Treatment for brain tumors is based on the type of tumor, the tumor location, age of the child and other factors. The healthcare team will develop an individualized treatment plan for each patient. More often than not, treatment will include multiple forms of therapy.

Because of the unique challenges of treating the brain and CNS, the healthcare team developing and implementing the treatment plan will include the following specialists:

• Pediatric neurosurgeon: a doctor who specializes in surgery to the brain and nervous system
• Pediatric neuro-oncologist: a doctor who specializes in treating brain tumors with chemotherapy
• Radiation therapist: a doctor who specializes in treating brain tumors with radiation therapy
• Pediatric neurologist: a doctor who treats brain and nervous system diseases in children
• Endocrinologist: a doctor who treats diseases in glands that secrete hormones

Almost all children will undergo a surgical biopsy. At that time the surgeon will remove as much of the tumor as can be done safely. Some children may not have surgery because it is too dangerous and/or there has not been a benefit shown for such patients. Examples of these patients are:

• Children with tumors in the brain stem (the upper part of the back of the neck)
• Children with tumors in the pituitary, pineal or thalamic areas (in the deep center of the brain) may undergo biopsy only

Most children recover very well from surgery, and many gradually regain any neurological function lost because of the tumor. Occasionally, a child will have additional brain damage caused by unexpected bleeding or pressure on the brain during surgery, but these children frequently recover as well.

Depending on the specific brain tumor and age of the child, there are a number of treatments that may be given after surgery.

Shunt

Some children will require the placement of a shunt to drain away excess cerebrospinal fluid caused by tumor blockage. A shunt is a small plastic tube coming from one of the normal cavities (ventricles) in the brain through a small hole in the skull. The fluid then drains either temporarily into a small plastic receptacle outside the skull or permanently through a longer tube directed underneath the skin into the abdominal cavity. The neurosurgeon decides whether only a temporary drainage over a week or so will be needed, or whether a permanent tube under the skin will be necessary. Many children with brain tumors have permanent shunts placed. These are hardly visible after treatment and may remain in place unnoticeably for years. It is best to discuss the reasons for a shunt and the outlook for the future with the neurosurgeon.

Steroids

Almost all patients undergoing neurosurgery will be given Decadron. Decadron is a strong steroid medication that reduces swelling of the brain, which often happens following surgery. Decadron is started at an initial dose and then slowly tapered over 1-2 weeks following surgery. The steroid is usually given with an antacid to prevent stomach irritation or ulcers and can be associated with increased appetite (and occasionally other side effects) when given for more than a few days.

Patients undergoing surgical resection in the upper part of the brain may also be placed on anti-seizure medications following surgery.

Radiation Therapy

Most patients with brain tumors will be treated with radiation therapy over a period of approximately 6 weeks following recovery from surgery.

• Very young children and those with low-grade tumors may have radiation therapy delayed or significantly reduced. Radiation therapy may be omitted entirely if chemotherapy alone is judged to be effective.
• Radiation is given on weekdays and only takes a few minutes, provided that the child can lie still with the head supported by a custom-made ‘cast.’ Young children and those who have difficulty lying still usually require anesthesia.
• Sometimes radiation therapy is given twice each day to try to maximize its effect.

Chemotherapy

The chemotherapy protocols for children with brain tumors are similar to those used for other cancers, and are tailored to both the tumor type and age of the child. In young children (less than 3 years of age), chemotherapy may be given in order to postpone radiation that can be damaging to developing brains. Sometimes chemotherapy is given weekly during the radiation treatments to enhance the effect of the radiation.

There are some experimental protocols evaluating chemotherapy given directly into the brain fluid via a reservoir in the skull. This reservoir is placed like a shunt with a tube that runs into the ventricles.

Specific Types of Brain Tumors and Treatment

Many of the different types of brain tumors have unique treatment regimens that researchers have shown to be the most effective for that specific type of cancer. Below are some descriptions of the different types of brain tumors and their treatment protocols.

