Brain Cancer

By: GROUP 5 (BSN 4-B)

Significance

The brain is the center of thoughts, emotions, memory and speech. Brain also control muscle movements and interpretation of sensory information (sight, sound, touch, taste, pain etc)

Significance

Tumors can effect any part of the brain and depending on what part(s) of the brain its effects can have a number of symptoms:

Seizures Difficulty with language Mood changes Change of personality Changes in vision, hearing, and sensation. Difficulty with muscle movement Difficulty with coordination control

Definition

Brain tumors are masses of abnormal cells that have grown out of control. It is a localized intracranial lesion that occupies space within the skull. A tumor usually grows as a spherical mass, but it also can grow diffusely and infiltrate tissue.

Definition

Most brain cancers can spread through the brain tissue but rarely spread to other areas of the body. Even so-called benign tumors can, as they grow, press on or invade normal brain tissues, causing damage that is often disabling and sometimes fatal.

Definition

For this reason, doctors usually speak of "brain tumors" rather than "brain cancers." The major differences are how readily they spread through the rest of the central nervous system and whether they can be removed and not come back.

Background

According to Surveillance Epidemiology and End Result Programs (SEER) of the National Cancer Institute of the USA; the estimated annual incidence of brain cancer in the Philippines is 5,390 in 86, 241, 697 population used of the year 2004.

2 types of brain tumors: primary and secondary.

Background

Primary Brain Tumor Originates from cells and structures within the brain. The cause is unknown. It includes gliomas, meningiomas, acoustic neuromas, and pituitary adenomas. Secondary Brain Tumor or Metastatic Developed from structures outside the brain and occur in 10% to 20% of patients with cancer.

Background
Classification

of Brain Tumors:

Those arising from the coverings of the brain, (eg. Dural meningioma). Those developing in or on the cranial nerves, (eg. Acoustic neuroma). Those originating within brain tissue,(eg. Glioma).

Background

In adults over 45 years of age 90% of all brain tumors are Gliomas

Gliomas: A general category of cancer that includes astrocytomas, oligodendrogliomas, and ependymomas

Astrocytoma

Astrocytes brain cells abnormally dividing causing tumors called astrocytomas. Astrocytes are glial cells that help nourish neurons they help repair damage. The most common type of glioma and are graded from 1 to 4, indicating the degree of malignancy. The grade is based on cellular density, cell mitosis, and appearance. Spread by infiltrating into the surrounding neural connective tissue and therefore cannot be totally removed without causing considerable damage to vital structures.

Astrocytomas--Treatments

If tumors have not infiltrated normal brain tissue then surgery can be a cure. Low-grade Astrocytomas are not curable by surgery. However through surgery as much of the tumor as possible is removed and then the patient usually goes through radiation treatment.

Oligodendrogliomas

These tumors start in mutated oligodendrocyte brain cells Oligodendrocytes make myelin which help neurons transmit signals through the axons These tumors may spread through cerebrospinal fluid pathways but typically do not usually spread to locations outside of the brain or spinal cord.

It represents 20% of gliomas and are categorize as low grade or high grade. More sensitive than astrocytomas to chemotherapy.

Oligodendrogliomas-Treatments

Because these tumors infiltrate normal brain tissue these tumors are not cured through surgery. However removal of part of the tumors can relieve some symptoms and prolong life. If the tumor is causing disabilities to the patient after surgery the patient may go through chemotherapy, perhaps followed by radiation treatments.

Ependymomas

Mutated ependymal cells Ependymal cells line the ventricles in the central area of the brain and they line part of the pathway through which the cerebrospinal fluid travels Theses mutated cells may block the cerebrospinal fluid from exiting the ventricles causing the ventricles to enlarge (hydrocephalus)

Ependymomas--Treatments

These tumors do not usually infiltrate normal brain tissue and are therefore curable through surgery. If surgery is unable to completely remove the tumors the patient may try radiation therapy.

Meningiomas

Represent 15% of all primary brain tumors, are common benign encapsulated tumors of arachnoid cell on the meninges. slow growing and occur most often in middle aged adults(women). Manifestations depend on the area involved and are the result of compression rather than invasion of brain tissue.

Meningiomas-Treatments

Preferred treatment for symptomatic lesions is surgery with complete removal or partial dissection.

Acoustic Neuromas

Tumor in 8th CN, arises just within the internal auditory meatus. May grow slowly and attain considerable size before it is correctly diagnosed. Patient usually experienced loos of hearing, tinnitus, and episodes of vertigo and staggering gait. Larger compression of 5th CN.

Pituitary Adenomas

Represent about 10% to 15% of all brain tumors Pressure on adjacent structures causing hyper/hypofunction of the pituitary. Pressure exerted on optic nerves, optic chiasm, or optic tracts or on the hypothalamus or the 3rd ventricle if the tumor invades the cavernous sinuses or expand in the sphenoid bone.

