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Brain tumour, malignant (cancerous)

Introduction

A malignant brain tumour is a fast-growing cancer that spreads to other areas of the brain and spine.

Most malignant brain tumours are secondary cancers, which means they started in another part of the body and spread to the brain. Primary brain tumours are those that started in the brain.

There are different types of malignant brain tumour, depending on the type of brain cells they have grown from. The most common type is a glioma, which accounts for more than half of all primary brain tumours.

Generally, brain tumours are graded from 1 to 4 according to their behaviour, such as how fast they grow and how likely they are to spread. A malignant brain tumour will be either grade 3 or 4, whereas grade 1 or 2 tumours are usually classed as benign or non-cancerous brain tumours.

What are the symptoms?

The symptoms of a malignant brain tumour depend on how big it is and where it is in the brain.

The tumour can put pressure on the brain and may cause headaches and seizures (fits). It can also prevent an area of the brain from functioning properly. See Malignant brain tumour - symptoms for more information.

Who is affected?

Brain tumours can affect people of any age, including children.

There are about 4,500 new cases of primary brain tumours in the UK each year. The exact cause of these is unknown, although an underlying genetic disease, such as neurofibromatosis, can increase your risk of developing one (see Malignant brain tumour - causes for more information). 

Treatment and outlook

A primary malignant brain tumour must be treated as soon as possible because it can spread to and damage other parts of the brain and spinal cord.

The tumour is usually operated on and as much of it removed as possible. This may be followed with chemotherapy and radiotherapy. However, malignant tumours will often return.

The outcome for malignant primary brain tumours depends on many factors, such as the type and location of the tumour and how ill you were when diagnosed. For more information, go to Cancer Research UK's page on Statistics and outlook for brain tumours.

Secondary brain tumours are serious as they have already spread throughout the body. Treatment aims to improve symptoms and prolong life.

For more information on the treatment options, see Malignant brain tumour - treatment.

Malignant gliomas

Most malignant brain tumours develop from the glial tissue, which supports the nerve cells of the brain. These tumours are known as gliomas.

Gliomas can be separated further, depending on the cells they developed from. For example:

  • an ependymoma develops from the cells that line the cavities in the brain
  • an oligodendroglioma develops from the cells that produce the fatty covering of nerves
  • an astrocytoma develops from cells thought to provide the brain's framework
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Symptoms

The symptoms of a malignant brain tumour depend on how big it is and where it is in the brain.

When symptoms do occur it is because the brain tumour is either putting pressure on the brain or preventing an area of the brain from functioning properly.

Increased pressure on the brain

If the tumour causes an increase in pressure inside the skull it can lead to the following symptoms:

  • epilepsy or fits, which can be either major seizures or twitching in one area of the body
  • severe, persistent headache
  • irritability, drowsiness, apathy or forgetfulness
  • vomiting, which is sometimes sudden and for no apparent reason
  • dizziness
  • partial loss of vision or hearing
  • hallucinations
  • personality changes, including abnormal and uncharacteristic behaviour

It is important to see a doctor if you develop a persistent and severe headache that does not appear to have any obvious cause, especially if you also have unexpected vomiting.

Loss of brain function

Different areas of the brain control different functions, so any loss of brain function will depend on where the tumour is located. For example:

  • A tumour affecting the frontal lobe may cause changes in personality, weakness in one side of the body and loss of smell.
  • A tumour affecting the parietal lobe may cause difficulty in speaking, understanding words, writing, reading and co-ordinating certain movements. There may also be numbness in one side of the body.
  • A tumour affecting the occipital lobe may cause loss of vision on one side.
  • A tumour affecting the temporal lobe may cause fits or blackouts, a sensation of strange smells and problems with speech and memory.
  • A tumour affecting the cerebellum may cause a loss of co-ordination, difficulty walking and speaking, flickering of the eyes, vomiting and a stiff neck.
  • A tumour affecting the brain stem may cause unsteadiness and difficulty walking, facial weakness, double vision and difficulty speaking and swallowing.

