Brain Tumour Meningioma

What are brain tumours?
The central nervous system (CNS) is made up of the brain and spinal cord. Cells in the CNS normally grow in an orderly and controlled way. If for some reason this orderis disrupted, the cells continue to divide and form a lump or tumour. A tumour is either benign or malignant. Benign tumours can continue to grow but the cells do not spread from the original site. In a malignant tumour, the cells can invade and destroy surrounding tissue and may spread to other parts of the brain.

What are meningiomas?
A meningioma is a tumour of the meninges, which are the protective membranes around the brain and spinal cord. A meningioma can start in any part of the brain or spinal cord, but the most common sites are the cerebral hemispheres of the brain, made up of the four lobes. Most meningiomas are benign and malignant ones are rare. Each year about 4,500people in the UK are diagnosed with tumours of the central nervous system(CNS). Meningiomas make up nearly 1 in 5 (20%) of all primary brain tumours. They are most likely to be found in middle-aged or elderly people. Meningiomas are more common in women than in men.

What causes meningiomas?
Like most brain tumours the cause of meningioma is unknown. In some people there may be an underlying genetic abnormality such as a mutation in a specific gene. Recent research has also shown a possible link between meningioma and breast cancer. Meningiomas frequently possess progesterone receptors and, less commonly, oestrogen receptors, which may explain their higher incidence in women.

What are the different types of menigioma?
Grading refers to the appearance of the tumour under a microscope. The grade gives an idea of how quickly the tumour may grow. There are three grades:

• Grade 1 tumours are the most common type and are slow-growing and benign. Most do not come back after treatment.
• Grade 2 tumours grow more quickly and have a higher chance of coming back after treatment..
• Grade 3 tumours are more likely to grow quickly and spread into the brain. It is common for the tumour to come back after the first treatment. This is known as a recurrence.

What are the symptoms and signs?
Meningiomas are usually slow-growing tumours and the main symptoms arise from increased pressure within the skull (raised intracranial pressure). This may be due to ablockage in the ventricles (fluid-filled spaces of the brain), which leads to a build-up of cerebrospinal fluid (CSF). CSF is the fluid that surrounds and protects the brain and spinal cord. The increased pressure mayalso be caused by swelling around the tumour itself. Raised intra cranial pressure can cause headaches, sickness (vomiting) and problems withyour vision. Changes in behavior and personality are general signs of a brain tumour. Fits(seizures) can be an early
symptom.

What are the specific symptoms and signs?
Meningiomas can growin different parts of the brain and symptoms will relate to the area of thebrain that is affected:

• A tumour in the frontal lobe of the brain may cause gradual changes in mood and personality. There may also be paralysis (inability to move) on one side of the body. This is called hemiparesis.
• If the left side of the brain is affected there may be problems with speech, such as slurring or muddling of words.
• A tumour in the temporal lobe of the brain may cause problems with coordination and memory loss.
• If the parietal lobe of the brain is affected, writing and other such activities may be difficult. Hemiparesis may also be present.
• Sometimes meningiomas cause little or no symptoms and are discovered during investigations into other conditions.

How do doctors examine for possible brain tumour?
The doctor will examine you thoroughly and test the power and feeling in your arms and legs and your reflexes. Your doctor will look into the back of your eyes using an ophthalmoscope. They can see if the optic nerve at the back of the eye is swollen. This can be caused by oedema (swelling of the tissues within the brain), which may occur due to an increase in the amount of fluid in the brain.

What are the investigations?

CT (computerised tomography) scan
You will be asked not to eat or drink for at least four hours before the scan. A CT scan takes a series of x-rays that build up a three-dimensional picture of the inside of the body. The scan is painless and takes 10-30 minutes. CT scans use small amounts of radiation, which will be very unlikely to harm you or anyone you come into contact with. CT scans take pictures of your brain and will reveal whether or not there is abnormal growth in the brain, CT scans will give information about the size and location of the growth.

CT (computerised tomography) scan with contrast (Dye)
You may be given a drink or injection of a dye, which allows particular areas to be seen more clearly. For a few minutes, this may make you feel hot all over. If you are allergic to iodine or have asthma you could have a more serious reaction to the injection, so it is important to let your doctor know beforehand.

MRI (magnetic resonance imaging) scan
This test is similar to a CT scan, but uses magnetism instead of x-rays to build up a detailed picture of areas of your body. Before the scan, you may be asked to complete and sign a checklist. This is to make sure it’s safe for you to have an MRI scan. Some people aregiven an injection of dye into a vein in their arm. During the test you will be asked to lie very still on a couch inside a long cylinder(tube) for about 30 minutes. It is painless, but can be slightly uncomfortable, and some people feel a bit claustrophobic during the scan. It is also noisy, but you’ll be given earplugs or headphones to wear.

