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Tumors of The Central and Peripheral Nervous System

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Brain and Spine

Tumors can form in and around the nerve tissue of the body’s nervous system – the brain and spine – growing as abnormal masses of tissue. The type of tumor depends on the location in the nervous system, and whether it is a cancerous (malignant) or non-cancerous (benign) tumor. There are more than 120 types of brain and central nervous system tumors. Brain and spinal cord tumors vary from person to person: tumors form in various areas and develop from different cell types, meaning treatment options are different for everyone.
Tumors of The Central and Peripheral Nervous System

Tumors of the Nervous System

The Central Nervous System (CNS) comprises the brain and the spinal cord. The Peripheral Nervous System (PNS) comprises the nerves and ganglia (tissue mass) outside the brain and the spinal cord.

A primary tumor is when the mass of cells originates in the brain or spine. Not all primary brain tumors are cancerous. Benign tumors (non-cancerous) are not aggressive and normally do not spread to surrounding tissues. Malignant tumors are cancerous and are typically more aggressive and spread fast to surrounding tissue.

Metastatic tumors, also known as secondary tumors, typically start elsewhere in the body, such as a lung or breast, and spread to the brain and spine. These tumors are more common than primary tumors.

Regardless of the tumor type, in these sensitive areas, even benign brain or spine tumors can seriously affect important functions of the body. The pressure caused by the tissue mass can cause general symptoms, or symptoms very specific to the area it is affecting.

Although brain and spine tumors are rare, serious symptoms should not be overlooked. Below we list the signs to look for, which can help detect a brain or spine tumor early.

If you or someone you know presents several of the listed symptoms, it is important to contact a physician.

Brain and Spine Tumor Recovery

Recovery from brain surgery requires substantial rest. The duration depends on the type of procedure.

In addition, surgery is often combined with other cancer treatments, such as chemotherapy, radiation therapy or hormone therapy. While some of these treatments are administered before surgery (neoadjuvant therapy) others are administered after surgery (adjuvant therapy). These also affect the recovery process.

Longer-term recovery treatment is designed by our collaborative team of specialists. Depending on its location, a brain tumor in particular can cause weakness, loss of balance, speech problems, and loss of vision. Various types of rehabilitation, such as physical and occupational, are important to address these side effects.

In addition, those recovering from brain tumor surgery may experience emotional or cognitive difficulties and changes. These outcomes are also dealt with by special cognitive rehabilitation therapy.

Periodic MRI scans are also performed to check for any new tumor growth.

The patient’s recovery after spinal tumor surgery and length of stay in the hospital will vary by the extent and type of surgery. Each patient responds and recovers differently.

After surgery, you may need help with daily activities. This is referred to as rehabilitation. Rehabilitation may be done in an inpatient setting, which means you are admitted to a rehab unit or hospital. It can also be done as an outpatient, which means you could receive therapy in your home or be transported to a rehab facility during the week.

The possible effects of the tumor and its treatment on your physical and mental function can range from mild to severe. After surgery, the patient may need to see a psychiatrist or psychologist to determine the extent of any damage caused by the tumor or surgery.

If the patient was treated with surgery for a tumor near the base of the brain, pituitary hormone production may be affected and an endocrinologist might be recommended. If hormone levels are affected, hormone treatments to restore normal levels may be needed for the rest of your life.

Post-Surgery and Recovery
Following treatment, the tumor is sent to the pathologist. Genetic testing is often performed, as well. The ANA multidisciplinary team of medical experts – your or your child’s Tumor Board – including surgeons, neurologists, neuro-pathologists, neuro-oncologists, radiologists, radiation oncologists, physical therapists, nurses, psychologists and social workers meet to review your or your child’s condition, needs and test results. This team approach is also taken in the recommendation of the personalized treatment protocol for you or your child.

