Types of surgeries to remove brain tumors

Hospitalization and treatment under the compulsory medical insurance quota. More details after viewing the pictures.

Brain tumors can be benign or malignant; the latter are aggressive in nature and pose a significant threat to life. Neoplasms form inside the skull due to abnormal disturbances in the cellular genetic apparatus, which leads to uncontrolled growth of tissue structures. Atypical cells are formed from normal ones as a result of mutations, exposure to physical, chemical or other factors. These can be various cells of brain tissue, for example, neurons, glial cells and others. Often, metastasizing cells formed from cancer of other organs enter the brain, which leads to the formation of secondary malignant tumors. The main treatment involves surgical removal of pathological foci, additionally radiation and chemotherapy are prescribed, as well as drugs to relieve negative clinical manifestations.

Causes of tumors

At the moment, medical science does not fully understand the reliable causes of the formation of cancer. Doctors name factors that increase the risk of tumor formation. An important role is played by the age and gender of a person. Some types of cancer, such as meningiomas, are more often diagnosed in women over 45-50 years of age. This is due to the characteristics of the female endocrine system and hormonal levels. For example, during pregnancy, some neoplasms progress more intensively. Brain tumors in men, as a rule, have a more severe course and complex prognosis, because in this case the tumors are highly malignant.

Other provoking factors include:

• adverse environmental impacts: radiation, hazardous industries, living in contaminated areas, etc.;
• constant contact with toxic elements;
• infection with viruses that can contribute to the development of cancer;
• genetic characteristics (the presence of certain genes in the human genome that increase the risk of developing a brain tumor);
• head injuries of various nature and origin;
• treatment with drugs, for example, hormones, chemotherapy;
• bad habits;
• consumption of low-quality food saturated with carcinogenic elements.

These factors can influence the formation of diseases both separately (for example, heredity) and in combination.

Minimally invasive surgery

Currently, oncological surgeons still have to resort to classic open operations, in which a large incision is made. There are situations when there are no alternatives.

However, in recent decades, the indications for minimally invasive surgical interventions have expanded. Their main advantages: minimizing tissue injury and blood loss, reducing the rehabilitation period.

In laparoscopic operations, instead of making an incision, several punctures are made. An instrument with a video camera and a light source (laparoscope) is inserted through one of them, and special surgical instruments are inserted through the rest.

Endoscopic interventions are performed without incisions or punctures. The endoscope and surgical instruments are inserted through natural openings: mouth, rectum, urethra, vagina. Indications for endoscopic operations are limited. You can remove a fragment of suspicious tissue, benign neoplasms, or cancer in the early stages that has not had time to grow deeper.

The Interventional Surgery Department of Euroonko in Moscow performs embolization (injection of special microspheres into the vessels feeding the tumor that block the blood flow), installation of venous port systems, vena cava filters, and intra-arterial administration of chemotherapy drugs.

For some tumors, they resort to laser surgery, cryosurgery (destruction of the tumor with low temperature), radio wave surgery and other modern methods.

In most cases, cancer surgery is performed under general anesthesia. For some minimally invasive interventions, local anesthesia is used or the patient is put into a state of “medicated sleep.”

Types of tumors

Neoplasms that form in the brain can be:

1. Benign – tumor tissue does not contain cancer cells. Neoplasia of this type is characterized by clear edges and slow growth. They are much easier to treat surgically, but can become malignant, that is, turn into cancer;
2. Malignant tumors contain abnormal cells that can divide uncontrollably and metastasize to other organs. In this case, the disease is difficult to control; in the later stages, surgery is impossible. Treatment in this case is difficult, has a high cost and, as a rule, poor prognosis.

Brain glioma

Glioma

This type of tumor is diagnosed more often, accounting for approximately 60% of all types of cancer that form in the brain. The tumor is formed from glial cells. In most cases, this is a primary neoplasm, most often formed in the area of ​​the chiasmata or ventricles, but it can also affect the brain stem; pathogenesis rarely extends to the bones of the skull, however, in rare cases this is possible. The size of gliomas is usually up to 14 cm. Metastases are rare, growth is usually slow, but due to penetration into adjacent tissues, the boundaries of the lesion are difficult to distinguish.

Three varieties are known

• astrocytoma – diagnosed more often than others (it accounts for about 50% of gliomas);
• oligodendroglioma – up to 10% of cases;
• ependymoma – less than 7%.