Brain tumour grades

  • Grade 1 and 2 (low-grade) brain tumours are slow growing, less likely to come back if they are removed and unlikely to spread. For more information, read Benign (non-cancerous) brain tumours.
  • Grade 3 and 4 (high-grade) brain tumours are malignant (cancerous). They are faster growing and likely to spread.
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Causes

Most malignant brain tumours are caused by a cancer that started somewhere else in the body and spread to the brain through the bloodstream.

The cause of primary malignant brain tumours (cancerous tumours that start in the brain) is not fully understood.

Underlying disease

Some genetic conditions can increase your risk of a primary malignant brain tumour. These conditions include:

These conditions tend to cause malignant gliomas (see Malignant brain tumour - introduction) that appear in childhood or early adulthood, whereas most gliomas start later in adulthood.

Other possible causes

Radiotherapy to the brain increases your risk of brain tumour, although this is still uncommon.

It is also thought that family history of brain tumours and exposure to chemicals (such as formaldehyde) may be risk factors.

Can mobile phones cause brain tumours?

There has been some publicity in the media about a possible connection between brain tumours and the radiofrequency (RF) energy emitted by mobile phones. RF energy produces heat, which can increase body temperature and damage tissue exposed to it.

It is thought that the amount of RF energy we are exposed to by the use of mobile phones is too low to produce significant tissue heating or an increase in body temperature.

However, research is under way to establish whether RF energy has any effects on our health in the long term, and no definitive conclusions have yet been reached. See Mobile phone safety for more information.

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Diagnosis

If you develop any of the symptoms of a brain tumour, such as a persistent and severe headache, make an appointment to see your GP.

Your GP will examine you and refer you to a specialist if necessary.

Your GP will examine the back of your eye and look for changes to the optic disc (the inside of the back of the eye) caused by an increase in pressure inside the skull. Raised pressure in the skull may indicate the presence of a tumour.

If a growth is suspected, you will be referred to a neurologist (brain and nerve specialist).

Referral to a specialist

The specialist will ask you about your medical history and symptoms. They will examine your nervous system, which may include tests of your:

  • reflexes, such as your swallow reflex and knee-jerk reflex
  • facial muscles (testing whether you can smile or grimace, for example)
  • hearing and vision
  • limb strength
  • balance and co-ordination
  • skin sensitivity to pinpricks, heat and cold
  • mental agility (simple questions or arithmetic)

Diagnosis of brain tumour is made based on your symptoms, the examinations above and the results of certain tests (see below).

Tests

You may have some of the following tests to help diagnose a brain tumour:

If a tumour is suspected, a biopsy (surgical removal of a small piece of tissue) may be taken to establish the type of tumour and the most effective treatment.

A biopsy involves making a small hole in the skull and using a fine needle to obtain the sample of tumour tissue. It involves a few days in hospital.

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Treatment

Your healthcare team

You will be cared for by a team of healthcare professionals that may include:

  • a neurosurgeon, who will operate on your brain
  • a neurologist, who will treat illness caused by the tumour and manage your chemotherapy, if necessary
  • a radiologist, who will administer radiotherapy
  • a specialist nurse, who will give you information and support

You should be given the name and contact details of a key worker, who will support you during your brain tumour treatment. 

If you have a malignant brain tumour, you'll usually need surgery to remove as much of the tumour as possible. Radiotherapy and chemotherapy are then used to treat any remaining tumour tissue.

However, most malignant brain tumours return after they have been treated. At this point, the aim of treatment is to extend life for as long as possible and treat any symptoms (see below). 

This page explains the treatment options for both primary and secondary brain tumours (those that started in the brain and those that spread to the brain from elsewhere in the body).

Primary tumours

Surgery

Most primary tumours will be removed using surgery. They will then usually be treated with radiotherapy and chemotherapy afterwards (see below), to reduce the risk of the tumour coming back. 

Surgery aims to remove as much of the tumour as possible, without damaging the surrounding tissue.

You are given a general anaesthetic (put to sleep) and an area of your scalp is shaved. A section of the skull is cut out as a flap to reveal the brain and tumour underneath. This is known as a craniotomy. The surgeon can then remove the tumour.

You may then be given photodynamic therapy, where the surgeon injects a light-sensitive drug into your veins, which is taken up by the remaining cancer cells. When a laser is focused on these cancer cells, the drug becomes active and kills them.

