TREATMENT OF CHILDHOOD BRAIN TUMORS IN INDIA

The world of childhood brain tumors has no “Welcome” sign leading into it. No matter what anyone says to minimize the situation, this statement is the most painful sentence a human can hear. The combination of fear, shock and pain can be too much to bear.

“To see such innocence, so roughly shaken by this terrible trial, at such a young age, is nothing short of incomprehensible.” I still hear this sentence, uttered by a visibly shaken parent. Instead of becoming more routine and distant, the visceral terror that it engendered in me (the supposed all-knowing physician/advisor), my delivery of such information has grown more and more difficult, even personal. I watch my own small children grow and develop. As a physician, one realizes that more than ever, there is no place for impersonal behavior when caring for the children who are afflicted by a brain tumor, benign or otherwise, and for their families as well. No amount of experience or training can help one to ease or minimize the situation.

When we discuss special areas such as:

• Outcome: Does “excellent long-term results” mean a ten-year survival for a 3-year old– your child living long enough to be frustrated by death at the age of thirteen? We parents think only of 50 and 60 year plans. Five- and ten-year plans are unacceptable. We want to know that our grandchildren will not live to see their parents die at a young age.

• Quality of life: Does that mean that a 5-year old child will have no hair, be skinny and slow to walk and play with his friends and classmates? How can we parents bear to live through the process of trying to give our child a childhood instead of a world of I.V. tubes, doctors who speak of life-and-death, hospital corridors and toys that our children will never play with?

• Doctors: Who are they? Can we do anything to keep them human, warm, and caring for our child? How do we deal with our own resentment for the fearful news, difficult therapies and their human frailty? How do we keep our child happy to see them? Most children cringe at the mere mention of visiting a doctor-with-a-shot-to-give, or a visit to the dentist with his drills and instruments.

• Hospitals: How do we keep these innocents away from such large and frightening monoliths?

• We parents: How can we possibly bear all of this without frightening our little, loving child?

• Hope: Yes, there IS hope! God and goodness are your guide. Your child is truly a precious gift. No matter what cards we are dealt, a child’s joy and innocence are somehow never lost. In the worst of times, a child’s pain often becomes the parent’s teacher. And when we expect the best for our children, we often get it despite all odds.

TREATMENT OF CHILDHOOD BRAIN TUMORS
Surgery:- In some cases the definitive treatment is surgery. In most, however, surgery serves as a temporizing measure that will keep a child out of trouble for long enough to get through definitive therapy that will hopefully eliminate of the tumor. Brain surgery is usually the easiest part of a child’s treatment.
Shunting:- Quite often (e.g. medulloblastomas) childhood tumors present the blockage of the fluid spaces of the brain, (obstructive hydrocephalus). In shunting, a thin silastic tube (the shunt) is placed into the fluid spaces of the brain and passed under the skin into the child’s abdomen where the fluid is absorbed.
Chemotherapy:- Unfortunately, chemotherapy is the hard part of brain tumor treatment. It is only required for more aggressive tumors. As a rule, chemotherapy should be even more aggressive than the tumor itself. The trials which are imposed both on the child and parents are many. Bravery and an unremitting attitude of hope are required by all involved.
Radiation:- Because the developing brain of a child is so very sensitive to radiation therapy, it is deliberately limited. The irony of effective radiation therapy is that when it works well, the brain damage it causes might exceed that done by the original tumor. More often than not, your doctor will recommend that if any radiation is to be given, it should be held off until the child has grown older and the brain has sufficiently matured.
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• The treatment of these tumors usually include a combination of approaches, each tailored to deal with the problems that children are presented with:

What Are the Symptoms of a Brain Tumor in Adults? : BRAIN TUMOR TREATMENT IN INDIA

Symptoms of brain tumors vary according to the type of tumor and the location. Because different areas of the brain control different functions of the body, where the tumor lies affects the way symptoms are manifested.

Some tumors have no symptoms until they are quite large and then cause a serious, rapid decline in health. Other tumors may have symptoms that develop slowly.

A common initial symptom of a brain tumor is headaches. Often, they don't respond to the usual headache remedies. Keep in mind that most headaches are unrelated to brain tumors.

