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Brain Tumour Meningioma

What are brain tumours?
The central nervoussystem (CNS) is made up of the brain and spinal cord. Cells in the CNSnormally grow in an orderly and controlled way. If for some reason this orderis disrupted, the cells continue to divide and form a lump or tumour. A tumour is eitherbenign or malignant. Benign tumours can continue to grow but the cells do notspread from the original site. In a malignant tumour, the cells can invade anddestroy surrounding tissue and may spread to other parts of the brain.

What are meningiomas?
A meningioma is atumour of the meninges, which are the protective membranes around the brain andspinal cord.A meningioma canstart in any part of the brain or spinal cord, but the most common sites arethe cerebral hemispheres of the brain, made up of the four lobes. Most meningiomas arebenign and malignant ones are rare. Each year about 4,500people in the UK are diagnosed with tumours of the central nervous system(CNS). Meningiomas make up nearly 1 in 5 (20%) of all primary brain tumours. They are most likelyto be found in middle-aged or elderly people. Meningiomas are more common inwomen than in men.

What causes meningiomas?
Like most brain tumours the cause of meningioma is unknown. In some people there may be an underlying genetic abnormality such as amutation in a specific gene. Recent research has also shown a possible link between meningioma andbreast cancer. Meningiomas frequently possess progesterone receptors and, less commonly,oestrogen receptors, which may explain their higher incidence in women.

What are the different types of menigioma?
Grading refers to theappearance of the tumour under a microscope. The grade gives an idea of howquickly the tumour may grow. There are threegrades:

  • Grade 1 tumours are the most common type and are slow-growing and benign. Most do not come back after treatment.
  • Grade 2 tumours grow more quickly and have a higher chance of coming back after treatment.
  • Grade 3 tumours are more likely to grow quickly and spread into the brain. It is common for the tumour to come back after the first treatment. This is known as a recurrence.

What are the symptoms and signs?
Meningiomas areusually slow-growing tumours and the main symptoms arise from increasedpressure within the skull (raised intracranial pressure). This may be due to ablockage in the ventricles (fluid-filled spaces of the brain), which leads to abuild-up of cerebrospinal fluid (CSF). CSF is the fluid thatsurrounds and protects the brain and spinal cord. The increased pressure mayalso be caused by swelling around the tumour itself. Raised intracranialpressure can cause headaches, sickness (vomiting) and problems withyour vision. Changes in behaviorand personality are general signs of a brain tumour. Fits(seizures) can be an early symptom.

What are the specific symptoms and signs?
Meningiomas can growin different parts of the brain and symptoms will relate to the area of thebrain that is affected:

  • A tumour in the frontal lobe of the brain may cause gradual changes in mood and personality. There may also be paralysis (inability to move) on one side of the body. This is called hemiparesis.
  • If the left side of the brain is affected there may be problems with speech, such as slurring or muddling of words.
  • A tumour in the temporal lobe of the brain may cause problems with coordination and memory loss.
  • If the parietal lobe of the brain is affected, writing and other such activities may be difficult. Hemiparesis may also be present.

Sometimes meningiomas cause little or no symptoms and are discoveredduring investigations into other conditions.

How do doctors examine for possible brain tumour?The doctor willexamine you thoroughly and test the power and feeling in your arms and legs,and your reflexes. Your doctor will lookinto the back of your eyes using an ophthalmoscope. They can see if the opticnerve at the back of the eye is swollen. This can be caused byoedema (swelling of the tissues within the brain), which may occur due to anincrease in the amount of fluid in the brain.

What are the investigations?

CT (computerised tomography) scan
You will be asked notto eat or drink for at least four hours before the scan. A CT scan takes aseries of x-rays that build up a three-dimensional picture of the inside of thebody. The scan is painless and takes 10-30 minutes. CT scans use smallamounts of radiation, which will be very unlikely to harm you or anyone youcome into contact with. CT scans takepictures of your brain and will reveal whether or not there is abnormal growthin the brain, CT scans will giveinformation about the size and location of the growth.

CT (computerised tomography) scan with contrast (Dye)
You may be given adrink or injection of a dye, which allows particular areas to be seen moreclearly. For a few minutes, this may make you feel hot all over. If you are allergicto iodine or have asthma you could have a more serious reaction to theinjection, so it is important to let your doctor know beforehand.

MRI (magnetic resonance imaging) scan
This test is similarto a CT scan, but uses magnetism instead of x-rays to build up a detailedpicture of areas of your body. Before the scan, youmay be asked to complete and sign a checklist. This is to make sure it's safefor you to have an MRI scan. Some people aregiven an injection of dye into a vein in their arm. During the test,you will be asked to lie very still on a couch inside a long cylinder(tube) for about 30 minutes. It is painless, butcan be slightly uncomfortable, and some people feel a bit claustrophobic duringthe scan. It is also noisy, butyou'll be given earplugs or headphones to wear.