Medulloblastoma

Also called PNET (Primitive Neuroectodermal Tumor)

Medulloblastoma is the most common malignant brain tumor in children. It is a fast growing tumor that begins in the lower back part of the brain (the posterior fossa) and can spread to other parts of the body. In up to one-third of patients, the tumor will have spread to the brain lining (meninges) and spinal cord at the time of diagnosis. These children often have vomiting, headache and balance problems at diagnosis and may need shunts placed to relieve obstruction of spinal fluid.

Chemotherapy: Children with medulloblastoma are usually treated with about one year of multi-agent chemotherapy.

Radiation: Children usually receive radiation to the whole brain and spinal cord. This is done to reduce the risk of later metastasis (spread of the cancer). Children less than 3 years of age may receive chemotherapy first with delayed and/or reduced radiation in order to lessen the effects of radiation on intelligence.

Future trends: Newer protocols will incorporate biological information about the tumors to adjust therapy. For tumors that are cured with current therapy, there will be an attempt to cautiously reduce therapy so that long-term side effects can be lessened.

Supratentorial PNET and Pineoblastomas

These tumors typically are located in the upper part of the brain. Due to the location of the tumor, the patient’s initial problems may include the onset of seizures or eye abnormalities, as well as problems with headache, nausea and vomiting. These PNETs have a similar pathology to medulloblastomas and are treated similarly.

Gliomas (sometimes referred to as Astrocytoma)

Gliomas are brain tumors that begin in the glial cells, which are cells that surround and support the proper functioning of nerve cells. Astrocytomas are brain tumors that form in astrocyte cells, which are a specific type of glial cell. About half of brain tumors in children are astrocytomas. As most gliomas originate from astrocytes, the terms are often used interchangeably.

Gliomas are classified as either high-grade or low-grade based on how likely they are to grow and spread. Low-grade gliomas usually are slow growing and stay in a local area of the brain. High-grade gliomas grow quickly and spread easily throughout the brain.

High-grade gliomas are the most common lethal tumors in adults, but also occur in children. Due to the location of the tumor, these patients may have seizures and significant paralysis at the time of diagnosis. Because high-grade gliomas are much more aggressive, they require more intensive treatments.

Low Grade Gliomas

Examples include pilocytic astrocytomas, grade I-II; fibrillary astrocytomas; ganglioglioma and oligodendroglioma

The location of the tumor and whether it can be removed completely through surgery (resectable) determines the treatment of low-grade gliomas. Children who have the tumor completely removed through surgery are followed closely with repeat MRI/CT scans to monitor for possible recurrence. No other treatment may be necessary.

Low-grade tumors that cannot be removed safely through surgery (unresectable) are usually located deep in the brain or along the optic pathway (along the nerves to the eyes). These children usually receive chemotherapy on an outpatient basis for at least 18 months. Increasingly, physicians are choosing to postpone radiation therapy, sometimes indefinitely, if chemotherapy prevents the tumor from growing.

High-Grade Glioma

Examples include anaplastic astrocytoma and glioblastoma multiforme (GBM)

These are aggressive cancers that are difficult to treat. As a result, doctors take an aggressive approach to treatment. Most children tolerate therapy better than adults, but fewer than 1 out of 3 children with these tumors become survivors. Treatment includes:

Surgery: Removal of as much of the tumor as can be done safely.

Chemotherapy: Chemotherapy to destroy any remaining cancer cells; may involve experimental drugs.

Radiation: High doses of radiation to the tumor to shrink it for later surgery, or to destroy the remaining cancer cells.

Brain Stem Glioma

These high-grade gliomas grow amidst the nerves coming down the upper spine. Children may be diagnosed with eye movement problems, imbalance, paralysis and swallowing difficulties. There are some children who survive, but this is an extremely difficult tumor to treat. Treatment includes:

Surgery: Because of their location, these tumors usually cannot be removed by surgery.

Radiation: Radiation therapy is given to the upper neck.