Other symptoms include:

·         Seizures

·         Changes in speech or hearing

·         Changes in vision

·         Balance problems

·         Problems with walking

·         Numbness or tingling in the arms or legs

·         Problems with memory

·         Personality changes

·         Inability to concentrate

·         Weakness in one part of the body

It's important to keep in mind that these symptoms can be caused by a number of different conditions. Don't assume you have a brain tumor just because you experience some of them. Check with your doctor.

How Are Brain Tumors Diagnosed?

To diagnose a brain tumor, the doctor starts by asking questions about your symptoms and taking a personal and family health history. Then he or she performs a physical exam, including a neurological exam. If there's reason to suspect a brain tumor, the doctor may request one or more of the following tests:

·      Imaging studies such as a CT(CAT) scan or MRI to see detailed images of the brain

·     Angiogram or MRA, which involve the use of dye and X-rays of blood vessels in the brain to look for signs of a tumor or abnormal blood vessels

The doctor may also ask for a biopsy to determine whether or not the tumor is cancer. A tissue sample is removed from the brain either during surgery to remove the tumor or with a needle inserted through a small hole drilled into the skull before treatment is started. The sample is then sent to a lab for testing.

HOW TO TREAT BRAIN TUMORS

• Tumors near the surface of the brain may be surgically removed. In many cases, however, it is only possible to remove a portion of a tumor, since taking it all out would cause unacceptable amounts of brain damage. Still, removing even part of it may afford a period of improvement by relieving pressure within the cranium.
• Tumors deep within the brain may be treated with microsurgery, laser surgery, or radiation therapy.
• For malignant primary tumors, surgery may be followed with radiation or chemotherapy. Surgery may also be preceded by radiation.
• Your doctor may prescribe corticosteroids to reduce swelling of brain tissue, anticonvulsant drugs to control seizures, and pain relievers.

Treatment for brain tumors is based on many factors, such as:

• Your age, overall health, and medical history
• The type, location, and size of the tumor
• How likely the tumor is to spread or recur
• Your tolerance for specific medications, procedures, or therapies

Treatment for these symptoms may include:

• Antiseizure/Antiepileptic Drugs (AEDs)
• Steroids
• Surgery

Often, low-grade tumors (grade I and II), which are not aggressive, are treated with watchful monitoring or surgery alone. Though all tumors are monitored with repeat scans, grade II tumors are watched more closely after surgery and over time to make sure there is no recurrence.

Higher grade tumors (grade III and IV), which are malignant and can grow quickly, are more difficult to remove and require additional treatments beyond surgery, such as radiation, chemotherapy, or a clinical trial if one is available. Microscopic tumor cells can remain after surgery and will eventually grow back. All treatments, therefore, are intended to prolong and improve life for as long as possible.

Additional treatment options for high-grade tumors include:

• Radiation therapy: X-rays and other forms of radiation can destroy tumor cells or delay tumor growth.
• Chemotherapy: The use of drugs to kill rapidly dividing cells. It can be taken orally or intravenously.
• Targeted therapy: The focus on a specific element of a cell, such as molecules or pathways required for cell growth, in order to use them as a target
  
  
  

Services offered at our Network Hospitals for the treatment of various types of Brain and Neurological Disorders

The neurologists and the neurosurgeons at our network hospitals in India take a multidisciplinary approach to care, using the latest research and technology. The modern surgical facilities at these hospitals include state-of-the-art dedicated operating rooms equipped for most advanced and latest intraoperative computerized tomography (CT) and magnetic resonance imaging (MRI) machines. The operating rooms are designed for both open and endovascular neurosurgery.

A lot of focus is given on new innovations that extend and improve medical care and patients' quality of life.

The expert team of neurologist, neurosurgeons and paramedical offers compassionate, world-class diagnosis and treatment for patients with all types of neurological problems like brain tumours, vascular diseases, movement disorders, epilepsy, chronic pain and traumatic brain injuries.

Our Network Hospitals in India use the most innovative technologies and latest research to deliver the best outcomes for our patients.

