Carl Rosenkilde, - Westchester Health
 
BRAIN  TUMORS
 
 
The diagnosis of a brain tumor is one of the most terrifying moments for a patient. Yet, in very many instances there is a lack of understanding between the doctor and the patient. The message is sometimes given in the wrong way, perhaps during a telephone conversation, perhaps by an intermediary, such as a technician that lets a word slip, or a doctor of the patient in another specialty that is the first to give the message that “of course, there is a small brain tumor, but your neurologist will discuss that with you later…”
MRI shows benign right temporal arachnoid cyst (NOT a tumor)
 
Yet, there is a very encouraging side to the topic of brain tumors, that does not apply to all, but that should be reviewed as an introduction.
 
The context of the finding is crucial. Usually, the test is a brain imaging such as a CT or MRI. By far the most cases of tumor, spot, mass, lesion, or scar are incidental findings of little consequence. Many results are in the context of a complaint of a headache. A misconception of some patients is that a new headache, with no other context of medical history or physical findings, might be the result of a “brain tumor”. Thus, the expectations, and the fears, and the anxiety level are already not proportional to any likely medical finding on the imaging study.
 
Brain tumors do NOT present with head aches, although the population of patients with significant brain tumors often have headaches as well as many other symptoms (see below). The headache of the patient with brain tumor is one of other symptoms in the setting of physical findings and medical history that the doctor will explore. Thus, do not expect your doctor to request brain imaging “to rule out a brain tumor” when you have a headache. It is not good medicine or the standard of medical practice. Bad news, with diagnosis of a brain tumor, is often the result of inappropriate brain imaging. Paradoxical, is it not..?
 
Further misunderstandings now follow a report of “a spot” or “a lesion” or “a white matter abnormality”. My website is full of information regarding this type of finding. Do not despair.
 
The patient’s level of concern is raised several levels when the report is “a benign mass”, or “a cyst”.
 
 CT of brain with benign right temporal arachnoid cyst
A common finding is usually incidental and of no medical consequence, the ARACHNOID  CYST. These are truly benign, outside brain matter, inside the skull, and within the so-called subarachnoid space. They are cysts like those in the breast of women, or on a tendon of the wrist, but with cerebrospinal fluid inside. The cyst does not communicate with the brain, the circulatory system or the hormonal system. It does not change during the cycle of a month or during the years coming. It does not need to be followed with repeat imaging every year. It stays and does not grow or expand, and it does not interfere with any functioning of the brain.  It does not cause headache or memory deficits. It can be of small size, or it can be large and jump in the eyes of the patient. It does not need to be removed. Surgery is contraindicated. Rarely, a neurosurgical consult is requested by the neurologist.
 
 
PINEAL  CYSTS are more common than arachnoid cysts. They are incidental findings on up to 1 in 4 MRIs, with the majority seen in women.  In autopsy series they are found in 25-40% of the brains. Although they do not grow, they may enlarge a bit with age in women, before shrinking again, perhaps related to hormonal changes. The do not change in males. They are rarely the cause of clinical complaints. Cysts larger than 5 mm occur in less that 3% of adults. If larger than 15 mm, the doctor may wonder about a connection with presenting symptoms, such as headache, nausea, blurry vision, unsteadiness or weakness. A report by the radiologist of calcification or enhancement of the rim is rarely of any significance.
 
 
CT of brain with third ventricular colloid cyst
 
COLLOID  CYSTS are seen less frequently than arachnoid or pineal cysts. These cysts have a fibrous wall and a gelatinous or mucoid center. The location is typically at the third ventricle (see image) where the cyst can obstruct the normal flow of cerebrospinal fluid and cause hydrocephalus with positional headaches that can change in the morning, and perhaps with drop attacks, leg weakness, confusion or memory deficits. The has been present for decades and can suddenly declare itself in adulthood when reaching a size of 1 – 3 cm.
 
 
PITUITARY ADENOMAS are benign tumors of the pituitary gland located at the base of the brain and connected to it by a thin stalk. They are common, found in 15-25% of patients on autopsy or imaging studies. These tumors are outside the brain (though inside the skull) and they are not cancerous. The pituitary gland produces hormones that control other glands in the body and the growth of the body. They may be detected due to excessive or diminished production of a hormone, resulting in unusual milk production, loss of menstrual periods in women, or abnormal body growth (acromegaly or gigantism).
 
Usually the adenoma is detected incidentally when a brain scan is done for some other reason. The normal gland is less than the size of a pea; a microadenoma measure less than 1 cm, a macroadenoma is larger than 1 cm and can expand outside the confines of the gland, called the sella turcica. The larger adenomas can affect vision.
 