According to the World Health Organization classification, there are 4 stages of glioma:

1. The first stage is benign. It is characterized by slow growth. Example: giant cell astrocytoma.
2. Second stage. Features: borderline malignancy with slow tissue growth, easily progresses to stages 3 and 4. In this case, only one symptom of cancer is identified - cellular atypia.
3. Third and fourth stage. In this case, the tumor has all the signs of cancer, for example, necrotic changes in glioblastoma multiforme.

Brain astrocytoma

Removal of a large GRADE II WHO astrocytoma of the right temporal lobe (before surgery)

This malignant neoplasm of varying degrees of aggressiveness is diagnosed quite often. The beginning is given by degenerated glial cells - astrocytes (hence the name - astrocytoma). There are:

1. Common astrocytomas: protoplasmic, fibrillary and hemisrocytic.
2. Special astrocytomas: cerebellar, piloid, microcystic and subependymal.

Astrocytomas are distinguished by the stage of malignancy:

1. The first stage (benign tumor) includes piloid or pilocytic astrocytoma of the brain.
2. Second stage of malignancy: fibrillary tumor is also an ordinary neoplasia, second degree of malignancy.
3. The third stage is already cancer. It includes anaplastic astrocytoma of the brain.
4. The most life-threatening are glioblastomas (giant cell glioblastoma and gliosarcoma), which are classified as stage 4 and are characterized by rapid growth and the ability to metastasize.

In addition to the ones mentioned, there are other types of astrocytomas, for example, ependymoma (develops from ventricular cells), oligodendroglioma (forebrain) - grow quite slowly without the formation of metastases, and glioma of the brain stem.

Meningioma of the brain

Removal of a large middle cranial fossa meningioma before surgery

Pathogenesis begins with pathogenic cells in the superficial membrane that surround the brain tissue. The neoplasm is oval in shape, grows slowly, and is therefore considered benign. Meningiomas are diagnosed in 15% of cases (of all brain tumors). The risk of degeneration into cancer is about 3-4%. The clinical signs that appear are caused by increased intracranial pressure and tissue compression. With malignancy (degeneration of somatic cells into carcinogenic ones), meningiomas become aggressive. Usually more than one lesion forms and may spread to the spinal cord. After surgical treatment, there is a high probability of relapses. As a rule, pathology is diagnosed by chance, because symptoms appear only when the lesion reaches a large size. There are no early signs of the disease.

Note. Meningiomas often form in females.

Other types of brain tumors

There are quite a lot of types of neoplasms. Here are some of those that are diagnosed relatively often (besides those mentioned above):

• medulloblastoma is a brain cancer that originates from the structures of the cerebellum;
• germinoma - formed from germ cells, most often it is detected in the first half of a person’s life;
• Craniopharyngeoma - develops in the pituitary gland at the base of the brain;
• Shawnoma – formed from degenerated Schwann cells;
• tumors in the pineal gland area.

Metabolic plasticity during metastasis

Epigenetic regulation is one of the most important mechanisms for programming cellular metabolism. As the tumor grows, areas with insufficient oxygen supply (hypoxia) form inside it, since blood vessels do not reach them. HIF-1α in cancer cells . This occurs due to epigenetic release, demethylation of the gene promoter, which becomes accessible to transcription factors. The increased production and activity of the HIF-1α protein, in turn, regulates the gene expression of multiple metabolic enzymes and transporters, leading to complex changes in cancer cell metabolism and supporting their needs.

Cellular metabolism is divided into the processes of breaking down to release energy ( catabolism ) and forming compounds using energy ( anabolism ). Cellular energy metabolism occurs through the stages of cellular respiration - glycolysis, the tricarboxylic acid cycle and oxidative phosphorylation. Cancer cells adapt in their own way to maintaining the productivity of energy metabolism in conditions of lack of oxygen. In the primary tumor, they primarily use anaerobic glycolysis rather than oxidative phosphorylation, as in normal cells. This increased uptake of glucose with conversion to lactate released by cancer cells is called the Warburg effect. It allows them to survive hypoxia and actively proliferate due to the use of intermediate compounds for biosynthesis and energy release [10].

