Brain tumors: going over the basics

Recently I have seen many patients with brain tumors in my office and that shall be the focus of my post.  Brain tumors are tumors (cancers) that arise in the brain or spread to the brain. We call these primary brain tumors (tumors arising in the brain itself) or metastatic tumors to the brain (the primary tumor/ cancer is somewhere else for example in the lung or breast but then spreads to the brain).

Let us now spend a moment to talk about how brain tumors present clinically. Many of you shall be surprised to learn that the brain itself is insensitive to pain (meaning if I was to put a knife through your brain tissue, you shall feel no pain!!!).  So a small brain tumor may be silent, causing no pain or discomfort. It is usually when the brain tumor increases in size and starts involving (stretching the blood vessels in the brain) or the covering of the brain (meninges) that the patient may complain of headache. Blood vessels and covering of the brain (meninges) are richly supplied by nerves and hence are exquisitely pain sensitive.  So first and foremost not all brain tumors present with headache. The corollary to that is that not all headaches are due to brain tumors. Most of the times when patients present to a doctor for evaluation of headache, a “benign” cause such as migraine or tension headache is found and not a brain tumor.

If I am examining a patient with headache, there are certain red-flags in the history and the examination which shall make me think about a possible brain tumor.

Laterality of the headache:  Headaches associated with brain tumors are usually holocranial (the whole head hurts). Remember migraines are typically hemicranial (patient complains of a throbbing headache on one side of the head). This though is not a hard and fast rule and I would not base my opinion on the laterality of the headache.

Is the headache associated with projectile vomiting: Because a large brain tumor  shall lead to an increase in the intracranial pressure (pressure inside the brain),  patients with brain tumors may have projectile vomiting. This again is not a hard and fast rule as patients with migraines are frequently nauseated and may throw up.

Does the headache awaken the patient at night from sleep? Headache associated with brain tumor may awaken the patient from sleep. Classically the headache is worst when lying down and abates in the morning when the patient gets up and starts to move around. Migraines usually do not awaken a patient from sleep, infact sleep frequently helps to abort a mgraine attack. Again a weak point and I would not base my opinion on this alone.

History! History! History!: 

Let us compare two different histories in two patients:

Patient number 1 (age=53 years male)

“Dr Sethi, I have never had a headache in my life, never had a headache in my adolescence but recently I am waking up with a severe headache.”–THE THOUGHT OF BRAIN TUMOR DOES CROSS MY MIND WHEN I HEAR THIS

Compare this to:

Patient number 2 (age 26 years female)

“Dr Sethi, I have headaches since my college days. Frequently I shall get a throbbing headache on one side of my head and at that time bright lights shall bother me. I used to feel nauseated when I had my headaches and at times threw up. My headaches went away in my 30s but now I am again having bad headaches” –MIGRAINE IS THE FIRST THOUGHT THAT CROSSES MY HEAD AND NOT BRAIN TUMOR.

Other presentations of brain tumors: brain tumors at times may present more dramatically. Patients may present with a generalized convulsion. When these patients are imaged (via a CT scan or a MRI brain scan) the brain tumor may be detected. At times patients present with progressive neurological deficits. The type of neurological deficit depends frequently on the location of the brain tumor. Let me explain this further. Let us assume the brain tumor is pressing on the optic nerve or other nerves which control eye-movements: patients may present with visual problems (such as blurring of vision, double vision or diplopia, cuts in their visual fields and so forth). If the tumor presses on the motor or sensory system: patients may present with weakness or numbness on the contralateral side of the body. If the tumor is in the cerebellum, they shall complain of balance problems or lack of coordination. If the tumor involves the auditory nerve, their presenting complaint shall be of hearing loss (usually though unilateral hearing loss may not be appreciated by the patient).