Angiogram
This test involves an injection of a dye to show up the blood vessels in the brain that supply the tumour. The dye is injected through a thin, flexible tube (catheter) that is inserted into an artery in the groin, arm or neck. A series of x-rays are taken. Your nurse or doctor will explain this test to you in more detail.

Treatment
The treatment for Meningioma depends on a number of things including your general health, and the size and position of the tumour. The results of your tests will enable your doctor to decide on the best type of treatment for you. Your treatment will usually be planned by a team of specialists known as a multidisciplinary team (MDT). The team will usually include:

• a doctor who operates on the brain (neurosurgeon)
• a doctor who specialises in treating illnesses of the brain (neurologist)
• a doctor who specialises in treating brain tumours (an oncologist)
• A specialist nurse and possibly other healthcare professionals, such as a physiotherapist or a dietitian.

There are some risk sassociated with treatment to the brain and your doctor will discuss these withyou.

Benefits and disadvantages of treatment
Treatment can begiven for different reasons and the potential benefits will vary for each person. There are different options of treatment depending on number of factors. Your doctor will explain the options and benefits and risks of each. If you feel that youcan’t make a decision about the treatment when it is first explained to you, you can always ask for more time to decide.

Consent
Before you have any treatment, your doctor will give you full information about the aims of the treatment and what it involves. They will usually ask you to sign a form saying that you give your permission (consent) for the hospital staff to give you the treatment. No medical treatment can be given without your consent.

Treatment for raised pressure in the head
If the pressure in the skull is raised, it is important to reduce it before any treatment is given for brain tumours. Steroid drugs may be used to reduce swelling around the tumour. Effects of steroids are temporary, short lived to buy time for active treatment to start. If the raised pressure is because of a build-up of CSF, a tube (shunt) may be inserted to drain off the excess fluid.

Wait and Watch / Wait and Scan / Surveillance Policy
If the tumour is small, immediate treatment may not be needed. This is because most meningiomas tend to be slow-growing and it may be a long time before and symptoms require treatment. In this situation, regular scans will be done to check for any growth of the tumour. This is called active surveillance.

Surgery
Where possible, surgery is the main treatment for meningioma and in many cases the tumour can be removed completely with no complications. Occasionally, the position of a tumour makes it impossible or too risky to remove surgically. If surgery is not possible, your doctor will discuss other types of treatment with you.

Radiotherapy
Radiotherapy treatment uses high-energy rays to destroy the cancer cells. It may be used after surgery for malignant meningioma to reduce the chance of the tumour coming back. It may be used after surgery for benign meningiomas that cannot be completely removed. If surgery is not possible, radiotherapy may be used alone. Sometimes a technique known as stereotactic radio-surgery may be used, in which hundreds of beams of radiotherapy are aimed at the tumour in a single session. This is a very accurate treatment allowing larger doses of radiotherapy to be given with less damage to the surrounding tissues. It is used mainly for smaller tumours and for tumours that have come back.

Chemotherapy
Chemotherapy is the use of anti-cancer (cytotoxic) drugs to destroy cancer cells. Chemotherapy is very rarely used for treating meningioma although research continues into developing this form of treatment.

Medicines for seizures
If you experience seizures you may be given a medicine called an anticonvulsant to help prevent them.

What is the Outcome?
The majority of meningiomas do not reoccur but you will have regular scans to check if there has been any regrowth. After a period of time you may stop having scans and checkups completely.

How else will beinvolved in the treatment?
A number of different health professionals can help you with these problems.

Clinical psychologist or neuropsychologist
They may perform a neuropsychological assessment to assess your intelligence, memory and other processes. They can also give therapy to help you cope with the problems you are having.

Physiotherapist
They can help with any difficulties you may be having with limb weakness, difficulty walking or lifting etc.

Occupational therapist
They can assess you to see if you might benefit from any adaptations to your home or special equipment.

How do people with meningiomas feel?
Often people who have had a meningioma find it hard to explain to people that although they may look fine, they still have difficulty with certain things.

It can be hard to cope with problems that are long term and you may feel frustrated and angry that you haven’t completely recovered. It often helps to confide in someone who understands how you feel. Keeping your thoughts and feelings bottled up inside of you can make everything seem worse. You might find it helpful to keep a diary of how you are feeling. This can help you see that you are making small improvements week by week.

Driving
In some circumstances you may not be allowed to drive for a period of time. If you have had an epileptic fit, the Drivers and Vehicle Licensing Association (DVLA) will not allow you to drive for a year after your last fit. You can then drive again provided you remain well. If you have a benign meningioma and have not had any seizures, the DVLA requires that you do not drive for at least six months after surgery. Initially, your license may only be for a short period. The hospital will not contact the DVLA. It is your responsibility to do so and your doctor will advise you how to do this. You can contact the DVLA by phone or at www.dvla.gov.uk