Cancer of the Brain

Presented by A4

Brain tumors can be deadly, significantly impact

quality of life, and change everything for a patient
and their loved ones. They do not discriminate,
inflicting men, women, and children of all races
and ethnicities.

SURVIVAL RATE

256, 213
NUMBER OF KNOWN CASES (As of 2012 - Most
recent available in southeast asia)

5, 390

NUMBER OF KNOWN CASES IN THE PHILIPPINES

2.58/1000

Cancer Cases per 1000 people (In PH)

2 - 5%

SURVIVAL RATE (In 5 years)

here are nearly 700,000 people in the U.S. living

with a primary brain and central nervous system
tumor.

MOST PREVELANT

36%

Meningiomas

80%
Gliomas

15%

Glioblastoma

LIFETIME COST

INTRODUCTION

Malignant brain tumors are the most common cause

of cancer-related deaths in adolescents and young
adults aged 15-39 and the most common cancer
occurring among 15-19 year olds.

INTRODUCTION

Brain cancers include primary brain tumours,

which start in the brain and almost never spread
to other parts of the body, and secondary

tumours (or metastases), which are caused by

cancers that began in another part of the body.

INTRODUCTION

There are more than 40 major types of brain tumours,

which are grouped into two main types:

Benign - slow - growing and unlikely to spread.

Common types are meningiomas, neuromas,
pituitary tumours and craniopharyngiomas.

Malignant - cancerous and able to spread into other

parts of the brain or spinal cord. Common types
include astrocytomas, oligodendrogliomas,

ependymomas, glioblastomas and mixed gliomas.

TISSUE OF ORIGIN
Glial (50%) Astrocytoma, oligodendroglioma, ependymoma
Meninges (25%) Meningioma, meningiosarcoma
Pituitary (20%) Craniopharyngioma, adenoma

Vascular (2%) Angioma, haemangioblastoma

Pineal (<1%) Pinealoma, pineoblastoma
Germ cells (<1%) Teratoma, dysgerminoma Miscellaneous
Chordoma, medulloblastoma, lymphoma


Glioma tumors are considered HIGH GRADE
TUMORS

INTRODUCTION

An individual's prognosis depends on the

type and stage of cancer, as well as their
age and general health at the time of
diagnosis.

Anatomy and
Physiology

THE BRAIN: Cerebrum

THE BRAIN: Cerebellum

THE BRAIN: Brain Stem

THE BRAIN: Cerebrospinal Fluid

THE BRAIN: Meninges

THE BRAIN: Corpus Collosum

GLIAL CELLS

ASTROCYTES

MICROGLIA

EPENDYMAL

OLIGODENDROCYTES

SATELLITE CELLS

ETIOLOGY

ETIOLOGY

The etiology of most primary brain tumours

is UNKNOWN

RISK FACTORS

RISK FACTORS

AGE More common in children

and older adults.
GENDER Men are more likely to
develop brain tumor.
FAMILY HISTORY About 5% of
brain tumors may be linked in
hereditary factors.

Risk factors

GENETICS
The most common chromosomal
changes in brain tumors occur in chromosomes
1, 10, 13, 17, 19, and 22.
RACE AND ETHNICITY
White people are more likely to
develop gliomas but less likely to develop
meningioma than black people.

Risk factors

Exposure to radiation
Previous cancer May due to the treatment
for previous cancer such as radiotherapy.
Note:
Electromagnetic fields such as energy from
mobile phone shows no link to an
increased development of cancer
according to researches.

BRAIN TUMORS
Despite the amount of brain tumors, and their
devastating prognosis, there have only been four
(4) FDA approved drugs and one device to
treat brain tumors in the past 30 years.