Services offered at ourNetwork Hospitals for the treatment of various types of Brain and NeurologicalDisorders

·         Highly advanced surgeries for the patients with Vascular Malformations, Cerebral Aneurysms, Complex Craniofacial Malignancies andAcoustic Tumours

·         Diagnosis and Treatment of Cancerous Brain Tumours with complete range of treatment options that include surgery, radiosurgery , radiation therapy, chemotherapy and other cancer treatments

·         Deep Brain Stimulation ( DBS) for patients with Parkinson's Disease and tremors from other neurological conditions

·         Paediatric neurologists and neurosurgeons who specialize in the surgical management of a wide range of paediatric diseases including brain tumours, epilepsy, spinal bifida and hydrocephalus

·         Minimally Invasive Brian Surgeriesusing the most sophisticated 3-D image-guided technology

Why should you choose ourNetwork Hospitals in India for Brain Surgery?

There are many reasons why so many patients from all over the world come to our network hospitals in India for various types of treatments related to Brain and other Neurological disorders. Following are the most common reasons.

Highly Skilled andExperienced Neurosurgeons and Neurologists

Our Network Hospitals in India have dedicated Neurology and Neurosurgery Department. The neurosurgeons operate with the most advanced technology systems. They use an image-guided management system for an improved perspective on the progress of complex brain surgeries. It can also help reduce the need for patients to undergo additional surgeries. The neurosurgeons have the expertise in Computer-assisted brain surgery, stereotactic radiosurgery, Awake Brain Surgery, Deep Brain Stimulation (DBS) and other complex surgical procedures related to brain and nervous system. They have been trained and have worked in some of the leading Brain Surgery Centres across the world. They work with a multi-disciplinary team of doctors that consists of neurologists, neuro-oncologists), neuroradiologists, orthopaedicsurgeons, ENT specialists, endocrinologists, general medicine and rehabilitation, pain medicine, and other areas to provide the most appropriate treatment for your condition.

Intraoperative Magnetic Resonance Imaging (iMRI)

The neurosurgeons at our network hospitals in India use a high-resolution intraoperative magnetic resonance imaging (iMRI) while performing brain surgeries. This helps them to see the brain tumours while performing surgery thereby greatly reducing the risk of damaging other parts of the brain. Moreover this also helps to confirm the successful removal of the entire tumour. The Intraoperative magnetic resonance imaging (iMRI) is used during the surgery to remove brain tumors and pituitary tumors with greater accuracy and safety. It is also used to place deep brain stimulator systems .

Computer-assisted Brain Surgery

In Computer-assisted Brain Surgery, various imaging technologies, such as Magnetic Resonance Imaging (MRI), Computerized Tomography (CT) and Positron Emission Tomography (PET) are used to create a 3-D model of the brain. The computer system precisely guides the neurosurgeon to the area/s of your brain requiring treatment. This helps the neurosurgeons to plan the safest way to treat your condition with greater degree of accuracy. The computer-assisted surgery helps a lot in performing Awake Brain Surgery. Computer-assisted techniques is also be usedin treating brain tumours and other lesions with precisely focused beams of radiation using stereotactic radiosurgery.

Stereotactic radiosurgery (SRS)

Stereotactic Radiosurgery (SRS) uses precisely focused radiation beams to treat brain tumours and other abnormal growths in the brain. The advantage of modern Stereotactic Radiosurgery is, it delivers high doses of radiation to the tumour with minimal exposure to surrounding healthy tissue. A multidisciplinary team of experts plan the treatment and carefully monitor doses to avoid the risk of radiation overexposure.Unlike traditional radiation therapy, in this treatment, no incision is made. This minimizes the chances of infection or excessive bleeding. A plan has to be developed before undergoing this surgery. A multi-disciplinary team of doctors plan an appropriate treatment for you depending on thetype of tumour, location and size.

Awake Brain Surgery

In an Awake Brain Surgery you're awake during the surgery. Awake Brain Surgery is done by expert brain surgeons to treat some brain conditions such asbrain tumors or epileptic seizures. Awake Brain Surgery allows yourbrain surgeon to work directly with you in order to locate critical functional tissue of the brain. This process is called mapping. Once the brain has been exposed, you will be awakened and the brain is stimulated to determine the function of each area of tissue. You may be awake during surgery to respond to your surgeon. Your responses will help the surgeon to ensure that he is treating the precise area of your brain that needs surgery. Awake Brain Surgery is mainly done if your tumor is near the parts of your brain that control movement or speech. Awake Brain Surgery helps in lowering the risk of damage to functional areas of your brain. In Awake brain surgery the important areas of the brain can be avoided and preserved during surgery.