Finally the neurological examination is of great help. Patients with migraines, tension type headaches and other “benign” headaches have a normal (we call this non-focal) neurological examination. On the other patients with brain tumors may have some subtle and other more prominent neurological findings. Thus your doctor shall examine you: check your cranial nerves (does the patient have a symmetrical smile, are eye-movements intact, is the visual field intact, do thay have any sign of increased pressure inside the brain (this is determined by looking into the eye to visualize the optic nerve head), is motor strength and sensory system intact,  are there any signs of cerebellar dysfunction (incoordination, ataxia–balance is off and so forth).

Patients with headaches who have an abnormal neurological examination should be imaged. Your doctor may then recommend either a CT scan of the head or a MRI scan. Frequently this is done with and without contrast. I shall dwell into different types of brain tumors and their management in my next post.

Nitin Sethi, MD

Radiation therapy: some facts

Hello everyone, it is Memorial day as I sit down to pen this. Thought since we were on the topic of management of brain tumors, I should give you all some information about radiation therapy. As I stated earlier, radiation therapy is one of the modalities we use in the treatment of brain tumors apart from surgery (debulking the tumor) and chemotherapy (anti-cancer drugs).

So how does radiation therapy work? Well put in a simple form, radiation is given to the tumor to kill the tumor cells. Either you can irradiate the whole brain or just the tumor site. Radiation of the whole brain is done when there are multiple metastasis or when you are worried that microscopic spread of cancer might have already occurred.

Advantages of radiation therapy: one of the biggest advantages of radiation therapy is the ease of administration. Usually you go to a radiation oncology center and it is an outpatient procedure. But we are jumping ahead of ourself. Before radiation is administered, the radiation oncologist in consultation with your neurologist and neurosurgeon shall look at your MRI scans and then determine which shall be the best protocol for you. How much radiation to give over how much time and sittings. Should the whole brain be radiated and then a boost of radiation given to the tumor itself? As you can imagine it is very technical and involved expertise. How to give the radiation without affecting any neighbouring cells (remember radiation by itself cannot differentiate between healthy and tumor cells. It shall kill all cells in its path). If the tumor is near the visual pathways (the optic nerve), then you have to be careful that you do not irradiate the optic nerve as it shall lead to blindness. All such issues are looked at and considered before the protocol is decided.

By studies on animals we now know approximately how much radiation we can safely give to the brain and spinal cord over how much time.

Points to remember: when radiation is started, it leads to death of tumor cells. This increases the edema and swelling in the brain initially. Your doctor may prescribe you steroids or additional steroids if you are already on them to make the swelling go down. Also as the brain swells after radiation, some patients can have seizures and it may make sense to be on an anti-epileptic drug at the time of radiation.

What are the long term side-effects of radiation: Radiation does have some side-effects. In adults and especially in children it can lead to cognitive deficits and affect memory. That is why we try to avoid radiating a developing brain of a child. Also radiation itself at times can lead to a secondary tumor ( we try to avoid this by using the lowest radiation dose as possible). There is an entity called post radiation necrosis which at times can cause some diagnostic problems. About 12-18 months after radiation, necrosis of brain tissue occurs. This at times can present with seizures and be confused with recurrence of brain tumor.

I hope I have been able to shed some light on radiation therapy with respect to brain tumors. It is a lovely Memorial day here in NYC. Plan to head to Central Park and read with the sun on my back. Life is beautiful, I try to remind myself everyday. I wish you all a restful and enjoyable day.

Personal Regards,

Nitin Sethi, MD


Brain tumors: malignant gliomas

Thank you for sharing your brother’s history with me Franciso, I understand how difficult it must be for you and the entire family. I wish him my very best and please feel free to contact me here if you have any particular questions related to him.

Let me continue a little about the management of brain tumors. Well like I said once we discover a glioma in the brain, we first try to determine its extent in the brain. Tests like CT scan and MRI brain  with contrast (dye) are carried out to determine its boundries. Then the question of staging the tumor arises. At times from the MRI itself one can be reasonably sure that this is a malignant glioma or GBM. GBM is one of the few brain tumors, that can spread to the underside of the brain via the corpus callosum and hence gives rise to what we call a butterfly lesion on the MRI (imagine a butterfly with her wings spread out). GBM usually have a lot of surrounding edema which we can see on the MRI again hinting that is a malignant tumor we are dealing with.