CLASSIFICATION
Classified by cell origin

ASTROCYTOMAS
Tumors that arise from astrocytes star-shaped cells that
make up the glue-like or supportive tissue of the brain.
Divided into four WHO grades:
Grade I - Pilocytic astrocytoma
Pediatric; 85% cerebellar; slow-growing; wellcircumscribed; cystic; benign
Grade II - Astrocytoma
Infiltrative; slow-growing
Grade III - Anaplastic astrocytoma
Hypercellular; anaplasia
Grade IV - Glioblastoma multiforme (GBM)
Poorly differentiated, with high mitotic rate; highly
malignant
Most common glioma

ASTROCYTOMAS

EPENDYMOMAS
Tumors that arise from the ependymal cells that line the
ventricles of the brain and the center of the spinal cord.
Divided into four major types:
Grade I - Subependymomas
Typically slow-growing tumors.
Grade II - Myxopapillary ependymomas
Typically slow-growing tumors.
Grade III - Ependymomas
This type can be further divided into the following
subtypes, including cellular ependymomas, papillary
ependymomas, clear cell ependymomas and tancytic
ependymomas.
Most common of the ependymal tumors.
Grade IV - Anaplastic ependymomas
Typically faster-growing tumors.

EPENDYMOMAS

GLIOBLASTOMA MULTIFORME (GBM)

The most common and most malignant of the glial
tumors.
Generally found in the cerebral hemispheres of the brain.
Two types of Glioblastomas:

1. Primary or de novo

These tumors tend to form and make their presence

known quickly. This is the most common form of
glioblastoma; it is very aggressive.
2. Secondary
These tumors have a longer, somewhat slower growth
history, but still are very aggressive. They may begin as
lower-grade tumors which eventually become higher
grade. They tend to be found in people 45 and younger,
and represent about 10% of glioblastomas.

GLIOBLASTOMA MULTIFORME (GBM)

MEDULLOBLASTOMAS
Medulloblastoma is a fast-growing, high-grade tumor. It is the
most common of the embryonal tumorstumors that arise
from emybryonal or immature cells at the earliest stage of
their development.
It is always located in the cerebellumthe lower, rear portion
of the brain. It is unusual for medulloblastomas to spread
outside the brain and spinal cord.
The various types of medulloblastoma include:
Classic medulloblastoma
Desmoplastic nodular medulloblastoma
Large-cell or anaplastic medulloblastoma
Medulloblastoma with neuroblastic or neuronal
differentiation
Medulloblastoma with glial differentiation
Medullomyoblastoma
Melanotic medulloblastoma

MEDULLOBLASTOMAS

OLIGODENDROGLIOMAS

Oligodendrogliomas come from

oligodendrocytes, one of the types of cells that
make up the supportive or glial tissue of the brain.
They can be low-grade (grade II) or high-grade
(grade III or anaplastic).
These tumors can be found anywhere within the
cerebral hemisphere of the brain, although the

frontal and temporal lobes are the most common

locations.

Generally soft, grayish-pink tumors. They often

contain mineral deposits (called calcifications),
areas of hemorrhage, and/or cysts.

OLIGODENDROGLIOMAS

CLINICAL FEATURES
Signs and Symptoms

GENERAL FEATURES

The common general features of cancer

in the brain are due to pressure and
swelling on the brain as a whole. This causes
headache, nausea, vomiting and
disturbances of vision due to swelling of the
optic nerve at the back of the eye (seen as
papilloedema). The most signicant single
feature is persistent headache.

GENERAL FEATURES

New onset or change in pattern of

headaches
Headaches that gradually become
more frequent and more severe

Weakness of the body

Difficulty with balance
Seizures

FOCAL FEATURES

Focal features are due to interference of

function of a local region of the brain. These
features will depend upon the site of the
tumour.
In one place it may be interference with
speech, in another it may be loss of
movement of an arm or leg, or elsewhere or
loss of sensation in a part of the body.

FOCAL FEATURES

Altered mental status - changes in concentration, memory,

attention, or alertness
Unexplained nausea or vomiting
Vision problems, such as blurred vision, double vision or loss
of peripheral vision
Gradual loss of sensation or movement in an arm or a leg
Endocrine dysfunction (hormone/gland changes)
Difficulty with speech
Gradual changes in intellectual capacity or emotional
response

DIAGNOSTIC
PROCEDURES
Investigations

DIAGNOSTIC PROCEDURES

Brain tumors are not usually detectable

until after symptoms appear
Usually a complete medical history,
physical assessment testing the neurological
status of the patient will precede an order of
a diagnostic test
After the test results come back, the
doctors will then begin with the staging
process