Minimally Invasive Brain Surgery

Minimally invasive brain surgeries are commonly done at our network hospitals in India. The hospitals have expert surgeons who specialise in minimally invasive brain surgery techniques. In a minimally invasive brain surgery , the brain surgeons insert two small tubes and use what are called endoscopes. One tube carries a fibre optic camera and light source, the other carries miniaturized surgical instruments. The surgeons operate by watching a TV monitor.

In the traditional way of doing a brain tumour surgery, a more invasive approach was used to remove tumors close to the brainstem. The surgery took much longer time and was performed through an incision behind and below the ear. This took hours of bone drilling to reach the tumor. Since it was an open surgery, the risks were more. Nowadays, with the development of technology and expertise, some of the brain surgeries can be done through nose. The technique is called the endoscopic expanded endonasal brain tumour surgery. 

This technique allows neurosurgeons to pass a camera and specialized surgical instruments to the back of the nasal passage and directly to various regions of the skull base, without scarring and with a shorter recovery. Even though this technique was first described decades ago for pituitary tumor surgery, but recent advancements have helped to use the endonasal approach to safely remove tumors in a variety of other critical skull-base locations. There are very few surgeons in the world who have the expertise to use this technique in brain tumour surgery. At our network hospitals in India, you will find some expert neurosurgeons who have successfully performed many brain tumour surgeries using this technique. Some of the benefits of Endoscopic TransnasalBrain Tumour Surgery are No Brain Retraction, Faster Recovery Time, No Facial Scars, Fewer Complications and shorter Hospital Stays.

Advanced DiagnosticFacilities

Our network hospitals in India provide sophisticated diagnostic services for diagnosing or detecting a wide range of brain and other neurological disorders and conditions. Some of the advanced diagnostic facilities available at our network hospitals in India are as follows.

·         

  Electroencephalograms (EEG): Electroencephalograms or EEG is a non-invasive diagnostic procedure that is done to study the electrical activity of the brain. Electroencephalograms or EEG helps to diagnose seizure disorders, stroke, headaches, dizziness and fainting episodes.

·        

     Evoked Potentials: Evoked potentials studies help to measure the electrical signals along nerve pathways.Evoked potentials studies are used to diagnose visual losses, hearing losses, and nerve damage or degeneration within the spinal cord or nerve roots.

·         

    Nerve Conduction Studies: Nerve conduction velocity test measures how quickly electrical impulses move along a nerve and it is often done with electromyogram to exclude or detect muscle and nerve disorders.

·         

        Electromyography: Electromyography is used diagnose neuromuscular disorders such as Motor Neuron Disease, neuropathy, nerve damage and muscle damage.

·         

      Brain Suite System: To treat complex neurosurgical casesefficiently and safely, our network hospitals in India are equipped with an advanced Brain Suite System. The Brain Suite System allows high-resolution MRI images to be taken while performing the surgery. This helps the brain or neurosurgeons to remove complex tumours without harming the critical brain tissues.

·         

    Flat Panel DSA with 3D technology: This diagnostic technology provides high-resolution 3D images. You will have a much decreasedexposure toradiation.

·         

     Other Diagnostic Facilities: Isocentric C Arm,Neurophysiology Laboratory, Cerebral Angiography, Computed Tomography Scan (CT Scan), Intracranial pressure monitoring, Lumbar puncture, Magnetic Resonance Imaging (MRI), Myleogram, NeuroHisto Pathology, Pathology, Transcranial Doppler, Support Services, 1.5 T MRI ,64-slice CT facilities, functional MRI, MRI spectroscopy, diffusion/perfusion MRI etc.

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Gamma Knife Radiosurgery uses radiation to kill cancer cells and shrink tumors :Gamma Knife Surgery for Brain in India

What is Gamma Knife Surgery or Radiosurgery ?