Low grade tumors usually are walled off (encapsulated) and do not much surrounding edema. So the next step is trying to stage the tumor and trying to determine its grade. For this reason at times a brain biopsy is done. At the time of the brain biopsy, a frozen specimen is sent to the lab and if the lab gives its initial impression as a tumor, the surgeon might try to debulk the tumor right then and there (that means at the time of biopsy, try to debulk the tumor. This makes sense because the skull is already open and it avoids a second operation).

There is one issue here which is unique for brain tumors like gliomas. The tumor may have one grade on one side and another grade in a different part of the tumor (meaning one part of the tumor may show grade II and the other grade III. To overcome this problem multiple biopsies are taken from different parts of the tumor. The highest grade found is the final grade given to the tumor).

Like I said earlier depending upon the stage of the tumor and its location, the surgeon may or may not be able to remove the entire tumor.

After the biopsy/ surgery patients undergo rehablitation and are then referred to either radiation oncology for radiation or to an oncologist for consideration of chemotherapy. Most of the times all these facilities are available under one roof in a big hospital.

I shall touch on the finer aspects of radiation and chemotherapy in my next post. Its 7.00 pm sat evening NYC, do not have any major plans but do want to get to the gym at some point. Hope all is well in the big world around me.

Personal Regards,


Brain tumors: malignant glioma

Since the diagnosis of Ted Kennedy with a malignant glioma, the focus has again turned to brain tumors. Let me discuss in this post a little about malignant gliomas. Glioma are one of the most common primary brain tumors. They are called gliomas because the tumor arises from the glial cells (the tumor does not arise from neuronal cells, rather from glial cells which form the structural supporting cells in the brain).

The WHO (world health organization) grades gliomas into 4 classes:

1) Grade I and II gliomas: are also what are called low grade gliomas. These are slow growing tumors, usually seen in the younger age groups. As they are slow growing, they are less malignant and compatible with a longer survival. They ususally present clinically with a seizure (when they irritate the underlying brain) or when they grow in size and become large, they present with mass effect (the mass and bulk of the tumor presses on surrounding structures and patients may present with weakness on one side). How are low grade gliomas treated?

Treatment of low grade gliomas; as these tumors are slow growing, they are at times amenable to surgical resection. This is because these tumors are usually well encapsulated and its margins are well defined. So in children or adults, if we catch these tumors in time and if the tumor does not involve the eloquent cortex (parts of the brain which subserve speech, or control the hand and leg movements), one may be able to resect the entire tumor out enbloc. In some patients, that is all what may be needed and we usually like to avoid radiation in children ( since radiation has its own problems and may cause cognitive deficits in the young child later on). You doctor may also put you on an anti-seizure medication for a short while to prevent you from having seizures.

Grade III and IV gliomas: or high grade gliomas. This includes glioblastoma multiforme or GBM. Since these tumors are high grade, they are usually fast growing and invade the surrounding brain tissue. Hence it is impossible to resect the entire tumor out usually. Even if you resect the entire tumor you see macroscopically (that is with the naked eyes), the tumor has already caused microscopic metastasis and spread in the brain. Here in lies the fact why these tumors are so hard to treat and patients usually have a poor prognosis. In the best centers in the world, we treat these tumors with a combination of surgery ( try to debulk the tumor and remove some of it and decrease the pressure in the brain), radiation (you may either radiate just the tumor or irradiate the entire brain to prevent metastatic spread) and chemotherapy. Radiation and chemotherapy may either be used concurrently  to supplement each other or one after the other. Again usually these tumor present at first with seizures and your doctor may start you on an anti-epileptic drug to prevent it.

I shall build on this discussion in my next post. Enjoy the weekend everyone, it is a beautiful day here in NYC.

