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Brain Tumours

Clinical Oncology

Brain tumours are not commonly seen, with approximately 1,000 new cases reported annually in Hong Kong (an average of about 15 cases per 100,000 people). Among primary malignant brain tumours (i.e., brain cancer), glioblastoma accounts for approximately 80 new topics each year.
The brain is the central organ of the human body, controlling our abilities, such as thinking, memory, language, emotions, and activities. Once invaded by cancer cells, the functions of the brain will be affected to varying degrees, and treatment is also more challenging compared to other types of cancers.

Symptoms

Brain cancer can be divided into primary and secondary types.

Primary brain cancer refers to malignant tumours originating in the brain, typically named after the primary brain cells (Gliomas). e.g. Astrocytomas, which develop from astrocyte cell mutations, are more common examples.
Secondary brain cancer, also known as "brain metastasis," occurs when malignant tumours from other parts of the body spread to the brain through the bloodstream. Common cancers that metastasize to the brain include lung cancer and breast cancer. Secondary brain cancer is more common than primary brain cancer.

Different brain regions have other functions, so a patient's symptoms are related to the tumour's location. Some patients may have no symptoms, only discovering the tumour during routine physical examinations. Others may experience multiple symptoms simultaneously.

Symptoms of brain tumours can be classified into four main categories: Increased Intracranial Pressure, Seizure Episodes, Systemic Impairments, and Local Neurological Dysfunctions.

Increased Intracranial Pressure	Headache: Typically, a dull ache is worsened by coughing, sneezing, or straining. Early morning headaches are common. As the tumour progresses, headaches become more severe, and medications may not alleviate them. Vomiting: Sudden and intense, often described as "projectile." It may occur without preceding headaches or nausea. Visual Impairment: Blurred vision, double vision, or other visual disturbances. Altered Consciousness: Due to reduced blood flow to the brain and affected brainstem function. Rapid tumour growth may lead to brain oedema, causing a quick transition from wakefulness to coma.
Seizure Episodes	Seizures may occur in brain tumour patients, ranging from localized to generalized seizures. The occurrence of seizures in adults should prompt suspicion of a brain tumour, necessitating detailed brain examinations.
Endocrine Disorders	Hormonal imbalances can cause abnormal growth, body shape changes, and sexual dysfunction. Tumours affecting the pituitary gland's hormone secretion may result in conditions like gigantism, acromegaly, infertility, and menstrual irregularities.
Local Neurological Dysfunctions	Patients may experience localized neurological symptoms, such as weakness or lack of flexibility in one side of the body, abnormal sensations, unsteady walking, difficulty with speech, personality changes, visual field defects, and localized seizure episodes.

Factors

The medical community still does not have a precise understanding of the causes of brain cancer, but it may be associated with the following risk factors:

Age: While individuals of any age have the potential to develop brain tumours, those aged 40 and above have a higher risk. However, certain brain cancers like medulloblastoma are almost exclusive to children.
Family history: A family history of individuals with neuroglial tumours.
Long-term exposure to chemicals: Prolonged exposure to substances like radiation, formaldehyde, chloroethylene, and propylene.

Diagnosis

The diagnosis of brain cancer includes three aspects: Clinical Physical Examination, Imaging Examination, and Pathological analysis:

Clinical Neurological Examination	Doctors evaluate the patient's nervous system function, including vision, balance, coordination, and reflexes.
CT Scan	Scan the entire body, multiple cross-sectional images are obtained, and a computer forms two-dimensional (2D) or even three-dimensional (3D) images to increase the accuracy and efficiency of diagnosis. A contrast agent may make the pictures more straightforward for brain tumour patients undergoing a CT scan. This examination involves a small amount of radiation.
MRI	It accurately displays detailed information about brain tumours and is an essential diagnostic tool for brain tumours. It is also used for preoperative evaluation to assist in the positioning and navigation of surgery.
PET-CT	Commonly known as a PET scan, it is an advanced isotope imaging technique that shows the metabolic activity of cells and effectively evaluates the location and extent of tumour spread.
Pathological Analysis	Doctors may extract cerebrospinal fluid through a lumbar puncture or perform a tumour tissue biopsy to examine the tumour cells' presence and determine the tumour's nature.