The preferential method of generating energy in metastases, however, is still poorly understood. Using breast cancer cells that have broad or specific organotropies during metastasis, scientists have discovered differences in the metabolism of the primary tumor and metastases. Cancer cells that colonized the bones and lungs activated the use of oxidative phosphorylation, while those that colonized the liver activated glycolysis. When cancer cells colonized all of the above foci, they activated both metabolic pathways at once (Fig. 4) [11]. This plasticity appears to help cancer cells develop new niches to colonize. For example, in the liver, the glycolytic phenotype is maintained during the growth of metastases due to the activity of the previously mentioned HIF-1α factor, as well as increased expression of the PDK1 . This is an enzyme that inhibits the formation of the acetyl-CoA compound. And since its flow at the fork with the glycolytic pathway into the tricarboxylic acid cycle decreases, the formation of the final product of glycolysis, lactate, increases [12].

Figure 4. Differences in metabolism of the primary tumor and metastases in different organs. Legend: OP - oxidative phosphorylation; HIF-1α —hypoxia-inducible factor 1; PDK1 —pyruvate dehydrogenase complex 1.

[12]

Why is it more advantageous to use predominantly one type of metabolism than another for metastases in one organ? The answer to this question and the role of various factors in regulating the metabolic plasticity of cancer cells remains to be known.

Clinical manifestations

Symptoms are usually divided into general and focal. In the latter case, the symptoms depend on where the tumor forms.

General symptoms

The clinical picture is caused by an increase in pressure inside the skull and the toxic effect of metabolites of pathogenic cells on healthy tissue. Common signs include:

• headache not relieved by conventional analgesics;
• various visual impairments, for example, fog, doubling, glare, decreased visual acuity and others;
• loss of appetite, poor health, nausea and vomiting that are not caused by food poisoning;
• changes in the usual emotional state: mood swings, depression or aggressiveness, and others;
• symptoms of an epileptic nature;
• weakening of the brain: it is difficult for a person to concentrate, mental activity is disrupted, there is a loss of concentration, memory problems, etc.

Important. Early signs of cancer are often misunderstood by sick people. They seek help when clinical signs significantly impair quality of life. In this case, the brain tumor is diagnosed late, which significantly complicates treatment and worsens the prognosis.

Focal symptoms

Signs of this type arise due to changes in the functioning of cerebral structures, so the clinic depends on the location of the neoplasm:

• when the hemispheres are damaged, tactile sensitivity decreases, muscles in the opposite part of the body weaken (in the presence of pathogenesis in the right hemisphere, problems arise on the left side);
• disease in the temporal lobe leads to a deterioration in the ability to speak, memory suffers, and the perception of smells changes;
• pathological changes in the cerebellum lead to disturbances in gait and coordination of movements;
• damage to the frontal lobe causes mental and cognitive changes;
• neoplasia in the parietal lobe changes tactile sensations and fine motor skills;
• damage to the occipital zone negatively affects vision, and hallucinations are possible.

Important. The presence of these signs (of any type and intensity) is a good reason to seek medical advice. Early detection of pathologies improves the prognosis of treatment.

Rehabilitation goals

The objectives of the program include preventing metastasis and relapse of cancer, reviving lost functions, and activating thought processes. Fortunately, the human brain has great potential for recovery if its structures are not permanently damaged. For example, a violation of the part of the cortex responsible for speech is compensated by training fine motor skills. At the time of brain regeneration, growth factors are produced, which not only recreate damaged fragments, but also stimulate the growth of new ones. Therefore, the main mission of neurorehabilitation is to provide the brain with external stimuli and appropriate medical support.

Cognitive rehabilitation is aimed at renewing conversation skills, long-term and short-term memory, and the ability to concentrate and maintain attention. For this, nootropic drugs are used in conjunction with gaming techniques (putting words together from puzzles, writing diaries). If complete restoration of functions is impossible, every effort must be made to adapt the person to the limitations that have arisen, which will make his life much easier.