Gamma Knife radiosurgery, also called stereotactic radiosurgery, is a very precise form of therapeutic radiology. Even though it is called surgery, a Gamma Knife procedure does not involve actual surgery, nor is the Gamma Knife really a knife at all. It uses beams of highly-focused gamma rays to treat small to medium size lesions, usually in the brain. Many beams of gamma radiation join to focus on the lesion under treatment, providing a very intense dose of radiation without a surgical incision or opening.

Gamma Knife radiosurgery is called “surgery” because a result similar to an actual surgical procedure is created by a one-session radiation therapy treatment. The beams of radiation are very precisely focused to reach the tumor, lesion, or other area being treated with minimal effect on surrounding healthy tissue.

Gamma Knife radiosurgery is most often used to treat tumors and other lesions in the brain. It is also used to treat certain neurological conditions, such as trigeminal neuralgia (a condition in which pressure on the trigeminal nerve causes spasms of extreme facial pain) and acoustic neuroma (a noncancerous tumor in the brain that affects the nerves that control hearing).

Gamma Knife radiosurgery may be used in situations where the brain lesion cannot be reached by conventional surgical techniques. It may also be used in persons whose condition is such that they might not be able to tolerate a surgical procedure, such as craniotomy, to treat their condition.

Because the therapeutic effects of a Gamma Knife procedure occur rather slowly over time, it is not used for persons whose condition requires more immediate therapy.

In what cases Gamma Knife Surgery is preferred in India?

Following are the conditions where Gamma Knife Surgery is successfuly used in India:

• Intracranial tumors such as acoustic neuromas, pituitary adenomas, pinealomas, craniopharyngiomas, meningiomas, chordomas, chondrosarcomas, metastases and glial tumors

•Vascular malformations including arteriovenous malformations

•Functional disorders such as Trigeminal neuralgia, Intractable pain , Parkinson’s disease, Essential tremors , Epilepsy and Obsessive-compulsive disorder

What are the advantages of Gamma Knife Surgery over traditional Open Surgeries?

•Non Invasive Procedure
•Very less or no complications
•Done on out patient basis so no admission required
•Cost of gamma kife surgery is lower than that of open surgery
•Minimal harm to the healthy tissue as compared to open surgery
•Very high success rate

Who can perform a Gamma Knife Surgery?

Gamma Knife Surgery is performed by a Neurosurgeon who is very well trained in performing the gamma knife surgery. In India there are some of the very good neurosurgeons for gamma knife surgery.

Back to your normal routine 

Once your treatment is complete, the head frame will be removed. If you had an angiogram, you might have to lie quietly for several more hours. Some patients experience a mild headache or minor swelling where the head frame was attached, but most report no problems. Your doctor will tell you whether or not he wants you to stay overnight for observation or if you can go home immediately. Either way, you should be able to return to work or your normal routine in another day or so.

The effects of your Leksell Gamma Knife treatment will occur over time. Radiation treatments are designed to stop the growth of tumors or lesions, which means they won’t disappear immediately but over a period of weeks or months. Your physician and Leksell Gamma Knife® team will stay in contact with you to assess your progress, which will include follow-up MRI or CT images in the near future and periodic check-ups.

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What's the difference between benign and malignant brain tumours? Latest and Advanced Treatment options for Brain Tumor in India

Brain tumours in adults

In a brain tumour, cells grow abnormally, but this doesn’t mean a tumour is cancerous.

Although brain tumours in adults can be caused by cancer, benign tumours are possible. These may be due to medical conditions or may have no obvious cause.

Primary brain tumours emerge from the various cells that make up the brain and central nervous system and are named based on the kind of cell they first form in. The most common types of adult brain tumours are gliomas, the commonest type of which is called an astrocytoma. These tumours form from cells called astrocytes, which are cells that help support the nerve cells.

The second most common types of adult brain tumours are meningiomas. These form in the meninges, the thin layer of tissue that lines the brain and spinal cord and can grow from a number of different kinds of brain and spinal cord cells.

What's the difference between benign and malignant brain tumours?

Benign brain tumours are non-cancerous. Malignant primary brain tumours are cancers that originate in the brain. They typically grow faster than benign tumours and aggressively invade surrounding tissue. Although brain cancer rarely spreads to other organs, it will spread to other parts of the brain and central nervous system.

