Brain Cancer

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	Introduction A tumor develops if cells multiply when they are not needed or if they stop obeying normal growth controls. A brain tumor is a mass of unnecessary and often abnormal cells located in or on the brain. The Central Nervous System (CNS) includes the brain, spine and cranial nerves. In this text, we use the term "brain tumor" to mean any tumor of the central nervous system. The CNS is the essence of our existence. The brain controls memory and learning, speech, movement, emotion, and along with the spinal cord, receives and interprets input from our senses (hearing, sight, smell, taste, and touch). The brain controls basic body functions such as breathing and the beating of our heart. The brain, spine, spinal cord, and cranial nerves enable us to function in our environment. How a brain tumor affects us and our ability to function depends on many variables: the type of tumor; where in the brain or spine it is located; our age; the state of our health; our attitude. Following is some of the basic information you will need to understand this disease and a list of the more common types of brain tumors. Brain Tumor Basics Benign or Malignant There are more than 125 different kinds of brain tumors. Some are called "malignant," and some are called "benign." Malignant brain tumors are composed of 1) cancer cells-abnormal cells that can grow rapidly and invade locally or spread to distant locations in the brain or spine (primary brain tumors rarely spread beyond the CNS, unlike most other cancers), or 2) normal or nearly normal cells growing in a critical area of the brain. A "benign" brain tumor in a critical area can be "malignant" because of its location. Other brain tumors are "benign"-their cells appear to be normal or nearly normal when viewed under the microscope, they usually grow slowly, have distinct borders, rarely spread and might be treated by surgery alone if they are accessible. Primary Primary brain tumors are tumors that begin in the brain such as gliomas, astrocytomas or medulloblastomas. Metastatic Metastatic brain tumors, also called secondary tumors (or lesions) , begin as cancer elsewhere in the body and travel to the brain. While many cancers can metastasize to the brain, cancers of the lung, breast, colon and melanoma skin cancer are the types most frequently associated with metastatic brain tumors. By definition, all metastatic brain tumors are malignant. Tumor Names Tumors are examined, identified, and then named based on a classification system. We are using the most common system which is the one published by the World Health Organization (WHO). Grading Tumors are usually graded on a scale of I to IV. In that scale, I is the most benign and IV is the most malignant. Pathologists determine the grade by viewing a sample of the tumor under a microscope and then evaluating it using several criteria. Those criteria include similarity to normal cells, rate of growth, indications of uncontrolled growth, potential for spread and blood supply. Staging Staging is the classification of tumors by their size and how far they have spread beyond their site of origin. Staging for brain tumors is often derived from scan information or by examining the cerebrospinal fluid. For some types of brain tumors, staging information can help your doctor decide what treatments to recommend. For benign and low grade brain tumors, staging may not be relevant. Childhood brain tumors About 2,200 children and adolescents in the United States are diagnosed with a brain tumor each year. These tumors fall into three main groups: astrocytomas (also called gliomas), most frequently occurring in the brain stem, the cerebellum and the optic chiasm; ependymal tumors; and primitive neuroectodermal tumors (PNETs), the most common of which is the medulloblastoma. Astrocytomas represent the majority of brain tumors in children, following in frequency by medulloblastomas, PNETs and ependymomas. Unlike those in adults, about half of all brain tumors in children are located in the area of the brain called the posterior fossa. Structures there include the fourth ventricle, the brain stem and the cerebellum. Brain tumors are more commonly diagnosed in children under the age of seven than in older children, and they tend to occur in boys more often than girls. Long term flu-like symptoms are commonly the first clue that a brain tumor may be present. Frequent headaches that are worse in the morning, early morning nausea or vomiting, a wobbly walk, worsening school performance, and changes in vision are often present. Symptoms that don't improve after a reasonable period of time should be brought to the attention of your child's doctor. Treatment of childhood brain tumors depends to a large extent on the age of the child. In very young children, attempts will be made to delay radiation as long as possible. Standard treatments most frequently include surgery and/or chemotherapy. Types of Brain Tumors Gliomas Glioma is the generic name given to tumors arising from the neuroglia of the brain. The four types of glial cells-ependymal cells, astrocytes, oligodendrocytes and microglia-serve nerve cells by providing nourishment and other support. Gliomas are the most common primary brain tumors. Astrocytoma, oligodendroglioma and ependymoma are all forms of glioma. If a sample of the tumor can be examined under a microscope, a more specific diagnosis is possible. Names such as "optic tract glioma" or "brain stem glioma" are used to indicate the glioma's location. A "butterfly glioma" is the generic name given to a higher grade astrocytoma with a "butterfly" appearance on scans (caused by its presence in both sides of the brain). "Mixed glioma" is the name given to a tumor containing oligodendroglioma and/or ependymoma cells in addition to astrocytoma cells. Standard treatment is the same as that for an astrocytoma or oligodendroglioma of the same grade. Most are Grade II or III tumors. The optic chiasm, optic nerve and/or the optic tract can be affected by an "optic glioma." This tumor rarely spreads, is most likely to occur in children under the age of 10 and is frequently a pilocytic or Grade II astrocytoma. Twenty percent of children with Neurofibromatosis 1 (NF1) will develop an optic glioma. Symptoms include loss of vision, rapid movement of the eyeballs and crossed eyes. Hormonal changes may cause developmental delay. "Watchful waiting" may be recommended as the primary treatment for children with NF or for those with slow growing tumors. Surgery might be the treatment of choice if the tumor involves only the optic nerve. Radiation therapy for tumors of the chiasm or pathway might be recommended. Astrocytoma Astrocytomas arise from astrocyte cells, one of the types of glial tissue in the brain. Astrocytomas are the most common primary CNS tumors. There are different kinds and different naming systems for astrocytomas. Pilocytic Astrocytoma (WHO Grade I) These tumors rarely infiltrate and almost always have well-defined borders. They are slow growing but can become quite large before causing symptoms. Pilocytic astrocytomas occur mainly in children and are the most benign of the astrocytomas. Many optic gliomas, cerebellar astrocytomas and some brain stem gliomas are pilocytic astrocytomas. Surgery alone may cure Grade I tumors. In adults and older children, radiation therapy might be recommended following surgery for incompletely removed tumors or for patients who don't undergo surgery. If the tumor recurs, a second surgery and some form of radiation may be options. Fibrillary Astrocytoma (WHO Grade II) These are relatively slow growing tumors that tend to spread into nearby, healthy tissue. If the tumor is completely removed during surgery, some doctors might recommend periodic follow-up visits only. Others might recommend radiation therapy as an additional treatment. Radiation is also used for partially removed tumors and for patients who don't have surgery. The role of chemotherapy for these tumors is being investigated. If the tumor recurs following initial treatment, a second surgery or radiation therapy are options. Anaplastic Astrocytoma (WHO Grade III ) These are infiltrating, malignant tumors that are more common in adults than children. They grow faster than lower grade tumors and invade nearby, healthy tissue. They also recur more often and more quickly. Some lower grade tumors may recur as a higher grade. Treatment depends on the location of the tumor (its accessibility), if and how far the tumor has spread, and the general health and age of the patient. Surgery plus radiation therapy or surgery plus radiation therapy and chemotherapy is the standard treatment for accessible tumors. Inoperable tumors can be treated with radiation therapy or radiation therapy and chemotherapy. Cerebellar Astrocytoma The cerebellum is the second largest area of the brain. It is located in the posterior fossa, just above the back of the neck, and is connected to the brain stem. It controls balance and complex motor activities such as walking and talking. Cerebellar astrocytomas typically are slow growing tumors that rarely spread. They are often pilocytic astrocytomas. The cerebellar location is more common in children than in adults. These tumors are usually accessible to the neurosurgeon. Surgery is the primary treatment, and if total removal is possible, that may be the only treatment required. Radiation might be recommended for partially removed or higher grade tumors, or for recurrences. Glioblastoma Multiforme (also called Astrocytoma Grade IV) This is the highest grade, most malignant astrocytoma. It commonly invades adjacent tissue and spreads widely throughout the brain and spine. Glioblastoma multiforme most frequently arises in a frontal lobe of the cerebrum. It represents about 30% of all primary brain tumors and about 50% of the astrocytomas. Glioblastoma is more common in older adults and affects men more often than women. Nine percent of childhood brain tumors are glioblastomas. The "multiforme" in glioblastoma multiforme indicates that it is a very heterogeneous tumor-it contains a mix of many types of cells and one part of the tumor can be quite different from another part. This characteristic makes it very difficult to treat. While one cell type may respond to treatment, other types in the tumor may not. The standard treatment for accessible glioblastoma multiforme tumors in adults and children is surgery. If surgery is not possible, a biopsy might be recommended to confirm the type of tumor. Some form of radiation therapy almost always follows surgery or biopsy for adults and older children. Chemotherapy might also be recommended, before, during or after radiation. In very young children, chemotherapy might be used to delay radiation therapy. Recurrent tumors can be treated with additional surgery, chemotherapy or some form of radiation therapy. (For more information about treatment, see the full treatment document.) Oligodendroglioma Oligodendroglial tumors arise from oligodendrocytes, the glial cells that help transmit signals between nerves. They most frequently occur in the cerebral hemispheres of young or middle-aged adults, but are also found in children. Slightly more women than men are affected. Seizures are the most