Chemotherapy and radiotherapy

Some tumours that are situated deep inside the brain are difficult to remove without damaging surrounding tissue. In this case, the tumour may just be treated with chemotherapy and radiotherapy (or both).

During radiotherapy, a dose of high-energy radiation is focused on the tumour to stop the cancer cells multiplying. The radiation is a lower intensity than that used in radiosurgery (see below), and is given over a period of time.

Radiotherapy can cause tiredness, headaches, hair loss, nausea and reddening of your skin.

Chemotherapy is medication used to kill any cancerous cells, and may be given as tablets, an injection or implants. Carmustine and temozolomide are both chemotherapy drugs used in the treatment of high-grade brain tumours, and are described below.

Carmustine implants are small wafers that are placed at the tumour site when the tissue has been surgically removed. As they dissolve, they release carmustine to slow or stop the growth of cancerous cells.

Carmustine implants may be used to treat gliomas that are in an advanced stage of growth. In 2007, NICE issued guidelines on the use of Carmustine implants to treat gliomas. NICE has approved them as treatment for newly diagnosed malignant gliomas, but only where 90% or more of the tumour has been surgically removed.

Carmustine implants need to be implanted immediately following surgery and before surgery is complete. This means your surgical team must be prepared to use them in advance if the removal of 90% of the tumour looks possible.

Possible side effects of carmustine implants are brain oedema (fluid in the brain), seizures and infection in the brain. For full details, see the summary of product characteristics.

Temozolomide is a chemotherapy drug that is given to some patients with a malignant glioma to slow down progression after initial treatment, or if the tumour has returned.

Possible side effects of temozolomide include anorexia, constipation, fatigue, headache, nausea and vomiting. For full details, see the summary of product characteristics.

Read more in the 2001 NICE guidelines on Temozolomide for recurrent malignant glioma.

Radiosurgery

Radiosurgery involves focusing a high-energy dose of radiation on the tumour to kill it. It is different to radiotherapy in that the radiation is:

  • a higher intensity
  • focused on a smaller area of the brain
  • given in one session (rather than over a period of time)

This means you will usually not experience any of the usual side effects of radiotherapy, such as skin reddening and hair loss. Recovery is good and an overnight stay is usually not required.

However, radiosurgery is only available in a few specialised centres across the UK. 

Secondary tumours

A secondary brain tumour indicates serious, widespread cancer that usually cannot be cured. Treatment aims to improve symptoms and to prolong life by shrinking and controlling the tumour. Treatment may include:

  • corticosteroids, which are tablets to reduce the swelling and pressure in the brain
  • chemotherapy and radiotherapy (see above)
  • anticonvulsant medicines, which prevent epileptic fits
  • painkillers to reduce headaches
  • anti-nausea drugs, which can help to relieve sickness caused by increased pressure inside the skull

What if I choose not to have treatment?

If your tumour is at an advanced stage or in a difficult place in the brain, a cure may not be possible and treatment may only be able to control the cancer for a period of time. This means you will be getting the side effects of treatment without getting rid of the tumour.

In this situation it may be difficult to decide whether or not to go ahead with treatment. Talk to your doctor about what will happen if you choose not to be treated, so you can make an informed decision.

If you decide not to have treatment, you will still be given palliative care, which will control your symptoms and make you as comfortable as possible.

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Recovery

After being treated for a brain tumour, you may be offered physiotherapy, speech therapy or occupational therapy.

These therapies can speed up your recovery and help you cope with any problems caused by the tumour.

  • An occupational therapist will recommend any equipment or alterations to your home that may help you carry out daily activities.
  • A speech therapist will help you with any speech or swallowing problems.
  • physiotherapist will help you to use parts of the body that have been affected by the tumour.

The National Institute for Health and Clinical Excellence (NICE) has made recommendations on the standards of care that brain tumour patients should receive. For more information, read the Improving Outcomes guidelines

Epilepsy may affect some patients for up to six months or longer after surgery. In rare cases epilepsy may continue for longer.

Help and support

A brain tumour is often life-changing. You may feel angry, frightened and emotionally drained. Your doctor or specialist should be able to refer you to a social worker and counsellor for help with the practical and emotional aspects of your diagnosis.

There are many organisations and helplines, such as Brain Tumour UK, that provide information and support.

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