance to visualize hypermetabolicMRI is not often used with people whoreturns.activity such as with malignant cells,have a pace maker or other metal device.or abnormalities from a tumor or scar F R A N K LY S P E A K I N G A B O U T B R A I N T U M O R S

TUMOR GRADINGThe World Health Organization (WHO)Grade I Tumorhas created a standard by which all Slow-growing cells Almost normal appearance under atumors are classified. There are over120 brain tumor classifications definedby the WHO, based on the tumor cellGrade IV Tumor microscoperapidly Very abnormal appearance under amicroscope Usually not cancercomplex diagnosis. Tumors are given a Associated with long-term survivalname based on the cells where they arise, Can potentially be cured with surgerytype and location, making this a veryAbnormal cells which reproduce rapid growth and a number ranging from 1–4, usuallyForm new blood vessels to maintainAreas of dead cells (necrosis) in centerrepresented by Roman numerals I-IV.Grade II TumorThis number is called the “grade” and it Relatively slow-growing cells Slightly abnormal appearance underdetermines the grade for the entire tumora microscope(even if most of the tumor is a lower Can invade adjacent normal tissuegrade). Some tumors can change the way Can recur as a higher grade tumorthey grow and may become malignantrepresents how fast the cells can growand are likely to spread. This is criticalinformation for planning treatment andpredicting outcomes.Lower grade tumors (grades I & II)are not very aggressive and are usuallyassociated with long-term survival.Higher grade tumors (grade III & IV)treat. These are considered malignantor cancerous.cells; however, the most malignant cellover time. Your doctor can tell you if yourtumor might have this potential.Grade III Tumor Actively reproducing abnormal cells Abnormal appearance under agrow more quickly, can cause moredamage, and are often more difficult toTumors can contain several grades ofmicroscope Infiltrate adjacent normal brain tissue Tumor tends to recur, often as ahigher gradeC H A P T E R 2 / U N D E R S TA N D I N G B R A I N T U M O R S11