common presenting symptom. The rare, pure oligodendroglioma is considered to be grade II tumor. More common is the mixed glioma, which contains astrocytoma and oligodendroglioma cells. This type of tumor is also called an oligoastrocytoma. An anaplastic oligodendroglioma or anaplastic oligoastrocytoma contains malignant cells and is considered to be a grade III tumor. Sometimes glioblastoma cells are found in these tumors. Those are grade IV tumors. Standard treatment for accessible tumors is surgery. Oligoastrocytomas and anaplastic tumors usually are treated with radiation following surgery. Sixty to sixty five percent of oligodendrogliomas respond to chemotherapy. Chemotherapy is also used in very young children to delay radiation therapy. Ependymal tumors Ependymal tumors arise from the cells lining the ventricles and central canal of the spinal cord. Cerebrospinal fluid created in the ventricles circulates, bathes and cushions the brain and spinal cord. These tumors represent about 6% of all gliomas and approximately 10% of childhood brain tumors. They most commonly occur in the posterior fossa (the area of the brain just above the back of the neck), and, while common in children, also occur in adults. About 10% of these tumors spread via the cerebrospinal fluid to the spine. There are several types of ependymal tumors. The two types of grade I, benign ependymomas are most commonly found in the spine (myxopapillary ependymoma) or the 4th ventricle (subependymoma). Grade II tumors (there are three types) are most frequently located in the 4th ventricle and the midline area (cellular and clear cell ependymomas). The rare papillary ependymoma is most commonly located in the cerebellopontine angle. The typical location for the Grade III anaplastic ependymoma is in the cerebral hemispheres. The very rare grade IV ependymoblastoma is more common in children. It is classified as a PNET in some systems. Ependymomas may also be classified as "low-risk" or "high-risk." That determination is based on the tumor's location and staging, and will influence treatment recommendations. Surgery followed by radiation therapy to the brain and spinal cord is standard therapy for the higher grade ependymomas. Chemotherapy or a form of local radiation might be used for recurrent tumors. For children under the age of three, chemotherapy may be used to delay radiation therapy. Brain Stem Glioma Brain stem glioma is the generic name given a tumor located in the brain stem-the bottom part of the brain that connects to the spinal cord. The brain stem is comprised of several structures including the midbrain, pons, medulla oblongata, tectum, and the cervicomedullary junction. This critical area of the brain is involved in basic life functions such as blood pressure, heart beat, breathing and consciousness. It also contains the origins of several cranial nerves. Ten to twenty percent of the brain tumors in children are brain stem gliomas. They are also found in adults. Brain stem gliomas are most often astrocytomas and can be of any grade. These tumors may be described by a specific area of the brain stem, for example, a pontine glioma (located in the pons) or a tectal glioma (located on the tectum). They may also be described as belonging to one of 4 groups: 1) diffuse=invasive; 2) focal=having defined margins; 3) exophytic=growing outward from the brain stem into the 4th ventricle; or 4) cervicomedullary=arising from the medulla oblongata and extending into the cervical spinal cord. These tumors rarely spread beyond the brain stem. The majority of brain stem gliomas, about 60-70%, are invasive Grade III tumors with a rapid onset of symptoms. About 10-20% are focal tumors with defined margins. These have a gradual onset of symptoms and often are pilocytic or low grade tumors (Grades I or II). Treatment is influenced by the location and grade of the tumor as well as the age of the patient. Surgery for biopsy or partial removal of the tumor might be recommended if the tumor is exterior to the brain stem and can be accessed by the neurosurgeon. Some brain stem gliomas, such as those in the tectum or a pilocytic astrocytoma might require no immediate treatment beyond "watching waiting." Radiation therapy might be used as a primary treatment for inaccessible, partially removed or malignant tumors in adults and older children. Chemotherapy might be an option for recurrent tumors or to delay radiation in children younger than three. Craniopharyngioma Craniopharyngiomas are benign tumors that occur near the pituitary gland, a small organ about the size of a pea located just above the nose. These tumors represent 2-3% of all primary brain tumors and 5-13% of childhood brain tumors. About 60% occur in patients older than 16. Craniopharyngiomas often involve the 3rd ventricle, optic nerve and pituitary gland. These localized tumors grow by expansion rather than invasion, and can become quite large before they are diagnosed. Symptoms are due to the increased intracranial pressure and direct pressure on the optic tract and the pituitary gland. Hormonal disturbances are common. Surgery and/or radiation therapy is the standard treatment and may be the only treatment required if the tumor can be completely removed. As a form of local therapy, intracavitary radiation or stereotactic radiosurgery might be recommended. Medulloblastoma The medulloblastoma is a fast-growing, invasive tumor that is always located in the cerebellum. It is also called "PNET-Medulloblastoma." Although these tumors represent 15-20% of childhood brain tumors, they are also found in adults. The medulloblastoma frequently spreads throughout the brain and spine