Diagnostics

The initial examination involves an oral interview and a physical examination. The doctor assesses the patient’s general condition, determines the nature of clinical manifestations, their duration and intensity, evaluates coordination, reflexes, psycho-emotional state, and so on. Next, the patient will have to undergo a thorough diagnosis, which may include the following types of studies:

• general blood and urine tests;
• blood chemistry;
• Ultrasound (echoencephalography);
• angiography - X-ray contrast study of the condition of the blood vessels of the head;
• examination of eye function and level of vision;
• computed tomography or magnetic resonance imaging – obtaining high-precision layer-by-layer images, which allows you to identify all the nuances of the disease and determine the method of tumor removal;
• magnetic resonance spectroscopy – study of the functioning of pathogenic tissues at the biochemical level;
• positron emission tomography (PET) of the head shows the characteristics of metabolic processes in the painful focus, which makes it possible to talk about the rate of development of the disease;
• biopsy - tissue collection for histological examination; in this case, the material is obtained after tumor removal.

Also of great diagnostic importance is the study of cerebral fluid, in which pathological cells are located. The stereotactic biopsy method is the most informative in terms of determining the type of carcinogenesis and its characteristics.

Rehabilitation programs and recovery periods

To talk about timing, you need to have an idea of ​​the complexity of the initial condition, surgical intervention and its results. If the process is launched on time and goes well, it usually takes about 3-6 months.

Among the most popular methods:

• physiotherapy. It is aimed at symptomatic treatment, helps relieve swelling and pain;
• massage. Prescribed for paresis of the limbs. Improves blood supply, ensures the outflow of blood and lymph, increases neuromuscular conductivity and sensitivity;
• Exercise therapy. Restores lost functions, forms reflex connections, eliminates vestibular disorders.

All rehabilitation measures are carried out by specialists. But the motivation of the patient himself, his desire to work and get results is very important.

Brain tumor removal

Therapy for neoplasms is complex, always complex and quite expensive. For example, in Russia, surgical treatment of a brain tumor is estimated at approximately 350 thousand Russian rubles. You can find out the final cost of treatment in one of the best oncology centers in the Russian Federation after consulting a neurosurgeon. Prices abroad are much higher. In Germany, for such therapy you will need to pay about 28,000-30,000 US dollars, in Israel it is several thousand cheaper, so it is important to take this fact into account when choosing a clinic. You need to pay attention to the nuances. For example, the equipment in foreign clinics is often better, although the treatment methods and results are not fundamentally different, but in the event of an unfavorable outcome, Western specialists will not have to deal with paying local insurance, so they easily take foreign patients who pay for everything themselves.

Note. The main treatment is a radical surgical operation; other methods used in combination act as auxiliary ones (chemotherapy, radiotherapy and other methods).

Brain cancer can only be removed through surgery. It is performed for nodular tumors and is impossible for diffuse neoplasms due to deep infiltration into nearby structures. In such circumstances, brain tumor surgery is performed to remove some of the abnormal tissue, relieve pressure inside the skull, and prevent dropsy. The size of the tumor and the stage of the cancer play a decisive role in deciding whether to remove the tumor.

Radiotherapy involves repeated exposure of cancer cells to radiation, which leads to blockade of division and death of the latter. With significant doses of radiation, pathogenic cells stop developing and most of them die.

At the same time, treatment involves the use of chemotherapy through oral and intravenous administration of cytostatics (toxic substances for pathogenic cells). These therapies have many negative effects. Recently, medicine has been producing more and more unique chemical drugs that selectively target tumor cells, which can significantly reduce the negative impact of poisons on the body.

At the same time, medications are prescribed to eliminate unfavorable signs that can be caused by both the tumor and side effects from the proposed treatment.

Surgery

Surgeries to remove tumors in the brain are the only effective treatment. This type of treatment is very complex. The possibility and effectiveness of the operation depends on many factors, among which important are the stage of cancer, the nature of the spread of pathogenic tissues, the presence of metastases and secondary foci, as well as the localization of pathogenic formations in brain tissue.

Any neurosurgical operation is quite complicated, because the doctor must remove a malignant tumor located between healthy brain tissue. Therefore, treatment of this kind is traumatic, and in some cases impossible. For example, cancer removal is not carried out if the tumor is large, when it affects vital parts of the brain, or if the disease is at a terminal stage. In addition, the person’s health status, the presence of chronic diseases, their stages, the patient’s age and other features are taken into account.

In each specific case, the choice of technique and method of tumor removal is selected individually. At the moment, doctors have a lot of specialized surgical equipment in their arsenal, for example, tomographs, laser and ultrasound equipment. This significantly increases the efficiency of operations to remove tumors.