Brain and Spinal Tumor Diagnosis

The complete method for determining the presence of a brain or spine tumor includes:
  • A medical or neurological exam to assess your symptoms.
  • Imaging (brain or spine scan, such as a MRI or CT scan) shows the size, location and impact of the tumor.
  • Evaluation of brain or spine tissue via a biopsy provides more detail about the tumor, such as where it started and whether it is benign (noncancerous) or malignant (cancerous).
The medical or neurological exam entails a series of tests that measure nervous system functions and physical and mental alertness. If the results of this exam are abnormal, a brain or spine scan will be administered by a neurological expert. A brain or spine scan consists of a picture of internal structures. A specialized imaging machine produces a scan in a manner similar to a digital camera taking a photo. With the use of computer technology, a scan creates an image by photographing the brain or spine from various angles. Some scans use contrast dye injected into the patient’s vein, which assists the neurosurgeon in differentiating between normal and abnormal tissue. Abnormal or diseased brain or spine tissue absorbs greater amounts of dye than healthy tissue. A biopsy is the final step in diagnosing a brain or spine tumor. Tumors are classified from the least aggressive (benign) to the most aggressive (malignant). The cell type of origin or the location of the tumor determines the classification of a brain tumor. Identifying the type of tumor determines the most appropriate type of treatment. Below we explain in detail each of the above diagnostic steps.
Tumor Definitions
  • Benign tumors are the least aggressive type and do not contain cancerous cells. They typically grow slowly and generally do not spread.
  • Malignant tumors contain cancerous cells and are considered life-threatening as they grow quickly and can invade nearby brain or spinal tissue.
  • Primary tumors refer to those that start in the brain or spine. They may spread within these areas but rarely to other organs. Primary tumors are typically more frequent in children and older adults.
  • Metastatic or secondary tumors are those that start elsewhere then spread to the brain or spine. These tumors are more common than primary tumors and are seen more in adults than children. They are named by the location in which they begin.
  • Grade I tumors are when the tissue is benign and the cells grow slowly. The cells almost look like normal brain cells, and rarely spreads. In some cases, it is possible to remove entirely with surgery.
  • Grade II is when the tissue is malignant and the cells look a little more abnormal compared to Grade I tumor cells. It is possible for this type to spread and possibly recur.
  • Grade III tumors comprise malignant tissue and actively growing cells (anaplastic). The abnormal cells look very different than healthy cells, and is likely to spread into nearby cells.
  • Grade IV tumors look the most abnormal and comprise malignant tissue and fast-growing cells. Metastatic tumors are often Grade IV.
Radiological tests are required for an accurate and positive brain and spine tumor diagnosis. Below are the most common radiological tests used for diagnosing brain and spinal tumors. X-rays may be used for the spine to search for potential causes of pain (e.g., tumors, infections, and fractures). It can also show if any vertebrae are compressing your spinal cord, and to evaluate spine alignment. X-rays show the structure of the vertebrae and the outline of the joints. However, X-rays are not reliable in diagnosing tumors. CT scans can show soft tissue, bone and blood vessels combined. As such, CT images can detect abnormalities, swelling, bleeding and bone and tissue calcification, as well as being effective in determining some types of brain and spine tumors. The CT scan is a combination of advanced x-ray and computer technology, usually with the use of iodine as a contrast agent. A CT/CAT scan is the diagnostic image created after a computer reads the X-ray, combining various x-ray angles to produce a detailed, three-dimensional image. Neurosurgeons use PET scans to look at organs and tissues. PET scans can determine the difference between scar tissue, recurring tumor cells, and necrosis (i.e. cells destroyed by radiation treatments). The PET scan creates a picture of the brain or spine by measuring the rate at which a tumor absorbs glucose (a sugar), which is typically faster than normal cells. This is in contrast to the other imaging techniques, which measure the structure of a brain or spine tumor. In the case of a PET scan, the patient is injected with deoxyglucose, a substance labeled with radioactive markers. The PET scan relays the measured brain or spine activity to a computer, which creates a live image.
The biopsy, the most accurate method of obtaining a tumor diagnosis, is administered to determine the type and grade of a tumor. A biopsy surgically removes a sample of tissue taken from a tumor site in order to be examined under a microscope. The biopsy provides information on the types of abnormal cells present in the tumor. There are two types of brain biopsy used for diagnosis:
  • A craniotomy is performed as part of an open biopsy. A craniotomy consists of removing a piece of the skull in order to gain access to the brain. Following the tumor resection (completely removed) or if the tumor is debulked (partially removed), the bone is usually returned to place.
  • A closed biopsy (also referred to as a stereotactic or needle biopsy) may be performed for difficult to reach areas of the brain in which a tumor is located. In a closed biopsy, the neurosurgeon drills a small hole into the skull, through which a narrow hollow needle is passed into the tumor in order to remove a tissue sample.
For spinal tumor biopsies, many are performed using minimally invasive techniques, where a CT scan is used to guide a thin needle into the tumor or surrounding areas. Once a biopsy sample is obtained, a pathologist examines the tissue under a microscope in order to analyze the brain or spine tissue and make a diagnosis. If necessary, due to a complicated case or one in which there is more than one grade of tumor cells located in the same tumor, the tissue is sent on for further expert analysis.