Diagnosis is based on imaging, hormonal studies, and sometimes visual fields by an ophthalmologist. Often, no treatment is necessary; the abnormality on imaging requires a repeat study, but not always. If abnormal hormones are detected, medical treatment may be needed supervised by an endocrinologist. Rarely, minimally-invasive surgical treatment is required for macroadenomas using endoscopic techniques through the nasal passages. Other techniques are available, including focal beam radiation.
 
 
MENINGIOMAS are benign tumors that grow in the tissue surrounding the brain or the spinal cord. They are not brain tumors as such, since they do not derive from brain tissue; they grow outside the brain, though inside the skull (or spinal canal, or behind the eye in the optic nerve sheath). They usually grow very slowly, expanding 1-2 mm per year, or less. They are benign if detected early during the course of growth, and provided that they are accessible to adequate treatment. The cause is unknown (but a rare familial form is associated with neurofibromatosis type 2). Multiple meningiomas are seen many patients. Incidence is less than 5% in people younger than age 50, but higher than 10% after age 70; after age 80, at least 1 in 5 patients will have the tumor.
 
Diagnosis is made by CT or MRI of the brain; the latter is the more sensitive test. More often then not the tumor is an incidental finding as a result of searching for other type of pathology.
 
Prognosis depends on several factors. If the is size is less that 2.5 cm, the tumor is small and will typically not be treated but followed for a number of years with imaging. The tumors larger than 3 cm are followed more closely. Since they are slow growing, or NOT growing at all, repeat imaging is usually not done more often that once yearly, sometimes less frequently.
The main type of management is watchful waiting, or “active surveillance”.  Treatment is reserved for a minority of patients: either surgery or radiation, and  initiated only after a period of expectant observation for months or years.  Radiation is offered if surgical approach is difficult or if the patient is considered at high risk (after age 80, or if multiple significant other medical conditions are present, in particular Alzheimer, diabetes, or heart disease). If surgery is done, masses that grew rapidly may reveal cellular features that predict recurrence.
 
Link for further information about meningiomas:
American Society of Clinical Oncologists, Cancer.Net
 
 
BRAIN  CANCER
True brain tumors are a varied group of neoplasms or growths that arise from different types of cells within the brain or from tumors in other parts of the body that have spread and settled inside the central nervous system (the brain and the spinal cord). A metastasis or metastatic tumor is due to a cancer that has invaded the CNS. Tumors are classified by cell type, size, and origin.  
 
There are many different symptoms of brain tumors, and they vary from patient to patient.  If you google your neurological complaint(s), “brain tumor” and “Lyme disease” will almost always appear on the list of possible diagnoses. Do not google your symptoms! Anxiety about a possible brain tumor is a common reason for a neurological consultation in my office when patients experience a new or a different type of headache. Yet, headaches are rarely the first symptom of a tumor. Do not be disappointed if a brain scan is not requested by your doctor when you have a headache. It is rarely necessary. We all have headaches, and they vary from time to time. Some are horrible in intensity and still clearly not due to a brain tumor. Let the doctor listen to your history and do an exam.  The possible need for diagnostic imaging is based on a consultation, not the severity of the headache (Please, see other section(s) on this website about Migraine, and (at a later time) Headaches).
 
Nevertheless, many patients with a brain tumor DO have headaches, but usually not severe and commonly in association with other symptoms, such as nausea and vomiting (which are more frequently indications of migraine headaches). Other associated symptoms may be altered alertness outlasting the duration of the headache. If, in addition, there is an episode of loss of consciousness or a seizure, the differential diagnosis is more complicated.
 
Some symptoms can easily be misinterpreted as depression or emerging dementia (“senility”). There may be fatigue, low energy, a loss of interest, memory problems, mood or personality change, lack of inhibitions, among others. Muscle weakness or lack of coordination limited to one side of the body, tingling and/or numbness may (or may not) be present. The nature of the symptoms is dependent upon which part of the brain is affected by the tumor; they differ from the right to left hemisphere of the brain, and from the front to back of it. Aphasia is a disorder of language, with either word finding difficulties or problems understanding written or spoken language. Aphasia usually is due to an abnormality in the left hemisphere of the brain. Difficulties with spatial orientation can be present with a lesion in the back of the brain at the occipital or parietal lobes. Such a lesion suddenly can interfere with driving one’s car back home after shopping or using the remote control to change channels on the TV.
 
