Tumours occur in the brain (called ‘intrinsic’ or ‘glioma’) and in structures around the brain (called ‘extrinsic’ and by the structure they arise from: schwannoma, adenoma, meningioma). Those that occur within the brain are often rapidly growing, typically a ‘glioblastoma’ which is malignant. Some are much more benign, growing slowly, typically an ‘astrocytoma’, although some will transform to more malignant behaviour years later. Diagnosis is usually made on a CT or MR scan of the brain. Some tumours may be cysts which have been present from birth and grow very slowly.
The management of tumours at the benign end of this spectrum may first be apparent by the development of epileptic seizures, or fits. This can be sudden and very frightening for both the person having the seizure, but also relatives who may witness it. Mostly this can be controlled with tablets, under the guidance of a Neurologist. Sometimes, if this is not helping sufficiently, surgical treatment to remove the tumour, cyst, or even a scarred area of brain, can help.
The Edinburgh Centre for NeuroOncology (ECNO) is run in the NHS through the Western General Hospital, although some parts of the service will soon move to the Royal Infirmary in Little France. Doctors, nurses and therapists here, including our own, look after people who present with a malignant brain tumour, and support them with up to date advice on the best forms of managing the problems that occur; which may involve supportive care only, a biopsy, surgery, radiotherapy, chemotherapy or alternative treatments.
Patients with benign brain tumours are dealt with in the Neurosurgical department at the Western General Hospital in Edinburgh, although we will soon move to the Royal Infirmary, Little France. They are discussed at a meeting of a variety of specialists (radiologists, radiotherapists, geneticists, endocrinologists and surgeons from different specialties) so decisions can be made about the best and most appropriate form of treatment.
The commonest benign brain tumours we see are meningiomas, pituitary tumours and schwannomas, which usually grow very slowly. These tumours usually grow to become two to four centimetres in size before they are detected. They may compress adjacent structures, such as specific nerves (hearing, vision, eye movements), or the brain surface, giving rise to focal deficits (difficulty dressing, word finding), or seizures (fits). For many, all that is necessary is to watch the rate of growth of the tumour with serial scans, but sometimes the tumour will need to be removed. Some, such as small vestibular schwannomas, are better treated with focussed radiotherapy (stereotactic radiotherapy), while others may need a combination of surgery and radiotherapy.
If operation is necessary there are three main routes used to access the tumour.
Transphenoidal– an approach through the nose used to remove most pituitary tumours and cysts.
Transcranial– an approach through the skull, taking a disc of bone out, to gain access to the tumour, removing the tumour, then replacing the bone and closing the scalp, commonly used in the removal of a meningioma.
Translabarynthine or retrosigmoid– an approach just behind the ear, to remove a tumour of the inner ear such as a vestibular schwannoma.