via the cerebrospinal fluid. It can also extend into the 4th ventricle and infiltrate the meninges. Standard treatment consists of surgical removal of the tumor, followed by staging. Medulloblastomas are classified as "standard risk" or "high risk" based on the age of the patient, the amount of tumor remaining after surgery and if the tumor has spread. For children older than three and adults, surgery is followed by radiation to the tumor area followed by a lower dose to the whole brain and spine. Chemotherapy is used before, during and/or after radiation therapy. Very young children are often given chemotherapy instead of radiation until they are older. This tumor is very responsive to the combination of surgery, radiation and chemotherapy. Standard risk children may receive lesser amounts of radiation in addition to their chemotherapy. Recurrent tumors might require a second surgery followed by chemotherapy. Meningioma Meningiomas are tumors of the membranes that cover and protect the brain and spinal cord (the meninges). About 20% of the primary brain tumors are meningiomas. They occur most commonly in middle-aged women. The majority of these tumors are benign, but they frequently recur, sometimes as a higher grade. Multiple tumors can occur. A medical history of Neurofibromatosis 2, prior radiation of the head or brain, or a history of breast cancer may increase a person's risk for developing a meningioma. Symptoms vary with location but the most common are headache, muscle weakness, seizures, personality change, confusion and vision changes. The benign meningioma is usually slow growing and can become quite large before it is diagnosed. Symptoms are due to compression rather than invasion. Surgery is the standard treatment for accessible tumors, and includes removing the section of the meninges to which the tumor is attached and any bone that may be involved. Radiation may be suggested for tumors which cannot be completely removed or for those that are inaccessible. For some patients, "watchful waiting" may be the only treatment recommended, particularly if the tumor was discovered incidentally. Less common are the atypical and malignant meningiomas. Radiation therapy in addition to surgery is often used to treat those tumors. Metastatic brain tumors Metastatic brain tumors, also called secondary brain tumors, begin as cancer elsewhere in the body and travel to the brain where they either form solid masses or circulate in the cerebrospinal fluid. These tumors are always malignant, and most frequently arise from lung, breast, colon or kidney cancer or from malignant melanoma. Breast, lung and prostate cancers are associated with metastases in the spine. If cancer cells are found in the spinal fluid, treatment with regional chemotherapy is often recommended, and radiation therapy may also be included in the treatment plan. Multiple tumors are common with lung cancer and melanoma. In patients with a controlled primary cancer and a small number of brain tumors, treatment often consists of surgery, possibly followed by radiation therapy. Radiation therapy is also used with metastases from primary cancers known to be radiosensitive. If many tumors are present, surgery would be considered only if the tumors were close together. Otherwise, whole brain radiation would probably be used. Pituitary tumors The pituitary adenoma is a benign, slow growing tumor, that represents about 15% of all primary brain tumors. It can occur at any age but is rare before puberty. Most grow in the front portion of the pituitary and they often compress the optic chiasm. The most common symptoms are headaches, vision loss and hormonal disturbances. The adenomas are grouped as "hormone secreting" or "non-secreting," and if they are secreting, by the hormone produced. Treatment of this tumor requires the efforts of many medical specialists because hormones affect so many parts of the body. Some form of hormone therapy may be required to counteract the effects of the tumor or to shrink it. Surgery may be required if the tumor cannot be controlled by drug therapy. The size and location of the tumor will influence which of the two types of surgery will be recommended. Radiation therapy may be another option. A pituitary carcinoma is the very rare, malignant form of the pituitary adenoma. It is diagnosed only when a pituitary tumor spreads into adjacent areas. Treatment might include surgery, radiation therapy, hormone therapy and chemotherapy. Role of the Pathologist A pathologist is the physician who makes the actual diagnosis of cancer. This medical professional has specialty training in the examination and diagnosis of cells and tissues. This material is removed from the body by various types of biopsy procedures then examined under the microscope by the pathologist. Based on detailed characteristics of the cells, the pathologist determines if the tumor is benign or malignant, slow growing or aggressive. A misdiagnosis can have consequences in the staging and grading of a malignancy and resulting treatment decisions. The American Cancer Society and the American Society of Clinical Pathologists recommend second opinions for cancer diagnoses.