DIAGNOSTIC PROCEDURES: COMPUTED

TOMOGRAPHY

DIAGNOSTIC PROCEDURES: COMPUTED

TOMOGRAPHY

DIAGNOSTIC PROCEDURES: COMPUTED

TOMOGRAPHY

DIAGNOSTIC PROCEDURES: MAGNETIC RESONANCE

IMAGING

DIAGNOSTIC PROCEDURES: MAGNETIC RESONANCE

IMAGING

DIAGNOSTIC PROCEDURES: MAGNETIC RESONANCE

ANGIOGRAPHY

DIAGNOSTIC PROCEDURES: POSITRON EMISSION

TOMOGRAPHY

DIAGNOSTIC PROCEDURES: POSITRON EMISSION

TOMOGRAPHY

DIAGNOSTIC PROCEDURES: POSITRON EMISSION

TOMOGRAPHY

DIAGNOSTIC PROCEDURES: OPEN BIOPSY

DIAGNOSTIC PROCEDURES: LUMBAR PUNCTURE

DIAGNOSTIC PROCEDURES: DIFFUSION TENSOR

IMAGING

DIAGNOSTIC PROCEDURES: DIFFUSION TENSOR

IMAGING

DIAGNOSTIC PROCEDURES: DIFFUSION TENSOR

IMAGING

DIAGNOSTIC PROCEDURES: DIFFUSION TENSOR

IMAGING

CONFIRMATORY

There is no actual confirmatory test

as brain tumors are often detected
when symptoms have already
appeare. Confirmarion depends on
the team that works on the case
which consists usually of an
oncologist, neurologist,
neurosurgeon and neuroradiologist.

STAGING
Prognostic Indicators

STAGING
Did you know that?

Brain cancer grading is much different

than staging other cancers in the body.
Cancers in the lung, colon and breast are
staged based on their location in the
body, size, lymph node involvement, and
possible spread.
Tumors in the brain are graded based on
how aggressive the tumor cells appear
under a microscope.

STAGING

Grade I: These are the least malignant tumors

and are usually associated with long-term
survival. They grow slowly and have an almost
normal appearance when viewed through a
microscope. Surgery alone may be an effective
treatment for this grade tumor. Pilocytic
astrocytoma, craniopharnygioma, and many
tumors of neuronsgangliocytoma and
ganglioglioma, for instanceare examples of
grade I tumors.

Here is a pilocytic astrocytoma (juvenile, or cystic, astrocytoma) of the cerebellum in a child. This
neoplasm typically is composed of a large cyst with a mural nodule of solid tumor

Staging

Grade II: These tumors are slowgrowing and look slightly

abnormal under a microscope.
Some can spread into nearby
normal tissue and recur,
sometimes as a higher grade
tumor.

STAGING

Grade III: These tumors are, by

definition, malignant although there is
not always a big difference between
grade II and grade III tumors. The
cells of a grade III tumor are actively
reproducing abnormal cells, which
grow into nearby normal brain tissue.
These tumors tend to recur, often as
a grade IV.

Diffusely infiltrating anaplastic astrocytoma of the right medulla oblongata, with

gross enlargement of affected structures

STAGING

Grade IV: These are the most malignant

tumors. They reproduce rapidly, can have a
bizarre appearance when viewed under the
microscope, and easily grow into nearby
normal brain tissue. These tumors form new
blood vessels so they can maintain their rapid
growth. They also have areas of dead cells in
their centers. The glioblastoma multiforme is
the most common example of a grade IV
tumor.

PATHOPHYSIOLOGY

PATHOPHYSIOLOGY

Non - Modifiable Factors

-Family history of brain cancer
-Health history of lower grade
astrocytoma or
oligodendroglioma
-Gender (more common in men)
-Age (50 years and above)

Modifiable Factors
-Ionizing radiation exposure
-Lifestyle
-Diet (eating cured foods with
nitrites)
-Cigarette smoking

Mutation inactivates suppressor genes within the brain

Increased glial cell proliferation within the brain tissue

Severe dysplasia of glial cells, leading to carcinoma in

situ

PATHOPHYSIOLOGY

Mutations inactivate DNA repair genes

Uncontrolled growth in the area of
first mutation

Proto-oncogenes mutate into

oncogenes

Glial cells within the area of first mutation experience loss of normal specialized
function
As tumor becomes larger, cells in the center of the tumor experiences decrease in
oxygen and nutrients