Chemotherapy: This tumor often requires experimental chemotherapy.

Ependymoma

Ependymoma (grade II), and the more malignant ependymoblastoma (grade III), tend to occur in children under 6 years old. These tumors usually are located in the lower back part of the brain (posterior fossa), but may also arise higher in the brain or in the spinal cord. As with medulloblastoma, children with posterior fossa tumors tend to be diagnosed because of vomiting, headache and/or balance problems. Treatment includes:

Surgery: Surgical removal of most of the tumor is key to a good prognosis (chance of recovery) if the cancer has not spread.

Radiation: Most children receive radiation therapy to the site of the tumor after the tumor has been removed.

Chemotherapy: New protocols that are being developed are adding chemotherapy to try to improve survival if there is residual disease and/or if the child is very young.

Germ Cell Tumors

Examples include pure germinomas and non-germinomatous germ cell tumors (yolk sac tumors, embyonal cell carcinomas, choriocarcinoma, mixed tumors, malignant teratomas)

These are rare tumors and occur most commonly in the pituitary or pineal glands just behind the eyes. In this location, it is usually possible to biopsy the tumor but not remove it. Germ cell tumors arise from the same kind of cells that exist in the ovaries and testes.

Patients may experience:

• Headache
• Nausea and vomiting
• Vision abnormalities
• Disturbances in water balance
• Disturbances of sex and/or growth hormone levels

Patients with pure germinomas have excellent survival with radiation alone. New research studies are exploring ways to reduce the long-term risks associated with radiation to the whole brain and spine.

Non-germinoma tumors are more malignant and require more intensive chemotherapy plus increased radiation to achieve probable long-term cure. Because these children often have hormone deficits related to tumor location, they may require life-long hormone replacement therapy.

Spinal Cord Tumors

Examples include ependymomas, and low- and high-grade astrocytomas.

Removal of as much tumor as possible without further damaging the spinal nerves is key.

Low-grade tumors: Following surgical removal, these children may be cautiously followed with frequent MRI’s. Some patients may receive outpatient chemotherapy similar to that used for low-grade astrocytomas.

High-grade tumors: These children are treated with chemotherapy and radiation to the tumor.

Other Rare Brain Tumors

Choroid Plexus Tumors, including papillomas and carcinomas, usually occur in infants and are treated primarily with surgical resection and occasionally chemotherapy.

Craniopharyngiomas are treated by surgical resection and radiation therapy based on the location of the tumor and involvement of the surrounding tissues.

Sarcomas of various types that usually arise from soft tissues in the body, including muscle, sometimes occur in the brain. These sarcomas are treated with maximal surgery, local radiation and chemotherapy appropriate for body sarcomas.

Research Studies

The majority of children with cancer participate in research studies. This high rate of participation has been essential to improving the cure rates for children’s cancer.

Researchers design various studies to improve treatment and advance the understanding of cancer and its causes. Clinical trials are carefully reviewed and must be approved through a formal scientific process before anyone can be enrolled. If there is a research study “open” that your child is “eligible for,” you may be asked to allow your child to participate. It is also possible that your child will be asked to participate in more than one study.

Whether an individual is eligible for a particular study may depend on age, location of the cancer, the extent of the disease and other information. Researchers usually must limit their study to some of these characteristics to have a scientifically valid study. Further, researchers must follow exactly the same restrictions throughout the study.

If your child is eligible to participate in one or more study, your doctor will discuss these with you during an initial treatment conference (also called informed consent conference). The doctor will describe the study, potential risks of participation, and other information you need to decide whether or not you would like your child to participate in the study. You always have the choice to participate or not in research studies.

If you do choose to have your child participate in a study, you doctor will explain what type of information you will receive about the results of the study. The overall results of the research study will be published to inform the public and other researchers. No study will publish any information that identifies an individual.

Visit the Clinical Trials section of this website to learn more about the various kinds of research studies.

Last updated July, 2011

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