	Treatment How your tumor will be treated depends on: the kind of tumor you have its size and location the number of tumors your age the overall state of your health Your doctors will probably recommend surgery, radiation therapy, chemotherapy, immunotherapy, or some combination of these. They may consult with other doctors who treat brain tumors. In addition, you might want to seek a second opinion before making any decisions about your plan of treatment. Most children with brain tumors are treated at medical school-affiliated medical centers. The pediatric oncologists there have access to the latest and most effective treatments, and multi-disciplinary teams are available to provide the special care children require. Surgery Goals and Purposes of Surgery In adults and children, surgery is the most common treatment for accessible brain tumors. Surgical removal of part or all of a tumor is called resection. Surgery alone may constitute a cure for benign, localized, reachable tumors. For a malignant or less accessible tumor, removing some (if not all) of the tumor often improves quality of life by relieving symptoms. Partial resection can also help other treatment methods be more effective because the remaining tumor is smaller. Sometimes surgery is needed to establish an exact diagnosis or to provide access for other treatments. Types of Surgery Biopsy - a small piece of tumor is removed to make a diagnosis. A pathologist examines the tumor under a microscope and determines its type. Biopsy can be part of the surgery to remove the tumor, or it can be performed separately. A needle biopsy is a separate surgical procedure. A narrow, hollow needle is inserted through an opening drilled into the skull. Then, a small amount of the tumor is drawn up into the needle. Craniotomy - a neurosurgeon removes as much of the tumor as possible without causing unacceptable neurological damage. An incision is made through the shaved skin of the scalp. Then, a piece of the skull is removed to expose the tumor. After removing the tumor, the bone is replaced and the scalp is stitched shut. In conventional craniotomy, surgeons are guided by their knowledge of anatomy, the information from pre-operative scans and what they see during the operation to guide themselves in removing the tumor. In a stereotactic craniotomy, computers help guide the surgeon's hands. Stereotactic Planning Procedures - Stereotaxy is computers creating a three-dimensional image based on information obtained from scans. The image provides the surgeon with exact information about a tumor's location relative to vital structures in the brain. Surgery can then be planned to avoid those structures, and can help doctors to "rehearse" their role. Stereotaxy can be used for a needle biopsy, craniotomy and for various forms of radiation therapy. Stereotactic surgery is the use of stereotaxy during surgery. A head frame is often used to help pinpoint the tumor's location by providing consistent reference points, but there are frameless systems as well, such as the Viewing Wand and other devices. Radiation Therapy Goals and Purposes of Radiation Therapy Radiation therapy is a common treatment for brain tumors. It causes cells to die as they attempt to reproduce. Radiation is used after surgery to remove any tumor cells that may have been left behind or instead of surgery for inaccessible tumors or for tumors that are particularly responsive to this form of treatment. Radiation may be used to relieve symptoms or to prevent a secondary tumor from forming. Unless the tumor is located in the brain stem, radiation is given after a tissue diagnosis is made. It may be used as a stand-alone treatment, or in combination with drug therapy.Radiation Therapy and Children Children are very susceptible to the side-effects of radiation because their brains are still developing. For that reason, radiation therapy is delayed as long as possible, or at least until a child is three years old. Surgery and chemotherapy often replace radiation therapy as an initial treatment.Types of Radiation Therapy Conventional external beam radiation therapy - radiation in the form of high energy x-rays from linear accelerators or gamma rays from isotopes used by cobalt machines are aimed at the tumor. Treatment usually begins soon after surgery and is delivered in divided doses called fractions. The usual fraction for standard conventional external radiation for primary brain tumors is 180-200 centiGray (cGy) given five days a week, for six weeks, for a total dose of 5400-6000 cGy (for adults). Children receive fewer cGy and so do people with metastatic tumors. Interstitial radiation therapy - also called implants, seeds pellets, intracavitary, internal radiation or brachytherapy, consists of sources of radiation energy placed directly into a tumor or the space left by a tumor after it is removed. The radiation attacks the tumor from within the body. Radiosurgery - precisely focused, high-dose radiation beams delivered from multiple directions surrounding the head to treat small brain tumors. This form of therapy can be used as a "boost" following conventional radiation, for a recurrent tumor after the maximum safe dose of external radiation has already been received, instead of surgery for benign tumors such as an acoustic neuroma, a pituitary or pineal tumor, or for metastatic brain tumors. Radiosurgery can be delivered by three different machines-Gamma Knife, linac and cyclotron. Common side effects Side effects vary among individuals. The ones you experience will depend on the type of radiation you receive, the total dosage, and your own body's biology. Listed below are the side effects you are most likely to encounter as you undergo conventional external beam radiation therapy. Hair loss - this is usually a temporary effect. About two weeks into your treatment, hair over the area being radiated will fall out. Regrowth will begin following your therapy, often within weeks or a few months. Some hair loss might be permanent, and color or texture changes can occur. Skin irritation - the skin over the treated area can become reddened, flaky and itchy. To