The cells on the outskirts of the tumor begin to send out signals (angiogenic factors)
Stimulation of the growth of capillaries from near by blood vessels (angiogenesis)
begin to provide the tumor with oxygen and nutrients

PATHOPHYSIOLOGY

Membrane erosion of surrounding brain tissues

Increased tumor growth
Increased pressure on surrounding structures
Signs and Symptoms:
-Headaches that gradually increase in frequency and pain
-nausea and vomiting,
-impaired vision,
-gradual loss of sensation in arms/ legs,
-difficulty with balance
-Speech difficulties
-Confusion/ behavior or personality changes
-Seizures
-Hearing problems

TREATMENT

SURGERY

It is often the first type of therapy for a patient with a

brain tumor.
Purpose:
Provide a tumor sample to establish an
accurate diagnosis.
Remove as much tumor as possible
Enable direct access for chemotherapy,
radiation implants, or genetic treatment of
malignant tumors.
Relieve seizures (due to a brain tumor) that are
hard to control.

SURGERY

Types:
The most common types of surgery for brain tumors are:

Biopsy: surgical removal of a sample of tumor tissue.

Stereotactic biopsy: is performed to establish
diagnosis only. It is used for tumors that are deep or
in eloquent areas of the brainstem where tumor
resection is not feasible.
Craniotomy: surgical removal of a portion of the skull.
Craniectomy: similar to a craniotomy. The main
difference is that the portion of the skull that was
removed to allow access to the brain is not replaced.

SURGERY

Debulking: surgical reduction of the size of the tumor.

Partial Removal: surgical removal of only part of the
tumor.
Complete Removal: surgical removal of the entire
tumor.
Shunt: insertion of a drainage system designed to
move excess fluid from the brain to another part of the
body.
Ommaya Reservoir: insertion of a small container
under the scalp which is attached to a tube. This
container can be used to:

SURGERY

Deliver chemotherapy treatment to the brain and the

surrounding cerebrospinal fluid(CSF).
Remove CSF to detect the presence of normal cells.
Remove cystic fluid without the need for surgery.
Transphenoidal Surgery: An approach often used to
operate on pituitary adenomas and
craniopharyngiomas.
Laser Interstitial Thermal Therapy (LITT): is a
minimally invasive means of ablating (cooking) tissue
with heat.

SURGERY: NURSING CONSIDERATIONS

1. Instruct patient and family about the necessity and

importance of diagnostic tests to determine the exact
location of the tumor.
2. Provide both verbal and written instructions to the
patient and family members with information to discuss
and to take home for further study
3. Supportive nursing care is given depending upon the
patient's symptoms and ability to perform activities of
daily living.
4. Monitor and record vital signs and neurological status
accurately q2-4h, or as ordered.
5. Obtain consent forms and review perioperative
routines.

CHEMOTHERAPY

It interferes with cell division and inhibits tumor growth. It

is typically used to treat malignant or higher grade
tumors, but may also be used to treat low grade and
benign tumors.
Purpose:
The goals of chemotherapy are to stop tumor growth
by rendering the cells unable to duplicate themselves
or to artificially start the normal process of cell death
(apoptosis).

CHEMOTHERAPY

Types
There are two main types of chemotherapy drugs:
1. Cytostatic: These drugs prevent cells from
reproducing. They include:
Anti-angiogenesis agents/Angiogenesis
inhibitorsit prevent the development of blood
vessels around the tumor that provide it with the
nutrients it needs to grow.
Growth factor inhibitorsit limit the supply of
growth factors, which prevent the tumor from
becoming larger.

CHEMOTHERAPY

2. Cytotoxic: These drugs artificially start the process of

cell death. They include:
Alkylating agentsdrugs affect DNA in tumor cells
in a way that prevents them from reproducing.
Antimetabolitesstop tumor cells from making the
enzymes needed for new cell growth.
Anti-tumor antibioticsstop the action of enzymes
needed for cell growth and may be able to change
the environment around the cell.
Hormonessubstances may interfere with tumor
growth by blocking the production of certain
proteins in the tumor cells.

