Treatment for brain tumors depends on a number of factors including the type, location and size of the tumor

as well as the patients age and general health. Treatment methods and schedules differ for children and adults. Brain tumors are treated with surgery, radiation therapy and chemotherapy. Surgery is generally performed as a craniotomy, which requires a section of skull to be removed in order for the surgeon to access the tumor. There are some newer experimental types of surgical methods but those are generally not in use at most facilities and in most cases the benefits for oligo patients would not warrant their use. What most surgeons will try to determine is how much of the tumor can be removed without a significant risk of creating permanent damage or deficits. There is always some risk so most surgeons feel that the risk is only worth taking if a significant majority of the tumor can be removed. Statistics have not proven an advantage to a patient unless most or all visible tumor can be removed. There is some benefit to having more tissue to test and in some instances there is an advantage to a patient by decreasing pressure on surrounding critical areas of the brain. As with all issues related to these tumors, experts will often disagree on what should or shouldnt be done. Another method that is becoming more common is the use of awake craniotomies. This is a method that brings the patient back to a state of consciousness during surgery so that the patient can answer questions and move body parts while the doctor is probing areas of the brain where tissue is to be removed. This enables the surgeon to determine whether or not it is safe to remove specific sections of the tumor. Of all treatment modalities, surgery is the one where the specific doctor is probably the most important factor. There are a handful of surgeons who are really good at operating on low grade oligos and they tend to be able to do things that other doctors would not even attempt. If your brother-in-law opts for surgery he should be very selective about the surgeon who performs the surgery. Radiation is the other treatment that has been used for a long time to treat brain tumors. The effectiveness of radiation on brain tumors is still controversial. Most large studies have shown that it will usually extend progression free survival (PFS) but not overall survival. Chemotherapy is a newer treatment for brain tumors that Ill discuss a little later but recent studies have indicated that the combination of chemo and radiation when done concomitantly (at the same time) does have a benefit over doing either one separately. There are two different types of radiation used to treat brain tumors and several different ways in which to deliver that radiation. The two types are photon (or x-ray) radiation and proton radiation. Photons are by far the most common but protons are beginning to gain some momentum. Proton radiation centers are extremely expensive to build and the benefits are not always easy to demonstrate so its use is somewhat controversial. The main benefit to protons over photons is that protons generally deliver less radiation to tissue adjacent to the target of the radiation. Explaining this here would take too long but if you google bragg peak you should find a pretty good explanation. The different ways of delivering radiation are a little beyond my ability to explain but they have to do with how the rays of radiation are aimed, the amount of radiation delivered, and the length of time that the radiation is administered. There are methods

that are often referred to as radiosurgery. Gamma knife is an example of radiosurgery. The concept is to focus a high dosage of radiation on a small target over a brief period of time. This has the result of killing the tissue within the target area. When there are small lesions, this method can be very effective. It is unusual for this to be useful for treating oligos but there are exceptions. Other methods of delivery give lower doses over a longer period of time. Typically, treatment will be done five days a week for six weeks. The radioactive beams are sent toward the target from multiple angles so that only where the beams intersect does the tissue receive the maximum exposure to radiation. This is done to minimize t he damage to surrounding tissue. The way that low dose radiation kills tumor cells is by damaging them in a way that causes them to die when the try to divide or prevents them from dividing. The radiation damage occurs to normal tissue as well as tumor tissue but normal tissue is able to repair itself. Chemotherapy is the use of chemicals to kill or prevent tumor cells from dividing. Experiments done on anaplastic oligodendroglioma patients (anaplastic is added to the name when the tumor becomes grade 3 or high grade) back in the 90s were the first to show that chemotherapy could be effective in treating brain tumors. In an effort to try to determine why this was the case, researchers discovered the phenomenon of 1p 19q deletions. What they discovered was that tumors with these characteristics were more responsive to chemo than were those without the deletions. Later studies have shown that the deletions are also a prognostic indicator of better response to other treatments as well and to overall survival. The chemo that was used back then was PCV, which was a combination of three different drugs. It had some pretty nasty side effects and has been replaced today, in most cases, by Temodar (temozolomide). Temodar is commonly used now for most gliomas not just oligos. There are many other drugs that have been tested on brain tumors in many different combinations but none have been officially approved for use. To get these other medicines, a patient must either be in a clinical trial or have doctor who will prescribe them off label. There is one drug that is often used for high grade tumors that are no longer responding to other treatments and it is called avastan (bevacizumam). It is in a class of medicines called antiangiogenics. Angiogenesis is the process of developing new blood vessels and tumors depend on this process in order to have a source of blood so that they can continue growing. Avastan has shown promise but not without some drawbacks. It is rarely prescribed for oligo patients and probably never for low grade (grade 2) tumors. There are other treatments being tested and used. Those include immunotherapy, homeopathy, electrical waves, and others.