prevent or lessen the chances of irritating your scalp, stay out of the sun as much as possible and use only mild products to wash your hair. If you do have problems, ask your doctor for advice on how to relieve your discomfort. This irritation is usually temporary. Hearing problems - this can sometimes occur if your ear is near the area being radiated. Notify your doctor if you notice a decrease in your hearing. Nausea or vomiting - this is a less common side effect, but if it does occur, your doctor may prescribe a medicine called an antiemetic to control or minimize the problem. Drowsiness and fatigue - this is a very common side effect, caused by a combination of factors. The emotional impact of your illness, the stress of surgery, the extra energy you use for your daily therapy sessions and to cope with your other side-effects all contribute to your fatigue. Neurologic effects - these occur during or shortly after radiation is complete and are caused by radiation induced brain swelling. Headache, speech problems, muscle weakness, nausea and double vision may occur. Steroid medications are often prescribed during the course of your treatment to avoid or minimize these problems. Seizures Seizures are sudden attacks that cause many different movements and sensations. They are caused by abnormal electrical activity in the brain. Brain tumors can cause seizures but there are many other causes, such as epilepsy, an injury to the head, high fever, stroke, alcohol consumption or drug withdrawal. Or the cause may be unknown. There are different types of seizures-the type depends on the part of the brain affected by the abnormal electrical signals. Partial seizures, also called focal seizures, affect limited areas of the brain and are divided into two groups: complex partial seizures-the person loses consciousness; simple partial seizures-the person remains conscious. Twitching, jerking and unusual sensations are common during these types of seizures. Generalized seizures affect large areas of the brain and produce more extensive symptoms. Absence, atypical absence, atonic, myoclonic and tonic-clonic seizures are all generalized seizures. Over half of all brain tumor patients will experience at least one seizure during the course of their illness. Medications called antiepileptics are prescribed to control seizures. These drugs must be taken on a regular schedule and will be monitored carefully by your doctor because of their potential for causing harmful side effects and because their effectiveness can be influenced by other medications or medical conditions. Antiepileptic medications There are several important points to remember while you are taking antiepileptic medications. Antiepileptic drugs work best when there is a steady level of the drug in your body. If you stop taking your medicine abruptly or don't take them regularly, seizure activity will increase. If you notice an increase in your seizures or if you develop a rash, call your doctor immediately. There are many medications-both prescription and over-the-counter-that can affect antiepileptic drugs. Be sure your doctor is aware of all the medications you take. And ask your doctor before drinking alcohol. Be aware that flu vaccines can increase seizure activity. Ask your doctor before being vaccinated. In the interest of protecting both the public and the driver, all states issue driving guide-lines for people who have seizures. Ask your doctor about driving, and follow your state's guidelines. Most people take antiepileptic medications for several years following their last seizure.Your doctor will advise you. Some of the commonly used medications for controlling seizures caused by brain tumors are: carbamazepine (Tegretol); gabapentin (Neurontin); phenobarbital (Luminal); phenytoin (Dilantin); divalproex sodium (Depakote). Several newer drugs are also available. Your doctor will discuss your medication options with you. Side-effects of antiepileptics You will be given specific instructions for taking your medication and you will be told about its common side-effects, the side-effects you should call the doctor about, and which side-effects will likely decrease after a while. Because most of the antiepileptic drugs can cause blood or organ disorders, your doctor will perform frequent physical exams and blood tests to avoid these potential effects. Listed below are the most frequent side-effects of the commonly used antiepileptic drugs. This is not a complete listing, however. Information about your drug and the circumstances in which to call your doctor should be provided by your healthcare team. Tegretol: Double or blurred vision, dizziness, drowsi-ness, nausea, headache, skin rash, decreased effectiveness of oral contra-ceptives. Neurontin: Dizziness, drowsiness, fatigue, ataxia, sleepiness, nausea, vomiting, slurred speech, skin rash. Do not take within two hours of taking an antacid. Luminal: Lack of concentration, sleepiness, hyper-activity, depression, "hangover-like" head-ache, skin flushing, nausea, vomiting, skin rash. Commonly used for seizures in children. In adults, it may be used with Dilantin, or when other antiepileptic drugs are not effective. Dilantin: Drowsiness, dizziness, low blood pressure, rapid jerky eye movements, clumsy walk, swollen gums, skin rash. Depakene or Depakote: Nausea, vomiting, indigestion, diarrhea, abdominal cramps which may lessen with continued use, drowsiness, anorexia or increased appetite, temporary hair loss, photosensitivity, reduced effectiveness of oral contraceptives. Do not break or crush the pills as they will irritate the mouth and throat. Notify your doctor immediately if you have any