PRESSURE EFFECTS: Headache, visual dysfunction, hypothalamic d/o(sleep,appetite,temp., and emotions), increase ICP, enlargement of sella turcica.

HORMONAL EFFECTS:

Prolactin-secreting pituitary adenomas and ACTH-produce pituitary adenomas that result in CUSHING SYNDROME

HORMONAL EFFECTS:

Prolactin-secreting pituitary adenomas and ACTH-produce pituitary adenomas that result in CUSHING SYNDROME Impotence and hypogonadism(condition in which the body doesn't produce enough testosterone) common in males CUSHING SYNDROME-result in increase prod. Of ACTH, s/s:obesity with redistribution of fat to

the facial, supraclavicular and abdominal areas, HTN, purple striae and ecchymoses, osteoporosis, elevated glucose level, and emotional d/o.

Brain Angiomas

Masses composed largely of abnormal blood vessels, found either in or on the surface of the brain. They occur in cerebellum in 83% of cases. Some persist throughout life w/o causing symptoms. Patients are risk in hemorrhagic stroke due to thin blood vessels.

Pathophysiology
Risk Factors: Radiation Exposure Family History Immune System Disorder

Mutation of normal cells to abnormal cells that the immune system fails to recognize or respond to:

Compression,invasion and infiltration

Cerebral edema

Increase ICP

Seizure Activity Focal Neurological Deficits Alteration in normal pituitary function

Clinical manifestation depends on the location and size of the tumor General Manifestation: Headache Nausea and vomiting Papilledema Changes in level of consciousness Visual disturbances

Clinical Manifestations
Increased Intracranial Pressure- result from gradual compression of the brain by the enlarging tumor. -s/s: headache, nausea w/ or w/o vomiting and papilledema (edema of the optic disk), personality changes and a variety of focal deficits, including motor, sensory, and cranial nerve dysfunction, are common.

Clinical Manifestations
Headache-common in early morning and made worse by coughing, straining or sudden movement. -caused by compressing or distorting the pain sensitive structures or by edema that accompanies tumor. -describe as deep or axpanding

Clinical Manifestations
Vomiting-result in the irritation of the vagal centers in the medulla. Forceful vomiting is describe as projectile vomiting. Visual disturbances-papilledema is present -decrease visual acuity,diplopia (double vision), and visual field deficits.

Localized Symptoms

Motor cortex tumor-seizure-like movements on one side of the body, called Jacksonian seizure Occipital lobe tumor- produces visual manifestations:contralateral homonymous hemianopsia (visual loss in half of the visual field on the opposite side of the tumor) and visual hallucinations

Localized Symptoms

Cerebellar tumor- causes dizziness, an ataxic or staggering gait w/ a tendency to fall toward the side of the lesion, marked muscle incoordination, and nystagmus (involuntary rhythmic eye movements), usually in the horizontal direction. Frontal lobe tumor- produces personality d/o, changes in emotional state and behavior , and an apathetic mental attitude.

Localized Symptoms
Cerebellopontine angle tumor- originates in the sheath of the acoustic nerve and gives rise to a characteristics sequence of symptoms. -tinnitus and vertigo appear first, soon followed by progressive nerve deafness (8th cranial nerve dysfunction) -numbness and tingling of the face and tongue due to involvement of 5th cranial nerve.

Localized Symptoms
-weakness or paralysis of the face later on develop due to 7th cranial nerve involvement. -because the enlarging tumor presses on the cerebellum, abnormalities in motor function may be present.

Diagnosis

These tumors can be detected through a MRI, CT scan or a PET scan. Once detected, depending on where the tumor is located, a biopsy officially is used to diagnosis cancer.

Staging and Grading

Cancers in or around the brain are not staged using the TNM system, since these cancers tend to spread to other parts of the brain and not to lymph nodes or other parts of the body. Because tumors in the brain or spinal cord almost never spread to other parts of the

body, there is no formal staging system. Some of the most important factors that help determine outlook include:

The type of tumor (such as astrocytoma, ependymoma, etc.) The grade of the tumor (how quickly the tumor is likely to grow, based on how the cells look under a microscope)

The person's age The person's functional level (whether the tumor has started to interfere with normal brain functions) The size and location of the tumor How much of the tumor can be removed by surgery (if it can be done) Whether or not the tumor has spread through the cerebrospinal fluid (CSF) to other parts of the brain and/or spinal cord

Stage I Cancer

Stage 1

In this stage, the cancer cells look normal. They can barely be seen through the microscope, but they are there. At this early stage, the cells rarely multiply and spread to other tissues. Treatment to cancer at this stage is most successful. The cells maybe removed through surgery.