CHEMOTHERAPY

Mitotic inhibitorsthese agents are usually plantbased, natural substances that interfere with the
production of the proteins needed to create new
cells.
Steroidsused to decrease swelling around the
tumor. While they are not intended to be
cytotoxic therapy, some researchers believe that
steroids have a toxic effect on tumor cells.

CHEMOTHERAPY

Potential Side Effects

Nausea and Vomiting (most common)

Headache
Diarrhea
Fatigue
Fetal injury

CHEMOTHERAPY

Potential Risks

Interactions with other drugs

Infertility
Seizures
Weakness
Balance or coordination problems
Memory or cognitive problems
Brain swelling
Damage to internal organs
Stroke
Coma
Death

CHEMOTHERAPY

Most commonly used chemotherapeutic agents for

primary brain tumors are:

Carmustine (BCNU)
Lomustine (CCNU)
Temozolomide
Procarbazine, CCNU, Vincristine (PCV)
Procarbazine
Gliadel chemotherapy wafers

CHEMOTHERAPY: NURSING CONSIDERATIONS

1. Assess knowledge of chemotherapy treatment plan,

possible side effects and self-care measures
2. Instruct patient on measures they can use to lessen the
severity of side effects from chemotherapy, such as
relaxation, imagery, music therapy.
3. Provide patient with written materials such as
Chemotherapy and You from the National Cancer
Institute, and institutional fact sheets on drugs
4. Inform patient of the names of chemotherapy
medications, purpose, route, method, schedule of
administration.

CHEMOTHERAPY: NURSING CONSIDERATIONS

5. Instruct patient not to take any other medications unless

prescribed by the physician, including OTC drugs.
6. Report of any signs of infections, persistent nausea and
vomiting, unusual bleeding or bruising, diarrhea or acute
changes in mental status.
7. Provide the patient a copy of teaching packet that
includes the contact numbers for use during business
and after hours.

Radiotherapy

An integral part of the treatment of

malignant brain tumors
Can be used alone or in combination with
chemotherapy or experimental drugs.
Some benign tumor may also benefit from
radiotherapy if they are recurrent or if there
is significant residual tumor.

Radiotherapy

Radiation oncologist makes a

recommendation based on tumor
classification, grade, location, and amount
of residual tumor.
Focused to treat tumor resection cavity
and surrounding brain, damages DNA as
cell division occurs.
Total dose is divided over a 6-week period,
with treatment 5 days per week.

Radiotherapy

Nursing Consideration:
1.Discuss radiotherapy before surgery
2.Discuss risks and benefits of radiotherapy
after surgery.
3.Inform of possible complications and what
symptoms should be reported immediately.
4.Discuss the side effects of radiotherapy
like: nausea, vomiting, fatigue, alopecia,
changes in saliva, and taste alterations.

Other treatment Modalities: Medical Treatment

New substances that are first studied in

laboratory animal models and then progress to
phase I, II, III clinical trials to evaluate safety,
toxicity, and effectiveness of new treatment.

Example: Antiangiogenic- substances have

been developed to disrupt the process of
angiogenesis in the hope of retarding blood
vessel proliferation.

Other treatment modalities: Gene Therapy

It uses viral vectors (retrovirus, adenovirus or

human herpes simplex virus) that are unable
to replicate.
Injected into dividing tumor cells, making the
tumor cells sensitive to antiviral drugs.

Example: Antiviral (Ganiclovir)- injected into

tumor with the goal of inactivating infected
cells

Reasons why patients enroll in investigational

protocols:

They would like to be involved in state-of-theart

therapies
They hope to help in the search for more
effective treatment modalities for brain tumors
They have exhausted more conventional
therapies
Limited treatment options
Note: Patient are aware that these therapies

have not yet shown efficacy and may in fact,

have unknown toxicities.

Other Treatment Modalities:

NURSING CONSIDERATIONS

1. Discuss informed consent by the principal

investigator/ research nurse.
2. Provide schedules for treatment and 24-hour
contact for reporting adverse effects
3. Inform patient and family that withdrawal from the
protocol is optional and carries no negative
consequences.
4. Use patient teaching sheets with drug description,
known side effects, and contact numbers minimizes
complications and maximizes patient compliance.