Every family reacts to a brain tumor diagnosis and treatment in their own way. Regardless of the family’s reaction, studies have shown that brain tumor patients and their relatives often need more support than do patients diagnosed with other types of lesions.

At ANA, our experienced brain tumor team also includes psychiatrists, psychologists, child life specialists and social workers. We recognize the need for support in this incredibly stressful time, and we are committed to providing compassionate care.

 

Brain and Spine Tumor Treatment

Several treatment options may be required to remove a brain or spinal tumor, depending on the type and location of the tumor in the nervous system. There have been significant advances in treating brain and spine tumors, meaning success rates have improved in the last two decades.
Biopsy
Any type of biopsy refers to the removal of cells or tissues for examination by a pathologist. The pathologist may study the tissue under a microscope or perform other tests on the cells or tissue. Biopsies can be used to diagnose as well as treat tumors, depending on how much of the tumor is removed. There are many different types of biopsy procedures. The most common types include: Incisional biopsy, in which only a sample of tissue is removed; Excisional biopsy, in which an entire lump or suspicious area is removed; Needle biopsy, in which a sample of tissue or fluid is removed with a needle. When a wide needle is used, the procedure is called a core biopsy. When a thin needle is used, the procedure is called a fine-needle aspiration biopsy.
Stereotactical Biopsy maps the brain in a 3-dimensional coordinate system. In conjunction with MRI and CT scans, the neurosurgeon is better equipped to accurately target the area of the brain in question. This allows the neurosurgeon to easily and safely remove small pieces of the tumor to determine what it is and how best to treat it.
Radiation is a localized, painless therapy to eradicate cancer cells by destroying them and/or by keeping them from reproducing. Two types of radiation treatment include:
  • External radiation therapy is a beam directed at the cancer from outside the body.
  • Internal radiation therapy (called brachytherapy or implant therapy) is from a source placed inside the body at the site of the cancer.
Radiation has come a long way, and can be delivered with more precision and effectiveness largely due to advanced imaging techniques.
Stereotactic radiation, which uses high-powered x-rays on a small part of the body, is used to treat certain types of nervous system tumors. It is a specialized type of external beam radiation therapy, delivered with accuracy and minimal exposure time, both of which are designed to provide results while limiting the effect of the therapy on healthy tissue.

Proton Beam Therapy is a type of radiation delivery system that uses protons rather than x-rays. Depending on the location of the tumor, proton beam therapy can treat it with lower radiation doses to surrounding normal tissue.

Protons (the positively charged parts of an atom) delivered at high energy destroy cancer cells. This type of radiation therapy is particularly desirable for pediatric or adult tumors in critical structures, such as the brain and spine.

Chemotherapy (chemo) uses anti-cancer drugs that are usually given into a vein (IV) or taken by mouth. These drugs are distributed throughout the body via the bloodstream. Since chemo drugs are unable to enter certain parts of the brain or spine via the above methods, some brain or spine tumors may be treated with drugs administered directly to the cerebrospinal fluid (CSF) or to the spinal canal. In this case, a member of the ANA specialized team will insert a thin tube, called a ventricular access catheter, into the skull via a small hole. In general, chemotherapy is used for faster growing tumors. Some types of brain tumors, such as medulloblastoma, are frequently treated with chemotherapy.

Doctors are continually working to learn more about brain and spine tumors. They study how to prevent them, treat them and provide the best care to their patients.

The following areas of investigative research may include new options for patients through clinical trials:

  • Enhanced imaging tests: These are new techniques for imaging scans.
  • Biomarkers: Using blood or other tests to determine the presence of a brain tumor before symptoms begin.
  • Immunotherapy: Also called biological response modifier (BRM) therapy, this technique is meant to fight the cancer by fortifying the body’s natural defenses, such as dendritic cells (the main function of which is to process and present antigens, causing an immune response), or vaccines. Several methods are being tested in clinical trials.
  • Targeted therapy: Treatment that targets faulty genes or proteins that contribute to cancer growth and development.
  • Blood-brain barrier disruption: A system to allow chemotherapy to more easily enter the brain via the bloodstream by temporarily disrupting the brain’s natural protective barrier.
  • New drugs and combinations of drugs: New drugs and combinations of drugs are being developed. And since tumors can develop resistance to chemotherapy, another approach is to use a treatment that targets how tumor cells develop resistance.
  • Gene therapy: Therapy that seeks to replace or repair abnormal genes that are causing or helping tumor growth.
  • Genetic research: Seeking to learn more about mutations of specific genes and how they relate to the risk and growth of brain tumors. This includes discovering more on the link between genetics and glioblastoma.