Stage 2

At this stage, the cancer cells register slow growth and may start to spread into neighboring cells. They are still treatable, however, but they also have the possibility of developing into a higher stage and aggressive cancer.

Stage 3

This stage is marked by speedy and aggressive growth and development of the cancer cells. At this point, they are now distinctive when viewed through the microscope, and can be differentiated from the normal, non-cancer cells. Spreading to other tissue may also be possible.

Stage 4

The last and most extreme stage of brain cancer, stage IV brain cancer cells grow aggressively and spreads itself to other tissue. Treatment is generally difficult at this point, but may be successful.

Medical Management

Chemotherapy chemotherapy is most

commonly used in combination with either surgical intervention and/or radiation. Chemotherapeutic drugs work by interfering with the transmission of genetic information that is necessary for tumor cells to grow or replicate.

Radiation Therapy radiation is the second most common treatment for a brain tumor. The objective of radiation therapy is to destroy the tumor cells without injuring the surrounding tissue Brachytherapy- use as an adjunct to conventional radiation therapy or as a measure for recurrent disease.

Medical Management

Intravenous Autologous Bone Marrow Transplantation- used in some patient who will received chemo or radiation therapy because it can rescue patient from the bone marrow toxicity associated with high doses of chemotherapy and radiation. Gene transfer therapy- uses retroviral vectors to carry genes to the tumor, reprogramming the tumor tissue for susceptibility to tx.

Surgical Management

Surgical Intervention surgical intervention is the most common approach to treatment for a brain tumor. Surgical removal of a tumor includes a complete or partial removal of the tumor depending on location, accessibility and the risk of injuring surrounding tissue. The main objective is to remove or destroy the entire tumor w/out increasing the neurologic deficit or to relieve symptoms by partial removal.

Stereotactic Biopsy - This is a procedure that uses an imaging device, such as CT or MRI, to guide the needle through the burr hole to the location of the tumor. The surgeon will then withdraw a sample of tissue with the needle. Craniotomy - is a procedure to remove a lesion in the brain through an opening in the skull (cranium).

Nursing Management

Nursing Assessment/Interventions:

Assess and monitor ABCs Monitor routine vital signs Monitor O2 saturation Monitor I&O (to prevent Foley related UTI, remove Foley when patient is stable). HOB 30 degrees/Side rails up Initially NPO (most orders allow for progression of diet as patient tolerates).

Nursing Management

HOB 30 degrees/Side rails up Initially NPO (most orders allow for progression of diet as patient tolerates). Initially bed rest (as with NPO, most orders allow for the progression of activity as the patient tolerates). Monitor Neuro exam

Nursing Management

Pain and sedation control Basic hygiene Turning Q 2 hours (note: do not combine nursing activities that are known to increase intracranial pressure) Range of motion Inspection of incision and dressing for drainage

Nursing Management

Common nursing diagnosis related to physical condition: Alteration in Comfort Alteration in Nutrition Altered Oral Mucous Membrane (r/t stomatitis) Fatigue

Nursing Management

Alteration in Cerebral Perfusion Risk of Infection Risk of Impaired Skin Integrity Knowledge Deficit (diagnosis, treatment, discharge and follow-up

Common nursing diagnosis related to emotional needs: Fear/Anxiety

Nursing Management

Personal Identity Disturbance Body Image Disturbance Dysfunctional Grieving Altered Role Performance Social Isolation Impaired Social Interaction Altered Family Processes Ineffective Individual/Family Coping Ineffective Denial

Nursing Interventions

Assess level of discomfort using a rating scale of 0 to 10. Provide a quiet, nonstimulating environment. Position the client for comfort, keeping the head of the bed elevated to promote venous drainage. Assess level of consciousness for potential increases in ICP.

Encourage to verbalize feelings about the surgery. Suggest measures that may help minimize the hair loss, such as the use of turbans, scarves, hats, and wigs. Suggest relaxation techniques to decrease anxiety. Diminished gag response: position patient in upright, teach patient to direct food and fluids toward the unaffected side, offer semisoft diet ,have suction readily available.

Perform neurologic checks, monitor VS, maintains a neurologic flow chart to prevent rapid increase in ICP. Reorient patient when necessary to person, time and place. Monitor patient with seizure to protect from injury. Prior to starting radiation, inform patient and family of the various activities that will occur during the administration of radiation

Provide proper skin care to radiation site.

To manage anorexia, offer small portions of food that are easily digested. For fatigue and malaise; schedule activities that allow for rest periods in between. Note results of CBC with special attention to WBC and platelet counts. (Bone marrow depression decreases platelets and increases risk of hemorrhage).

Prognosis

For people ages 15-44 five year survival rate is 55% For people ages 45-64 five year survival rate is 16% For people over 65 five year survival rate is 5%