The patient initially will have the evaluation by the neurologist with a detailed history given by the patient and the family, and with an equally important neurological exam. If a tumor is suspected by the neurologist, imaging is necessary, either by CT or MRI, depending upon the situation. MRI is more sensitive for detection of small tumors, particularly at sites in the back of the brain (cerebellum and brain stem). The addition of an intravenous solution increases sensitivity for detection. Not all patients are initially given this contrast material, called gadolinium for MRI imaging. Before injection, some patients may need a blood test for renal functions (BUN and creatinine), although the risk of any side effects is miniscule.  Dr. Rosenkilde does not support the use of “Open MRI” except for the rare patient that cannot do the regular study, which has better resolution of imaging details.
 
When the study is complete, do not expect a phone call from Dr. Rosenkilde with the results: our brains have so many variants, idiosyncratic congenital changes, and incidental findings that these must be seen by and discussed with the patient (see above in this chapter on Brain Tumors). If there indeed is a brain tumor, such report will never be conveyed on the phone. The neuroradiologist always has to give a final opinion, preferably in writing, before the meeting with the neurologist; that reading is occasionally delayed, because the radiologist may want to have a colleague review the images before concluding the report (such additional opinions are not included in the final report).  Perhaps, the imaging study still is ambiguous: maybe it is a stroke, or multiple sclerosis, or a brain abcess, but yet might be a tumor. You, the patient, should understand that good opinions may take a little bit longer. The anxious patient that wants an immediate explanation usually will be left increasingly anxious when the opinions on the study change from one day to the next.  There are other medical situations where rushing the images is critical, but this is not one of them.
 
A surgical brain biopsy is done if a definitive diagnosis cannot be obtained any other way, and IF it is of crucial importance that a diagnosis be made soon. The appearance of low-grade tumors may be diagnostically ambiguous , but surgical biopsy may not be necessary, or can be delayed 6 months, or even 1-2 years, depending on change or growth. Nor is biopsy always necessary in a patient with a known primary cancer outside the brain, if the imaging show multiple tumors.
 
Grading and typing of the tumor is best done by biopsy, done by a neurosurgeon. If the biopsy shows metastasis in a patient who is otherwise well, an evaluation is started to locate the primary tumor. A number of tests follow, based on the more likely sites: more than 60% of such patients have a primary lung cancer. Other frequent causes are melanoma, colon cancer and breast cancer. Surprisingly, the primary cancer remains unknown in more than a quarter of the patients. Additional tests done in these patients typically include CT of chest, abdomen and pelvis; bone scan and PET scan (positron emission tomography) can be useful.
 
 
Biopsy showing glioblastoma
 
The most common brain cancers are metastatic cancers and primary brain cancers. Metastatic brain tumors are nearly 10 times more common than primary brain tumors. Metastasis is a spread of a primary tumor from a variety of other sites in the body; most derive from the lung or breast, and less often from kidney, colon, and melanoma. Cancers of prostate, esophagus, throat and the “benign” skin cancers (squamous cell and basal cell carcinomas) rarely metastasize to the brain.  The spread typically occur through the blood circulation, but occasionally, cancer cells can grow directly through skull or spinal column.
 
Primary brain tumors originate in the brain.  Gliomas develop from glia cells, which are different from nerve cells, called neurons. Gliomas are graded according to their histology, or microscopic appearance. Grades I and II are low-grade and may remain benign. High-grade gliomas are malignant, with the classification of grade III and grade IV; the latter are called glioblastoma.
 
Treatment of the patient with brain cancer is done by a team of physicians, including neurologist, neurosurgeon, oncologist, radiation oncologist, and the primary care physician. Initial treatment often involves a steroid to reduce cerebral swelling with edema, along with a seizure medication, even if the patient has not had a seizure. Surgical resection and radiation of either solitary tumor or of the entire brain may follow soon. Any underlying medical issues should be addressed. Some patients will need a medication to keeps the blood thin and thereby preventing clots to form in the circulation or the lungs (pulmonary embolus). A shunt, or a tube, is sometimes placed in the brain by the neurosurgeon to restore flow of blocked cerebrospinal fluid and in this way lower heightened pressure within the brain and improve hydrocephalus, if present. Chemotherapy for primary brain cancers is sometimes an option. Temozolomide (Temodar) is now widely used for high-grade gliomas. Trials have been encouraging for use of bevacizumab (Avastin), an antibody that helps decrease the rapid growth of blood vessels when tumors grow and spread, thus depriving the cancer its supply of nutrients. There are often clinical trials offered at large hospital centers to improve management. Experimental protocols with new drugs, with side effects and efficacies still undefined, are reasonable to consider for the patient with a relapse after initial treatments. Read about clinical trials for gliomas:
 
Link about brain tumors in general:
National Cancer Institute,
 
 
 
 Cells of pituitary adenoma
 
 
 
“All photographs are accurate but none of them is the truth”; - Richard Avedon, photographer.
 
 
Website Builder provided by  Vistaprint