For many patients with brain or spine tumors, clinical trials offer the best treatment options. Clinical trials are studies designed to test the most promising new treatments.

People participate in clinical trials for a variety of reasons. They want to:

  • Try a new and promising treatment method
  • Contribute to the development of future treatments
  • Help find a cure

Most clinical trials require certain medical criteria in order for a patient to qualify. Some trials can be joined before surgery, others during radiation, or even in the event of recurrence. At ANA, we determine whether a patient is eligible and best served by a number of clinical trials.

Collaboration also extends to organizations that serve as hubs for experts to share their knowledge and research. Dr. Arno Fried explains that memberships in these organizations allow patients “to get the best treatment available—whether they are at Hackensack, Morristown or a hospital in any other part of the country.”

Brain and Spine Tumor Surgery

When dealing with the sensitive areas of the brain and spine, it’s important to choose an expert neurosurgeon that has experience with your type of tumor. You can contact our clinic to discuss your particular case and whether surgery would be a successful treatment option. Our neurosurgeons have decades of experience in treating complex brain and spine surgeries.

Are All Tumors Operable?

With advances in neurosurgery and technology, most tumors are operable, and many are curable. While some may be inoperable, there are protocols available to treat all tumors. At ANA, we also collaborate with pediatric and adult oncologists to consider and implement every possible treatment option. For operable tumors, however, surgery is often performed. At ANA, we are widely experienced in all brain tumor surgery. In addition, follow-up surgical treatment is a comprehensive and ongoing process. Following surgery, a multi-disciplinary team of medical experts, called the Tumor Board, convenes to review the patient’s condition, needs and test results. This collaborative approach is part of a patient’s personalized treatment protocol that ANA is an integral part of.
Does Benign or Malignant Relate to Surgery?
Benign brain tumors are noncancerous while malignant brain tumors are fast-growing cancers that can originate in the brain (primary tumors) or originate in another part of the body and spread to the brain (secondary tumors). Malignant tumors typically grow quicker than benign tumors, aggressively invading surrounding tissue. These types of tumors most often require additional treatments such as radiation and/or chemotherapy or biological agents. As a slower growth, benign brain tumors usually have clearly defined borders and are not deeply rooted in brain tissue. Assuming they are in an area of the brain that can be safely operated, this makes them easier to surgically remove. Once removed, benign tumors are less likely to recur than malignant ones. They can still return, but it is unlikely.

For a typical brain tumor surgery, there are two main objectives:

  • Obtain tissue to make a diagnosis
  • Remove the tumor (total or partial removalAt ANA, our multidisplinary team of experts is committed to the best possible result and that team includes surgeons, neurologists, neuro-pathologists, neuro-oncologists, radiologists, radiation oncologists and specialized nurses.
A biopsy of the brain or spine involves removing a piece of tissue or cell, typically for the purpose of examination and deciding on your course of treatment.
Debulking is the surgical removal of a portion of a tumor in order to decrease the tumor burden on a patient and/or to decrease the mass effect on surrounding structures. This technique is often performed in brain surgery when the entire tumor cannot be removed without serious damage to proximate structures.
GTR is the removal of all visible tumor, and in which subsequent scans show no apparent tumor. GTR is considered when the surgeon believes the entire tumor can be safely removed without substantial risk of unacceptable injury.
An innovative and minimally invasive surgical technique, Endonasal Endoscopy allows the neurosurgeon to remove brain tumors or lesions from the base of the skull, such as in the pituitary area, or the top of the spine through the nose and sinuses. It may also be referred to as a Transsphenoidal Approach Endoscopy.
ANA is experienced in stereotactic radiosurgery, also known as Gamma Knife® or CyberKnife® radiosurgery. It is a non-invasive (no cutting) procedure used to treat brain lesions that are small, inoperable or are residual tumors left after a debulking. It is a same-day radiation treatment procedure done to halt the growth and sometimes shrink these lesions.