difficulty breathing, run a temperature, notice the whites of your eyes appear yellow or you have tiny purple spots on your skin, become unusually confused, have difficulty urinating, or bruise easily. Chest pain or inability to arouse someone taking antiepileptic drugs is always a medical emergency. Late effects Radiation therapy may also cause late effects. These are caused by damage to blood vessels or myelin in the path of the radiation and can occur months to years after treatment. Chemotherapy Chemotherapy refers to the use of chemical agents to destroy cancer cells. Chemotherapy drugs travel throughout the body to slow the growth of cancer cells or kill them. Chemotherapy drugs can be given orally (pills or liquids) or intravenously as an injection into a vein. Chemotherapy treatment is generally spaced out over an extended period (typically every three to four weeks) to gradually lower the number of tumor cells while allowing healthy cells to recover. Many patients receive their chemotherapy over a four- to 12- month period. The type of chemotherapy used and the length of time it is given depend upon the stage of disease and general health of the patient. Newer regimens using lower weekly doses of chemotherapy are being evaluated to determine if they can lower the toxicity while achieving the same benefits as standard regimes. Blood Brain Barrier - this is a natural filtering mechanism. It blocks the passage into the brain of foreign substances circulating in the blood. Only those drugs capable of passing through or bypassing this barrier can hope to be effective in treating brain tumors. Some drugs have this capability, and methods are available to temporarily disrupt the barrier. This is an area of active research.Types of Chemotherapy Chemotherapy may be given as a single agent or in combination. Chemotherapy most commonly acts on the genetic material in the cell. Actively dividing cells, such as those found in a tumor, are the most vulnerable to this form of treatment. But normal cells in the body that are dividing can also be affected, particularly the bone marrow which manufactures blood cells, the lining of the gastrointestinal tract (mouth, esophagus, stomach and intestines), your skin and hair. Drugs may be given in combination to increase their effectiveness and reduce their side effects. Drugs that vary in their mode of action are selected. This method may also eliminate or reduce a tumor's tendency to resist an effective drug over time. High dose chemotherapy may be given with an antidote or with bone marrow or stem cell transplantation. Chemotherapy given this way can cause massive damage to the bone marrow, which the transplant or antidote can remedy. Hormone therapies inhibit tumor growth by blocking the effect of hormones. The blood brain barrier can be deliberately disrupted using drugs that affect the walls of blood vessels. This allows chemotherapy drugs to flow from the blood into the brain. The barrier is restored as the effects of the disrupting drug wear off. Intrathecal chemotherapy is another treatment option. A catheter is placed into the space under the arachnoid membrane of the brain or spinal cord delivering medication (chemotherapy) into the brain and bypassing the barrier. Intrathecal delivery of medication may be used also for treating pain or infection. Common side effects Side effects are due to the effect of the therapy on normal cells. The severity depends on the type of drug, how it is administered and how much you are given. Most side effects are temporary; they end when your treatment ends. Blood counts - chemotherapy can decrease the ability of your bone marrow to produce blood. That is why you will have frequent blood tests. Notify your doctor immediately if you experience any of the following symptoms. If your red blood cells (RBCs) are affected, you may become anemic and feel tired, chilly or become short of breath. Medicines can be prescribed to increase the production of RBCs. If your white blood cells (WBCs) are affected, you may be at risk for infection. If you think you have an infection (you have a fever, are sweating or have chills, have a sore throat etc), notify your doctor immediately. If your platelets are affected, you may bruise more easily and heal more slowly. Your gums may bleed and women may bleed more heavily during menstruation. Digestive system - cells that line your mouth, esophagus, stomach and intestines may become inflamed. You may notice adry mouth and lips, burning or tingling sensations, or sores. This can make chewing and swallowing difficult. Notify your doctor immediately if this becomes severe. Diarrhea or constipation might indicate inflammation in your intestines. Nausea and vomiting can signal the chemotherapy's affect on your stomach. Medicines called antiemetics can be prescribed to decrease nausea. Skin reactions such as a rash, dryness or itching can be related to chemotherapy. Hair loss is caused by some chemotherapy drugs and not others. Ask your doctor if the drugs you are receiving normally cause this side effect. Fatigue, different from just feeling tired, is a common side effect, and may require you to temporarily change your daily habits. Immunotherapy Introduction This type of treatment alters the environmental in which your tumor exists, thus making it difficult for it to grow. Using substances called biologic response modifiers, many of which grow naturally, it is hoped that your immune system will fight tumors more effectively either by making tumors more susceptible to destruction or by blocking the actions that create tumor cells. While surgery and radiation therapy are "standard" treatments