Teamwork – Where should I have my treatment?

   We would like to emphasise that we feel that treating brain tumours calls for teamwork. A specialized multiprofessional team consisting of a neurologist, a neurosurgeon, a neuroradiologist, a psychologist and experienced nurses is necessary. They highlight the approach each from their own speciality and get a consensus on the treatment. The coordinator keeps contact with you and informs you and your surroundings. A good communication and information reinforces your confidence and understanding, which may result in a better recovery, and it certainly reduces psychological problems.

   Choose a centre which treats at least 50 brain tumour patients per year, and where each specialist has at least 25 brain tumour patients per year. This is necessary to get the needed know how and experience, the infrastructure and the multiprofessional team. Quality of treatment is much more important than the nearness to your home in the case of brain tumours. Choose a “Centre of Excellence”. Each country should define standards for the establishment of such centres of excellence.

   The treatment of brain tumours is not only an example of medical teamwork, but also of teamwork at the paramedical, psychological and social level.

   Ask your MD which centre fulfils all these condititions.

Surgery

   The standard treatment is surgery (resection of the tumour, craniotomy). This method depends on the definition, the location and the accessibility of the brain tumour. The surgeon will avoid harming the really vital parts of the brain. The actual techniques have resulted in high standards and safety for surgery. Surgery is spectacular, but not the most decisive part of the treatment in the case of high grade tumours.

   Prior to surgery the team may decide to do a biopsy. This gives more information on the various aspects of the tumour.

   If immunotherapy should be considered later on, your surgeon must make arrangements with the centre of immunotherapy, because this centre will need some tissue from the tumour. See the chapter about immunotherapy below.

   If the tumour is not accessible a combination of radiotherapy and chemotherapy will be used in most of the cases.

   For low grade tumours the surgical resection will often satisfy as treatment, if the tumour could be removed entirely. A follow up will be sufficient.

   For high grade tumours there is a need for adjuvant therapy (chemotherapy, radiotherapy or immunotherapy).

Radiotherapy

   Standard is a series of 30 sessions of 2 Gy (Gray) each. This is spread over 6 weeks. The tumour bed and its surroundings are radiated with the aim of destroying tumour rest cells.

   Older people will only get a part of this treatment in order to avoid side effects.

   Recently some methods were developed to administer more punctual or focal radiotherapy for small tumours (up to 2 cm). This can be done in just one session or a limited series of sessions. The technologies are called gamma-knife and tomotherapy. They are often used for the treatment of secondary brain tumours or metastasis.

   At this moment the so-called hadrontherapy is in development. It operates without ionizing radiation.

Chemotherapie

By Prof. Dr. Bart Neyns, Oncologist, University of Brussels.

    It is only since the end of the nineties that treatment with chemotherapy has found its place in the treatment of brain tumour patients with the development of temozolomide ( Temodal in EU, Temodar in the US). It is used for high grade gliomas.

   Treatment with temozolomide in combination with radiotherapy, followed by 6 treatments on 5 per 28 days is the standard treatment for patients with newly diagnosed glioblastoma. Compared to treatment with radiotherapy alone, the survival chances are clearly higher on the long term. This chemotherapy does not have many side-effects and does not harm the quality of life.

   Temozolomide is also the most efficient treatment after a first relapse of a low grade or high grade glioma. The cure has also got a good palliative effect. With patients with a second or third grade glioma a long-term remission (stabilisation) can be obtained.

   Patients who do not react to temozolomide, or who do not tolerate the cure (which is rare), or who have a new progression after a period of stability, will have to recur to other drugs. These have been generally developed for other kinds of cancer, and they may already be recognized for these indications.

   The following investigational treatments have already proved their usefulness in the treatment of glioma:

-          The combination between bevacizumab (Avastin) with irinotecan   CPT-11 Camptosar) or other cytostatics like CCNU or etoposide.

-          Drugs with an anti-angiogenetic effect such as Cedirinab, Sunitinib, Aflibercept, Avastin or Sofrafenib.

-          Drugs with a anti-EGFR effect such as Erlotinib and Cetuximab.

-          Drugs that inhibit PCK, such as Enzastaurine and Tamoxifen (Nolvadex), an anti-estrogen developed initially for breast cancer.

-          Cilengitide, an inhibitor for intrigines.

   We recommend you to consider an experimental treatment if you have a high grade brain tumour which does not react (anymore) to temozolomide. Talk about it with your oncologist. He or she can evaluate if your condition allows you to receive an extra chance by means of an experimental therapy.

   You will find a lot of information about this subject on the site of the Musella Foundation, www.virtualtrials.com and www.virtualtrials.com/williams.cfm .

   You may also have a look at the site of the National Cancer Institute,    NCI - NIH   PDQ trial database.

   Contact: Prof. Dr. Bart Neyns, Universitair Ziekenhuis Brussel, Laarbeeklaan 101, 1090 Brussels, Belgium, 0032 (0) 2 477 64 15                  

E-mail: Bart.Neyns@uzbrussel.be .    

Immunotherapy

   Immunotherapy uses your own brain tumour tissue to develop a vaccination. The therapy only can be used if the tumour could be almost totally resected by your surgeon. Arrangements have to be made between your centre of excellence and the centre of immunotherapy before the treatment of your tumour starts. In Europe the coordination centre is at the University of Leuven, Belgium. You can get more information from Prof. Dr. Stefaan Van Gool and Prof. Dr. Steven De Vleeschouwer.

   Contact: Prof. Dr. Stefaan Van Gool, Universitair Ziekenhuis Gasthuisberg, Herestraat 49, 3000 Leuven, Belgium, 0032 (0) 33 22 11 ext 4335, e-mail: stefaan.vangool@uz.kuleuven.ac.be .