Cancer begins in cells, the building blocks that make up tissues. Tissues make up the organs of the body.Normally, cells grow and divide to form new cells as the body needs them. When cells grow old, they die, and new cells take their place. Sometimes this orderly process goes wrong. New cells form when the body does not need them, and old cells do not die when they should. These extra cells can form a mass of tissue called a growth or tumor.
INCIDENCE
The annual rate of newly diagnosed brain tumors is 17000,with an estimate of 13100 deaths The brain is a frequent site of metastasis.Brain tumors rank as fourth cause for death of people between the age group of 35 to 54 years.Whites have a higher risk of malignant tumors compared with blacks.Meningiomas are the common brain tumors in Africa
TYPES
Brain tumors can be classified as:- Primary-Arising from the tissues within the brain
- Secondary-It results from metastasis from a malignbant neoplasm that originates in some other parts of the body
- Astrocytomas-These are called gliomas.It arises from star shaped cells called glial cells.It accounts for about 65% of the primary brain tumors.These tumors can range from low grade to moderate grade malignancy. In adults, astrocytomas most often arise in the cerebrum. In children, they occur in the brain stem, the cerebrum, and the cerebellum. A grade III astrocytoma is sometimes called an anaplastic astrocytoma. A grade IV astrocytoma is usually called a glioblastoma multiforme.
- Glioblastoma Multiforme-It arises from the primitive stem cells(glioblast).They are highly malignant and invasive, among the most devastating of primary brain tumors
- Oligodendroglioma-Tissue origin is Oligodendrocytes.It is characterized by benign encapsulation and calcification
- Ependymoma-It arises in the ependyaml epithelium.It ranges from benign to malignant,most are benign and encapsulated..
- Acoustic neuroma-(Schwannoma)-Cells arises from the myelin sheath around the nerves,commonly affects cranial nerve 8.They grows on both sides of the brain,usually benign or low grade malignancy
- Pituitory Adenoma-It arises in the pituitary gland.It is usually benign
- Hemangioblastoma-It arises from the blood vessels of the brain.It is rare and benign and the surgery is curative.
- Primary central nervous system lymphoma-It arises fromthe lymphocytes.It arises in in transplant recepients and acquired immunodeficiency syndrome(AIDS)patients.
- Metastatic tumors-It occurs in the lungs,breast,kidney,thyroid,prostate.It is malignant
Some types of brain tumors do not begin in glial cells. The most common of these are:
- Medulloblastoma - This tumor usually arises in the cerebellum. It is the most common brain tumor in children. It is sometimes called a primitive neuroectodermal tumor.
- Meningioma - This tumor arises in the meninges. It usually grows slowly.
- Schwannoma - A tumor that arises from a Schwann cell. These cells line the nerve that controls balance and hearing. This nerve is in the inner ear. The tumor is also called an acoustic neuroma. It occurs most often in adults.
- Craniopharyngioma - The tumor grows at the base of the brain, near the pituitary gland. This type of tumor most often occurs in children.
- Germ cell tumor of the brain - The tumor arises from a germ cell. Most germ cell tumors that arise in the brain occur in people younger than 30. The most common type of germ cell tumor of the brain is a germinoma.
- Pineal region tumor - This rare brain tumor arises in or near the pineal gland. The pineal gland is located between the cerebrum and the cerebellum.
- Benign brain tumors do not contain cancer cells. Usually, benign tumors can be removed, and they seldom grow back.The border or edge of a benign brain tumor can be clearly seen. Cells from benign tumors do not invade tissues around them or spread to other parts of the body. However, benign tumors can press on sensitive areas of the brain and cause serious health problems. Unlike benign tumors in most other parts of the body, benign brain tumors are sometimes life threatening.
- Malignant brain tumors Very rarely, a benign brain tumor may become malignant containing cancer cells. Malignant brain tumors are generally more serious and often life threatening. They are likely to grow rapidly and crowd or invade the surrounding healthy brain tissue.Very rarely, cancer cells may break away from a malignant brain tumor and spread to other parts of the brain, to the spinal cord, or even to other parts of the body. The spread of cancer is called metastasis
BRAIN TUMOR LOCATIONS AND PRESENTING MANIFESTATIONS
- FRONTAL LOBE TUMORS –Unilateral hemiplegia,seizures,memory deficit,personality and judgement changes,visual disturbances.
- PARIETAL LOBE-Speech disturbance( If the tumor is in the dominant hemisphere inability to write,unilateral neglect
- OCCIPITAL LOBE-Blindness and seizures.
- SUBCORTICAL-Hemiplegia,other symptoms may depend on the area of infiltration
- MENINGEAL TUMORS-Symptoms are associated with compression of the brain
- METASTATIC TUMORS-Headache,nausea or vomiting because of increased ICP
CLINICAL MANIFESTATIONS
- Headaches (usually worse in the morning)
- Nausea or vomiting
- Changes in speech, vision, or hearing
- Problems balancing or walking
- Changes in mood, personality, or ability to concentrate
- Problems with memory
- Muscle jerking or twitching (seizures or convulsions)
- Numbness or tingling in the arms or legs
DIAGNOSTIC EVALUATION
- Physical examination - The doctor checks general signs of health.
- Neurologic examination - The doctor checks for alertness, muscle strength, coordination, reflexes, and response to pain. The doctor also examines the eyes to look for swelling caused by a tumor pressing on the nerve that connects the eye and brain.