for a brain tumor, immunotherapy is investigational. Its effectiveness and long-term effects are still being studied.Immunotherapies under investigation Angiogenesis inhibitors - growing tumors need large quantities of oxygen and food. To supply their needs, the tumor produces proteins that encourage the formation of new blood vessels. Substances that block those proteins limit new blood vessel development which inhibits tumor growth. Differentiators - normal cells are mature; they know their place and function. Cancer cells are immature. They have never grown up or they have regressed. Differentiating agents help cancer cells become more normal. Gene therapy - genes carry instructions for making proteins. If they are damaged or are abnormal, the proteins they produce are defective and cause tumors. Gene therapy seeks to replace defective genes with healthy ones, or with genes that produce tumor destroying proteins. Growth factors - promote growth. By manipulating these substances it is hoped that tumor growth can be controlled. Interferons - are proteins produced by white blood cells. They are thought to inhibit the growth of tumor cells. Interleukins - are proteins produced by white blood cells. They help coordinate the activities of the immune system. Steroids Introduction Steroid drugs are commonly used to reduce the accumulation of fluids in the brain that often occurs with brain tumors and their treatment. Prednisone, Decadron and Prednisolone are all steroid drugs. Accumulation of fluids causes swelling which in turn causes many of the symptoms of brain tumors. Swelling can also destroy brain tissue. Steroids prevent, minimize or decrease swelling. Symptoms are relieved and you feel better. Steroids have side effects of their own, which is why they must be used exactly as your doctor prescribes and why they are monitored closely. Steroid drugs should never be stopped abruptly--they should be tapered gradually. This allows your body time to adjust to their withdrawal. Steroid use Steroids may be given before, during and after surgery to control the swelling caused by the surgery. Steroids may be given during the course of radiation therapy to control radiation induced swelling. Steroids may be given on a long term basis to relieve symptoms. Common side effects Weight gain due to fluid retention or increased appetite Mood fluctuations Stomach irritation Complementary and Alternative Medicine (CAM) This broad range of healing philosophies, approaches and therapies is generally defined as those treatments and practices not widely taught in medical schools, not generally used in hospitals and historically not reimbursed by medical insurance companies. Attitudes are changing however.

	العلوم والتكنولوجيا ذكرت مجموعة من العلماء كلفتهم الأمم المتحدة دراسة آثار ارتفاع حرارة الأرض أن التغييرات المناخية ستزيد من حدة السيول وشح المياه في آن واحد, وستضعف المحاصيل الزراعية وتزيد من خطورة الوضع الصحي في القرن الحادي والعشرين. ورأت "المجموعة الحكومية حول تطور المناخ" في تقرير جديد نشر في جنيف بعنوان "التغييرات المناخية 2001.. الآثار والتكيف", أن "كل مناطق الكرة الأرضية ستتأثر على ما يبدو ببعض الانعكاسات السلبية" لارتفاع حرارة الأرض. وأضاف التقرير أن الدول النامية ستكون على الأرجح الأكثر هشاشة في هذا المجال, موضحا أنه يتوقع تسجيل زيادة أو كثافة في "الظواهر بحدودها القصوى". ورجح التقرير هطول أمطار غزيرة على ما يبدو في عدد كبير من المناطق بما في ذلك الدول المتطورة، مما سيؤدي إلى زيادة الفيضانات والانهيارات الأرضية والثلجية. وأضاف أن موجات من الحر ستضرب "على ما يبدو" كل مكان لترفع من الوفيات وتزيد من الأضرار للمحاصيل. أما الجفاف الذي ازداد حدة في الدول المعتدلة, فسيؤثر على منسوب المياه في الأنهار وموارد المياه ونوعيتها. وستشهد دول الجنوب "على الأرجح" أعاصير استوائية أكثر كثافة وزيادة في الجفاف والسيول. أما الدول الواقعة تحت خط الاستواء فستعاني خصوصا من شح في المياه. وسيؤدي ارتفاع مستوى مياه البحر إلى سيول وعواصف على السواحل، ويهدد خصوصا مناطق الدلتا والدول القائمة على جزر صغيرة. وعلى الصعيد الاقتصادي ستتسع الهوة بين الشمال والجنوب مع ارتفاع حرارة الأرض. وفي الدول الغنية "سيؤدي ارتفاع الحرارة بضع درجات إلى مكاسب وخسائر", لكن الزيادة في الارتفاع لن تؤدي سوى إلى آثار اقتصادية سلبية. وستسجل الدول الفقيرة باستمرار "خسائر اقتصادية واضحة" ستتزايد مع ارتفاع حرارة الأرض. وقال التقرير إن "معظم المناطق الاستوائية وتحت خط الاستواء ستشهد تراجعا عاما" في محاصيلها الزراعية، حتى مع ارتفاع طفيف في درجات الحرارة بالنسبة لبعض المحاصيل. وعلى الصعيد الصحي ستتسع الأمراض الاستوائية جغرافيا كما جاء في التقرير. وفي دول الشمال ستسجل الوفيات بسبب الحرارة والرطوبة والتلوث ارتفاعا. ويستند العلماء في تقريرهم على تقرير أعدته مجموعة أخرى، ونشر في 22 يناير/ كانون الثاني في شنغهاي، مشيرا إلى أن الحرارة سترتفع بين 1.4 و5.8 درجات في القرن الحادي والعشرين، وأن مستوى مياه البحر سيرتفع ما بين تسعة سنتيمترات و88 سنتيمترا. ورأى معدو التقرير الذين بدوا أكثر حزما من قبل عند إعداد تقرير عام 1995, أن ارتفاع درجات الحرارة في القرن العشرين "أثر أصلا في أجزاء كبيرة من العالم على أنظمة فيزيائية وبيولوجية مختلفة". وأشاروا على نحو خاص إلى تراجع الكتل الجليدية، وتغييرات في سلوك الحيوانات، وإزهار بعض الأشجار قبل أوانها. ورأوا أن هذه التغييرات ستستمر في القرن الحادي والعشرين, وبذلك يمكن أن تزول "نصف الثلوج على جبال الألب"، وعدة أصناف من الحيوانات المهددة بالانقراض حاليا. ويمكن أن يؤدي ارتفاع حرارة الأرض في القرن الحادي والعشرين أيضا إلى تغييرات على نطاق واسع في مرحلة لاحقة لا يمكن تلافيها، وستكون لها عواقب على صعيد القارات والعالم. فقد يؤدي ارتفاع الحرارة إلى "تباطؤ كبير" في التيارات الدافئة في المحيطات، وتراجع الكتل الجليدية في غرينلاند وغرب القطب الجنوبي. ويمكن أن تحول الظاهرة الأولى أوروبا الغربية إلى منطقة جليدية، في حين يمكن أن تسبب الظاهرة الثانية ارتفاع مستوى مياه البحار "حتى ثلاثة أمتار خلال ألف عام", لتغمر عددا كبيرا من الجزر والمناطق الساحلية.