This test involves aninjection of a dye to show up the blood vessels in the brain that supply thetumour. The dye is injectedthrough a thin, flexible tube (catheter) that is inserted into an artery in thegroin, arm or neck. A series of x-raysare taken. Your nurse or doctor will explain this test to you in more detail.

The treatment formeningioma depends on a number of things including your general health, and thesize and position of the tumour. The results of your tests will enable yourdoctor to decide on the best type of treatment for you. Your treatment willusually be planned by a team of specialists known as a multidisciplinary team (MDT). The team will usually include:

  • a doctor who operates on the brain (neurosurgeon)
  • a doctor who specialises in treating illnesses of the brain (neurologist)
  • a doctor who specialises in treating brain tumours (an oncologist)
  • A specialist nurse and possibly other healthcare professionals, such as a physiotherapist or a dietitian.

There are some risksassociated with treatment to the brain and your doctor will discuss these withyou.

Benefits and disadvantages of treatment
Treatment can begiven for different reasons and the potential benefits will vary for eachperson.
There are differentoptions of treatment depending on number of factors. Your doctor will explainthe options and benefits and risks of each. If you feel that youcan’t make a decision about the treatment when it is first explained to you, you can always ask for more time todecide.

Before you have anytreatment, your doctor will give you full information about the aims of thetreatment and what it involves. They will usually ask you to sign a form sayingthat you give your permission (consent) for the hospitalstaff to give you the treatment. No medical treatmentcan be given without your consent.

Treatment for raised pressure in the head
If the pressure inthe skull is raised, it is important to reduce it before any treatment is givenfor brain tumours. Steroiddrugs may be used to reduce swelling around the tumour. Effects of Steroidare temporary, short lived to buy time for active treatment to start. If the raisedpressure is because of a build-up of CSF, a tube (shunt) may beinserted to drain off the excess fluid.

Wait and Watch / Wait and Scan / Surveillance Policy
If the tumour issmall, immediate treatment may not be needed. This is because mostmeningiomas tend to be slow-growing and it may be a long time before andsymptoms require treatment. In this situation,regular scans will be done to check for any growth of the tumour. This iscalled active surveillance.

Where possible, surgery is the maintreatment for meningioma and in many cases the tumour can be removed completelywith no complications. Occasionally, theposition of a tumour makes it impossible or too risky to remove surgically. Ifsurgery is not possible, your doctor will discuss other types of treatment withyou.

Radiotherapy treatment uses high-energy rays to destroy the cancer cells. Itmay be used after surgery for malignant meningioma to reduce the chance of thetumour coming back. It may be used after surgery for benign meningiomas thatcannot be completely removed. If surgery is notpossible, radiotherapy may be used alone. Sometimes a technique known as stereotactic radio-surgery may be used, in which hundreds of beams of radiotherapy are aimed atthe tumour in a single session. This is a veryaccurate treatment allowing larger doses of radiotherapy to be given with lessdamage to the surrounding tissues. It is used mainly for smaller tumours andfor tumours that have come back.

Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. Chemotherapyis very rarely used for treating meningioma although research continues intodeveloping this form of treatment.

Medicines for seizures
If you experienceseizures you may be given a medicine called an anticonvulsant to help prevent them.

What is the Outcome?
Themajority of meningiomas do not reoccur but you will have regular scans to checkif there has been any regrowth. Aftera period of time you may stop having scans and checkups completely.

How else will beinvolved in the treatment?
Anumber of different health professionals can help you with these problems.

Clinical psychologist or neuropsychologist
Theymay perform a neuropsychological assessment to assess your intelligence, memoryand other processes. They can also give therapy to help you cope with theproblems you are having.

Theycan help with any difficulties you may be having with limb weakness, difficultywalking or lifting etc.

Occupational therapist
Theycan assess you to see if you might benefit from any adaptations to your home orspecial equipment.

How do people with meningiomas feel?
Often people who have had a meningioma find it hard to explain to people thatalthough they may look fine, they still have difficulty with certain things.

It canbe hard to cope with problems that are long term and you may feel frustratedand angry that you haven’t completely recovered. It often helps to confide insomeone who understands how you feel. Keepingyour thoughts and feelings bottled up inside of you can make everything seemworse. Youmight find it helpful to keep a diary of how you are feeling. This can help yousee that you are making small improvements week by week.

In some circumstancesyou may not be allowed to drive for a period of time. If you have had anepileptic fit, the Drivers and Vehicle Licensing Association (DVLA) will notallow you to drive for a year after your last fit. You can then driveagain provided you remain well. If you have a benignmeningioma and have not had any seizures, the DVLA requires that you do notdrive for at least six months after surgery. Initially, yourlicence may only be for a short period. The hospital will notcontact the DVLA. It is your responsibility to do so and yourdoctor will advise you how to do this. You can contact the DVLA by phone or at www.dvla.gov.uk


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