Personal Regards,

Nitin Sethi, MD

Brain tumors primary Vs secondary (what we know and what we don’t)

This is a continuation of my earlier post on brain tumors where I went over the classification of brain tumors, their presentation (what signs and symptoms they present with) and briefly discussed about their management.

Primary brain tumors that is tumors which arise from the brain itself need to be differentiated from secondary brain tumors or metastatic spread of tumor to brain (this refers to a tumor which arise somewhere else as for example in the lung and then spreads to the brain. That is the primary site of the tumor is the lung and then it has metastasis to the brain). Various tumors can spread to the brain but the most common among them are:

1) Lung tumor–most common cause of lung tumor is smoking and it commonly spreads to the brain. Infact many times it is first detected only when it has spread to the brain. that is the time the patient either has a seizure or develops weakness on one side of the bogy. When a CT scan or MRI scan of the brain is done a tumor is found and when further investigations are done like Chest X-ray and CT scan of the chest the primary is found to be the lung. Lung tumor may produce multiple metastatic lesions to the brain (by that I mean there are commonly more than one lesion found when the brain is imaged). How does lung tumor spread to the brain you may ask. Well the most common route of spread is what is called the hematogenous route (meaning that some tumor cells from the lung enter the blood stream and are carried to the brain where they develop into secondary tumors).

2) Breast cancer: also commonly spreads to the brain and can present with multiple metastatic lesions. As you can imagine the prognosis is poor once there is evidence of metastatic disease. Thus oncologists (doctors who treat cancer) like to treat cancers aggressively so that they do not spread further and cause widespread disease).

3) Renal cell carcinoma: renal carcinoma may also spread to the brain.

4) Thyroid cancer

5) Colon cancer

6) Choriocarcinoma: choriocarcinoma is usually fulminant and has the potential for causing hemorrhagic brain lesions (meaning that the metastatic lesions in the brain are prone to bleeding).

7) Melanoma: malignant melanoma is frequently seen in the west. It too has the potential for causing hemorrhagic brain metastatic lesions. Hence it is imperative that you follow closely with your doctor if you are diagnosed with melanoma.

As you can imagine the treatment varies if you have a primary brain tumor versus if you have a secondary brain tumor. Treatment decisions also vary depending upon whether you have a solitary brain tumor versus if you have multiple metastatic lesions in the brain. The treatment also depends upon the site (location) of the tumor in the brain. Let me explain this a little further. If the tumor is in a part of the brain which can be easily accessed surgically, is small in size and does not involve any eloquent area of the brain then it more likely that it can be removed surgically. What do I mean by eloquent area of the brain. By eloquent I mean parts of the brain which perform vital functions. So if the tumor involves the speech center of the brain or lies very close to the area which controls the movement of the hand and leg or involves the area of the brain which controls vision, then you can understand that if the surgeon decides to remove it, more than likely the patient has awake from the surgery and be not able to speak or have weakness on one side of the body or may not be able to see. Thus surgical options are limited when tumors involve the eloquent cortex.

Primary brain tumors like glioblastoma multiforme (GBM) rarely ever metasize outside the brain. By this I mean it has been seen that primary brain tumors ususally remain confined to the brain itself and do not spread outside. That said and done, this is not a hard and fast rule and there are cases documented in which a primary brain tumor has spread outside the brain. Primary brain tumors though may spread via the white matter tracts to other parts of the brain and also spread via the cerebrospinal fluid (CSF). So sometimes one may have what we called a multi-centric primary brain tumor. As there are multiple lesions in the brain, this has to be differentiated from a secondary brain tumor (a tumor from outside that has spread to the brain).

Thus usually whenever someone is diagnosed with a brain tumor, multiple other tests are done apart from a MRI brain to rule out a secondary tumor. These include a CT scan of the chest (rule out lung cancer), CT scan of the abdomen and pelvis as well as a bone scan. These investigations also help in determining the spread of the disease and this information is vital in treatment decision making process.

 Dr Sethi