SUPPORTIVE THERAPY

Dexamethasone 416 mg daily is very effective

at relieving raised intracranial pressure.
Mannitol intravenously is useful as an adjunct
in an acute exacerbation of raised intracranial
pressure.
Anticonvulsants should be given only for
documented ts and patients with epilepsy or
recent craniotomy should be advised not to drive
until t free according to national guidelines.

COMPLICATIONS

COMPLICATIONS

Serious and sometimes life-threatening

complications can develop with brain cancer:
Obstructed flow of cerebrospinal fluid from the third
ventricle may cause sudden death.
Cerebral hernia is a progressive, fatal condition in
which the brain is forced through an opening in the
skull.
Hemorrhagic stroke produces sudden loss of vision
and/or speech, unconsciousness, and paralysis.

COMPLICATIONS

Brain herniation:
Loss of ability to interact or function
Permanent, worsening, and severe loss of
brain function
Return of tumor growth
Side effects of medicines, including
chemotherapy
Side effects of radiation treatments

POSSIBLE NURSING
DIAGNOSIS

NURSING DIAGNOSIS

1. Anxiety related to unknown future following surgery

as manifested by restlessness/disorientation
2. Situational Low self-esteem related to
chemotherapy effects (Loss of hair/weight loss,
sterility, overwhelming fatigue or uncontrolled pain)
as manifested by verbalization of change in
lifestyle/negative feelings about body
3. Anticipatory grieving related to anticipated loss of
physiological well being (change in bod function) as
manifested by changes in eating habits/alterations in
sleep pattern/activity levels

NURSING
INTERVENTIONS/CARE
FOR BRAIN TUMOR
PATIENTS

Anxiety related to unknown future following

surgery as manifested by restlessness/disorientation
Independent
- Monitor vital signs (Anxiety may affect physiologic
change)
- Assist patient to reduce present level of anxiety b
providing reassurance and comfort
- Discuss/demonstrate affecting coping mechanisms
for dealing with anxiety
- Encourage therapeutic relationship and be available to
client for listening and talking
- Provide diversional activities (Watching TV or listening
to music)
Dependent
- Administer medications as ordered (Antidepressant)
Collaborative
- Refer to psychologist if appropriate

Situational Low self-esteem related to chemotherapy effects (Loss of

hair/weight loss, sterility, overwhelming fatigue or uncontrolled
pain) as manifested by verbalization of change in lifestyle/negative
feelings about body

Independent
- Discuss with the patient and so how the diagnosis and treatment are
affecting patients personal life, home and work activities
- Evaluate support structures available to and used by patient and
significant others
- Use therapeutic touch during interactions, if acceptable to patient
and maintain eye contact
- Acknowledge difficulties patient may be experiencing give
information that counselling is often necessary and important in the
adaptation process
- Provide emotional support for patient and SO during diagnostic tests
and treatment phase
Dependent
- Administer medications or IV therapy as ordered by the physicians
Collaborative
- Refer to professional counseling as indicated

Anticipatory grieving related to anticipated loss of

physiological well being (change in bod function) as
manifested by changes in eating habits/alterations in sleep
pattern/activity levels
Independent
- Assess patients SO of stage of grief currently being experienced
- Provide open, nonjudgemental environment. Use therapeutic
communication skills of active listening and acknowledgement
- Encourage verbalization of thoughts or concerns and accept
expressions of sadness, anger, rejection. Acknowledge normality of these
feelings
- Be aware of debilitating depression ask patient direct questions about
state of mind
- Note evidence of conflict; expressions of anger; and statements of
depression
Dependent
- Administer medications as ordered (Antidepressant)
Collaborative
- Refer to psychologist if appropriate

TRIVIA

TRIVIA

Just 14% of adults survive for five years after

diagnosis.
Brain tumours reduce life expectancy by on
average 20 years the highest of any cancer.
Between 1998 and 2014, there were 78
investigational brain tumor drugs that entered
the clinical trial evaluation process. 75 failed.
That is a 25:1 failure ratio in developing new
brain tumor treatments over the past two
decades

TRIVIA

The four approved drugs for brain tumors have

provided only incremental improvements to
patient survival, and mortality rates remain
little changed over the past 30 years.
Even benign brain tumors can be deadly if they
interfere with portions of the brain responsible
for vital bodily functions.
Almost 5,000 people lose their lives to a brain
tumour each year.

FIN