Benign brain tumours usually have clearly defined borders and are not usually deeply rooted in brain tissue. This makes them easier to surgically remove, assuming they are in an area of the brain that can be safely operated on. However, even after they've been removed they can still come back, though benign tumours are less likely than malignant ones to recur.

Although benign tumours in other parts of the body can cause problems, they are not generally considered to be a major health problem or to be life threatening. However, even a benign brain tumour can be a serious health problem. Brain tumours damage the cells around them by causing inflammation and putting increased pressure on the tissue under and around it as well as inside the skull.

What are the symptoms of a braintumour in adults?

Symptoms of brain tumours vary according to the type of tumour and the location. Because different areas of the brain control different functions of the body, where the tumour lies affects the way it's manifested.

Some tumours have no symptoms until they are quite large and then cause a serious, rapid decline in health. Other tumours may have symptoms that develop slowly.

A common initial symptom of a brain tumour is headaches, but a lot of things besides a brain tumour can cause headaches. However, brain tumour headaches may be described as worse in the morning and then better after a couple of hours. Often they occur when a person is sleeping and will cause the person to wake up. The headache may be accompanied by vomiting and may get worse when the person changes position, coughs or exercises. The headaches also typically don't respond well to the usual headache remedies.

Other common symptoms include:

·         Seizures

·         Changes in speech or hearing

·         Changes in vision

·         Balance problems

·         Problems with walking

·         Numbness or tingling in the arms or legs

·         Problems with memory

·         Personality changes

·         Inability to concentrate

·         Weakness in one part of the body

It's important to keep in mind that these symptoms can be caused by a number of different conditions. You shouldn't assume you have a brain tumour just because you experience some of them. Seek medical advice if you are concerned.

How are brain tumours diagnosed?

The doctor starts by asking questions about your symptoms and taking a personal and family health history. Then he or she performs a physical examination, including a neurological examination. If there's reason to suspect a brain tumour, the doctor may request one or more of the following tests:

·         Scanning tests such as a CT (CAT) scan or MRI to see detailed images of the brain.

·         Angiogram, which involves the use of dye and X-rays of blood vessels in the brain to look for signs of blockage.

·         Spinal tap/Lumbar puncture, which examines fluid taken from the spinal cord.

The doctor may also ask for a biopsy to determine whether or not the tumour is cancer. A tissue sample is removed from the brain either during surgery to remove the tumour or with a needle inserted through a small hole drilled into the skull before treatment is started. The sample is then sent to a laboratory to see if there is any cancer present.

Brain Tumor Treatment at World Best Cancer Hospitals in India

• Surgery : Surgery is often the first treatment if the tumour can be removed without causing harm to the surrounding brain tissue. Treatment of brain cancer is usually complex. Most treatment plans involve several consulting doctors.The team of doctors includes neurosurgeons (surgical specialists in the brain and nervous system), oncologists, radiation oncologists (doctors who practice radiation therapy), and of course, your primary health-care provider. A patient's team may include a dietitian, a social worker, a physical therapist, and probably other specialists.
• Chemotherapy : Chemotherapy is not used to treat all brain tumours. It may be used for people with high-grade primary brain tumours, either as an initial treatment alongside radiotherapy, or where the tumour has come back. In this situation, chemotherapy is unlikely to be able to cure a brain tumour, but it can sometimes shrink a tumour down or slow its growth, which can reduce symptoms.
• Radiation therapy : Radiation therapy (also called radiotherapy) is the use of high-energy rays to kills tumor cells, thereby stopping them from growing and multiplying.Radiation therapy may be used for people who cannot undergo surgery. In other cases, it is used after surgery to kill any tumor calls that may remain. Radiation therapy is a local therapy. This means that it affects only cells in its path. It does not harm cells elsewhere in the body or even elsewhere in the brain
  
  Latest and Advanced Treatment options for Brain Tumor in India

Brain Tumor is no more a scary health condition as modern technology and advanced surgical modalities now offer near perfect clinical outcomes and the patients can soon return to normal life after surgery.

Brain Suite - Intra-operative MR Navigation Microsurgery

Trans-Nasal Endoscopic Removal of brain Tumor through the nose

Stereotactic Radiosurgery - Gamma Knife & Novalis TX

Tumor Embolization using Neuro Interventional Radiology

CyberKnife Radiosurgery