- CT scan - An x-ray machine linked to a computer takes a series of detailed pictures of the head. The patient may receive an injection of a special dye so the brain shows up clearly in the pictures. The pictures can show tumors in the brain.
- MRI - A powerful magnet linked to a computer makes detailed pictures of areas inside the body. These pictures are viewed on a monitor and can also be printed. Sometimes a special dye is injected to help show differences in the tissues of the brain. The pictures can show a tumor or other problem in the brain.
- Angiogram - Dye injected into the bloodstream flows into the blood vessels in the brain to make them show up on an x-ray. If a tumor is present, the doctor may be able to see it on the x-ray.
- Skull x-ray - Some types of brain tumors cause calcium deposits in the brain or changes in the bones of the skull. With an x-ray, the doctor can check for these changes.
- Spinal tap - The doctor may remove a sample of cerebrospinal fluid (the fluid that fills the spaces in and around the brain and spinal cord). This procedure is performed with local anesthesia. The doctor uses a long, thin needle to remove fluid from the spinal column. A spinal tap takes about 30 minutes. The patient must lie flat for several hours afterward to keep from getting a headache. A laboratory checks the fluid for cancer cells or other signs of problems.
- Myelogram - This is an x-ray of the spine. A spinal tap is performed to inject a special dye into the cerebrospinal fluid. The patient is tilted to allow the dye to mix with the fluid. This test helps the doctor detect a tumor in the spinal cord.
- Biopsy - The removal of tissue to look for tumor cells is called a biopsy. A pathologist looks at the cells under a microscope to check for abnormal cells. A biopsy can show cancer, tissue changes that may lead to cancer, and other conditions. A biopsy is the only sure way to diagnose a brain tumor.
COMPLICATIONS
- If the tumor mass occludes the ventricles or occludes the outlet,ventricular enlargement (hydrocephalus)can occur
- The client should be continuously assessed for signs of altered level of consciousness,restlessness,blurred vision,vomiting without nausea and signs of infected shunts if shunts are placed to relieve the increased ICP. Such as high fever,persistent head ache etc..
TREATMENT
Treatment goals are aimed at identifying the tumor type and location,removing or decreasing the tumor massand preventing and managing increased ICP.
SURGICAL THERAPY
- Stereotactic surgical techniques are used with high frequency to perform a biopsy and to remove small tumors.
- Meningiomas and oligodendromyomas are completely removed where as invasive gliomas and medulloblastomas can be partially removed.Computer guided stereotactic biopsy ,ultrasound,functional MRI and cortical mapping is used to locate the brain tumors
- Radiation therapy is usually used in followup care.Radiation seeds can be implanted into the brain.Cerebral edema and rapidly increasing ICP can be a complication of radiation therapy.,they can be managed with high doses of corticosteroidsEg Dexamethasone,prednisolone.Stereotactic radiosurgery is a method of delivering high concentration of of radiation
- A group of chemotherapeutic agents called nitrosureas are administered.Eg:Carmustine,lomustine
- Chemotherapy laden biodegradable lesions Eg:Gliadel waferis implanted
- Methotrexate and Procrbazine
- Radiation can be delivered by Ommaya reservoir and intrathecal administration.
- Temozolomide is the first chemotherapeutic drug which crosses the blood brain barrier.
- Local hypothermia and biotherapy
NURSING MANAGEMENT
NURSING ASSESSMENT- The initial data should contain the information about the present status of the client.
- Areas to be assessed includes LOC, state of consciousness, motor abilities,sensory perception integrated function including bowel and bladder function,balance and coordination and coping ability of the client.
- Watching the patient doing ADL and conversing to the patient is a method of assessment.
- The patient should be allowed to ventilate the feelings.
- Questions concerning medical history,intellectual abilities,educational level and history of nervous system infections and trauma should be collected.
NURSING DIAGNOSIS
Self care deficit related to loss of impairment of motor and sensory functionand decreased cognitive abilities- Assess the level of cognitive function to obtain a baseline data
- Encourage the patient as wellas the family members to keep the patient as independant as possible
- Provide assistance with the self care activities
- The patient is encouraged to plan for each day to make the atmost of each day because the patient lives in uncertainity.
- An individualized exercise programme to maintain strength,endurance and range of motion
- Assess the nutritional status of the client to obtain a baseline data.
- Symptoms like nausea,vomiting,breathlessness and pain should be managed.
- The nurse should teach the family members how to position the patient during feeding.
- The patient should be provided adequate rest to reduce the fatigue.
- The patient should be clean,comfortable and free of pain when on meals
- The environment should be attractive as possible.Avoid offensive sights,sounds and odours.
- Provide fluids and provide oppurtunities for socialization.
- Dietary suppliments provided should be rich in calories if it is advisable for the patient.
- If the patient cannot tolerate orally paranteral nutrition should be initiated.
- Assess the level of anxiety to obtain a baseline data.
- Explain about the disease condition and the treatment measures undertaken
- Encourage the family members and the friends to be with the patient
- Provide psychological support and provide oppurtunities to ventilate the feelings
- Open communication is encouraged
- If the patients emotional response is very intense additional help is taken from a clergy,social worker or a mental health professional.
- The family must be reassured that their loved one is receiving the maximum care.
- When the patient is not able to carry out the basic needs the family members should provide support
- Psychological support should
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