Grading on Brain Tumours

To formulate the most appropriate treatment plan and assess prognosis, the World Health Organization (WHO) classifies the malignancy of primary malignant brain tumours into four grades based on the histological changes observed under a microscope:

Grade I
Tumours with the lowest malignancy, where the cells appear almost normal under the microscope. Grade I tumours can be effectively treated through simple surgery, and patients typically have a longer survival time.
Grade II
Microscopically, slightly abnormal cells are observed, and their growth rate is relatively slow. There is a chance of invading nearby brain tissues or developing into a higher-grade malignant brain tumour.
Grade III
Microscopically, abnormal cells are visible, and the tumour tends to invade nearby brain tissues. It is a higher-grade malignant brain tumour.
Grade IV
The highest malignancy level is characterized by rapid proliferation of abnormal cells visible under the microscope. The tumour cells densely populate and have a high proliferation index. The tumour extensively invades nearby brain tissues, stimulates the formation of abnormal tumour blood vessels, and exhibits endothelial proliferation within the blood vessels. Necrotic cells are often seen in the centre of the tumour. Glioblastoma multiforme (GBM) is the most common case in this category, and the majority of patients do not survive beyond two years.

Treatments

Surgical Treatment	Removing the tumour is a standard treatment method, and surgery may involve partial or complete removal.
Radiotherapy	It uses high-energy radiation to irradiate the brain, aiming to kill or inhibit the growth of tumour cells.
Chemotherapy	Treatment with drugs delivered to the brain through the bloodstream to kill tumour cells.
Targeted Therapy	Drugs targeting specific molecules in tumour cells are used to slow down or inhibit tumour growth.
Immunotherapy	It obtains autologous or allogeneic tumour cells from the patient, treating them to eliminate their ability to divide and proliferate, retaining their immunogenicity, and reintroducing them into the patient's body to trigger specific attacks and destroy tumour cells.
Proton Therapy	Using proton particle beams to treat tumours reduces damage to surrounding normal tissues.
Gene Therapy	"Cytokine Gene Therapy" involves: Using a virus to carry cytokine genes into brain tumour cells. Promoting white blood cell function. Enhancing the body's immune response. Reducing the generation of brain tumour cells. "Suicide Gene Therapy" involves inserting genes into cancer cells that increase their sensitivity to drugs. Injecting antiviral drugs into the organism selectively kills dividing cancer cells.
TTFields	A novel cancer treatment technique, its principle involves delivering low-density, intermediate-frequency alternating tumour electric fields to the brain. It interferes with the usual division of cancer cells in the patient's brain, slowing the growth rate of cancer cells and causing them necrosis.
Other Drug Treatments	The most commonly used treatments include anti-epileptic drugs to control seizures throughout the body or locally. Steroids may also be used to reduce swelling in tissues near the tumour.

Recovery Instructions

Due to the tumour itself or treatments, different brain areas may be damaged, leading to varying degrees of neurological impairments in patients, affecting hearing, vision, language expression, or limb mobility. Therefore, patients may need to undergo physical, speech, and occupational therapy through rehabilitation training sessions to help them recover a certain level of function. Additionally, maintaining good lifestyle and dietary habits, regular exercise, consistent sleep patterns, appropriate stress relief, and a positive and optimistic mindset contribute to recovering health.

Patients must follow the doctor's instructions for regular check-ups, which help in the early detection and management of complications arising from treatment. If cancer recurrence occurs, early detection enables prompt and appropriate treatment.

Although brain cancer is a challenging disease, with mutual understanding and knowledge about the condition and treatment methods, patients can reduce unnecessary panic and increase confidence in their treatment. Patients should openly communicate their need with family members, discussing treatment and family responsibilities. Having the support of family members, rather than facing the situation alone, can be beneficial for the patient's well-being.