Reasons surgery would be a good option for spine tumors:

  • Control of tumor growth by surgical removal, sometimes accompanied by radiation and/or chemotherapy.
  • Improving symptoms by reducing pressure on nerves and stabilizing spine to prevent deformities, collapse or paralysis.

The goal is usually to reduce the severity of symptoms, including:

  • Lessen pain
  • Restore spine stability to improve mobility
  • Preserve neurological function
  • Alter or change outcomes
  • The type of spine surgery will depend on the type of tumor, its location, and the patient’s symptoms.

Brain and Spine Tumor Surgery

When dealing with the sensitive areas of the brain and spine, it’s important to choose an expert neurosurgeon that has experience with your type of tumor. You can contact our clinic to discuss your particular case and whether surgery would be a successful treatment option. Our neurosurgeons have decades of experience in treating complex brain and spine surgeries.

Are All Tumors Operable?

With advances in neurosurgery and technology, most tumors are operable, and many are curable. While some may be inoperable, there are protocols available to treat all tumors. At ANA, we also collaborate with pediatric and adult oncologists to consider and implement every possible treatment option. For operable tumors, however, surgery is often performed. At ANA, we are widely experienced in all brain tumor surgery. In addition, follow-up surgical treatment is a comprehensive and ongoing process. Following surgery, a multi-disciplinary team of medical experts, called the Tumor Board, convenes to review the patient’s condition, needs and test results. This collaborative approach is part of a patient’s personalized treatment protocol that ANA is an integral part of.
Does Benign or Malignant Relate to Surgery?
Benign brain tumors are noncancerous while malignant brain tumors are fast-growing cancers that can originate in the brain (primary tumors) or originate in another part of the body and spread to the brain (secondary tumors). Malignant tumors typically grow quicker than benign tumors, aggressively invading surrounding tissue. These types of tumors most often require additional treatments such as radiation and/or chemotherapy or biological agents. As a slower growth, benign brain tumors usually have clearly defined borders and are not deeply rooted in brain tissue. Assuming they are in an area of the brain that can be safely operated, this makes them easier to surgically remove. Once removed, benign tumors are less likely to recur than malignant ones. They can still return, but it is unlikely.

For a typical brain tumor surgery, there are two main objectives:

  • Obtain tissue to make a diagnosis
  • Remove the tumor (total or partial removalAt ANA, our multidisplinary team of experts is committed to the best possible result and that team includes surgeons, neurologists, neuro-pathologists, neuro-oncologists, radiologists, radiation oncologists and specialized nurses.
A biopsy of the brain or spine involves removing a piece of tissue or cell, typically for the purpose of examination and deciding on your course of treatment.
Debulking is the surgical removal of a portion of a tumor in order to decrease the tumor burden on a patient and/or to decrease the mass effect on surrounding structures. This technique is often performed in brain surgery when the entire tumor cannot be removed without serious damage to proximate structures.
GTR is the removal of all visible tumor, and in which subsequent scans show no apparent tumor. GTR is considered when the surgeon believes the entire tumor can be safely removed without substantial risk of unacceptable injury.
An innovative and minimally invasive surgical technique, Endonasal Endoscopy allows the neurosurgeon to remove brain tumors or lesions from the base of the skull, such as in the pituitary area, or the top of the spine through the nose and sinuses. It may also be referred to as a Transsphenoidal Approach Endoscopy.
ANA is experienced in stereotactic radiosurgery, also known as Gamma Knife® or CyberKnife® radiosurgery. It is a non-invasive (no cutting) procedure used to treat brain lesions that are small, inoperable or are residual tumors left after a debulking. It is a same-day radiation treatment procedure done to halt the growth and sometimes shrink these lesions.

Reasons surgery would be a good option for spine tumors:

  • Control of tumor growth by surgical removal, sometimes accompanied by radiation and/or chemotherapy.
  • Improving symptoms by reducing pressure on nerves and stabilizing spine to prevent deformities, collapse or paralysis.

The goal is usually to reduce the severity of symptoms, including:

  • Lessen pain
  • Restore spine stability to improve mobility
  • Preserve neurological function
  • Alter or change outcomes
  • The type of spine surgery will depend on the type of tumor, its location, and the patient’s symptoms.
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