Most often, surgical removal of brain cancer involves trepanation and resection of the skull. The methodology is as follows:

1. At the beginning of the operation, the surgeon dissects the skin layers above the cranial vault (a scalp incision is made).
2. After turning away the cut skin, the doctor moves the muscle layers aside.
3. At the next stage of the operation, the required part of the bone tissue of the skull is removed so that the brain tumor becomes accessible for manipulation.
4. Then the pathological focus is excised and the extracted bone tissue is installed in its original place (this is called trepanation). If part of the skull is not returned to its original place, then such an operation is called resection.
5. At the final stage of the operation, the soft tissues covering the skull are restored and sutures or staples are applied.

After resection, the hole in the skull is closed with a special material or mesh. Removing pathogenic tissue reduces intracranial pressure, freeing up space for swollen tissue afterwards. In addition, craniotomy is necessary if the tumor process has spread to bone tissue. After removal, the extracted biological material is sent for histological analysis.

Curative resection

Often, if an organ is affected by a tumor, it must be completely removed. But in some cases, usually in the early stages, it is possible to save the organ by removing only its affected part. This operation is called resection. For example, if one small tumor is found in the liver, which does not grow into neighboring organs and does not have time to metastasize, resection can be performed. Due to its ability to regenerate, the liver can restore its previous volume within about 6 months.

In some cases of cancer, it is necessary to resort to amputation of limbs and their parts. In particular, such interventions are performed for malignant bone tumors and melanoma.

Life forecast

Without surgery, treatment of malignant tumors is ineffective, and the prognosis is extremely negative. After removal of a tumor, life expectancy depends on the stage, level of malignancy, type of carcinogenesis and the degree of its germination into other structures. As a rule, after partial removal of the tumor, brain cancer comes back again, so surgery in this case prolongs the patient’s life for a very short time. The patient will live no more than a year if the relapse is aggressive, and only 25% of patients will live more than two years. After removal of the pathological focus at the first stage of malignancy, life expectancy in 80% of patients is estimated at more than 5 years (in the case of complete removal of carcinogenic tissue). The most dangerous are the late stages of the disease. The prognosis for life at the quadruple stage is not very encouraging - a person will not live longer than a year.

Chemotherapy

Chemotherapy drugs can have a neurotoxic effect on the central nervous system, resulting in cognitive impairment. The effect of cytostatics is expressed in the cessation of the processes of growth, development, and the mechanism of cell division, unfortunately, not only malignant, but also normal. Antitumor agents are administered in various ways:

• orally – through the mouth;
• parenterally - by administering intramuscular, intravenous, intra-arterial injections;
• directly into the tumor itself or surrounding tissues;
• in the cavities remaining after removal;
• into the epidural space (cerebrospinal fluid).

Since all these drugs are substances with high biological activity and lack of selectivity, the bone marrow, mucous membranes of the digestive system, and hair follicles are affected. The severity and frequency of adverse events depend on the type of cytostatic, dosage used, administration regimen, and general condition of the patient. The most common side effects:

• inhibition of hematopoiesis (leukopenia, thrombocytopenia, anemia);
• symptoms of intoxication – nausea, vomiting, diarrhea;
• stomatitis;
• alopecia – loss of hair on all parts of the body;
• allergic reactions - rash, skin itching, erythema;
• development of cardiomyopathy;
• neurotoxicity;
• hepatotoxicity;
• nephrotoxicity;
• thrombophlebitis and phlebosclerosis;
• local irritating effect with necrosis and ulceration up to exposure of tendons and muscles;
• flu-like syndrome - chills, fever, weakness, headache and muscle pain.

The selection of a specific drug depends on the sensitivity of living cancer cells taken from the human body to it. Resistance is determined through testing, which makes it possible to avoid taking ineffective drugs and not waste time.

Other treatments

In the future, depending on the indications, radiation therapy or chemotherapy may be necessary. Radiation therapy can be used either if surgery is not possible or after surgery to kill any remaining abnormal cells. Depending on the individual situation, external or internal radiotherapy may be prescribed. With internal, a chip with radioactive material is installed directly into the malignant formation and remains there for the required amount of time. As for chemotherapy, it can also be either the main method of treatment or an additional one, in combination with surgery. The drugs can be administered intravenously, taken orally, or injected directly into the cerebrospinal fluid.