Treatment of Adult Brain and Spinal Cord Tumors, by Type

The treatment options for brain and spinal cord tumors depend on several factors, including the type and location of the tumor, how far it has grown or spread, whether the tumor cells have certain gene or chromosome changes, and a person's age and overall health.

Non-infiltrating (grade I) astrocytomas

These tumors include pilocytic astrocytomas, which most often develop in the cerebellum in young people, and subependymal giant cell astrocytomas (SEGAs), which are almost always seen in people with tuberous sclerosis. Many doctors consider these tumors benign because they tend to grow very slowly and rarely grow into (infiltrate) nearby tissues. (Pleomorphic xanthoastrocytomas (PXAs), which are rare grade II tumors, are often treated the same way as these tumors as well.)

Many times, surgeons can’t be sure a tumor is one of these types until surgery is done to remove it. But if these tumors can be removed completely by surgery, they can often be cured (although this is less likely in older patients). Radiation therapy may be given after surgery, particularly if the tumor is not removed completely, although many doctors will wait until there are signs the tumor has grown back before considering it. Even then, repeating surgery may be the first option.

The outlook is not as good if the tumor occurs in a place where it can’t be removed by surgery, such as in the hypothalamus or brain stem. In these cases, radiation therapy is usually the best option.

If surgery and radiation therapy are no longer good treatment options, chemotherapy (most often with temozolomide or the PCV regimen – procarbazine, CCNU, and vincristine) might be used at some point.

For SEGAs that can’t be removed completely with surgery, treatment with the targeted drug everolimus (Afinitor) may shrink the tumor or slow its growth for some time, although it’s not clear if it can help people live longer.

Low-grade (grade II) infiltrating astrocytomas
(Diffuse astrocytomas)

The initial treatment for diffuse astrocytomas is typically surgery to remove the tumor if it can be done. If surgery is not feasible, a biopsy may be done to confirm the diagnosis. These tumors are hard to cure by surgery because they often grow into (infiltrate) nearby normal brain tissue. Usually the surgeon will try to remove as much of the tumor as safely possible. If all of it can be removed, the person might be cured.

Other types of treatment might be used after surgery. Sometimes lab tests of the tumor are used to help determine which of these treatments should be given.

• Radiation therapy may be given after surgery, especially if a lot of tumor remains. Younger adults whose tumors were small and not causing many symptoms may not need radiation unless the tumor shows signs of growing again. (In some cases, surgery may be tried again before giving radiation) In people who are older or whose tumors are at higher risk of coming back for other reasons, radiation is more likely to be given after surgery.
• Chemotherapy (most often with temozolomide or the PCV combination regimen – procarbazine, CCNU, and vincristine) may also be given after surgery. Sometimes lab tests of the tumor are used to help determine if radiation and/or chemotherapy should be given.
• A targeted therapy drug such as vorasidenib might be an option after surgery, if the tumor cells are found have an IDH1 or IDH2 gene mutation. 

Radiation and/or chemotherapy may be used as the main treatment if surgery is not a good option.

Intermediate-grade (grade III) gliomas
(Anaplastic astrocytomas, anaplastic oligodendrogliomas)

Surgery is often the first treatment if an imaging test shows what is likely one of these types of tumors, although the specific type of tumor might not be known until after the operation. As much of the tumor is removed as is safely possible, but because of the way they grow into nearby areas, these tumors are almost never removed completely. Radiation therapy is given after surgery in most cases. Chemotherapy may also be given before, during, or after radiation therapy if a person is healthy enough. For some people who are in poor health or whose tumor cells have certain gene changes found on lab tests, chemo may be used instead of radiation therapy.

For tumors that can’t be treated with surgery, radiation therapy along with chemo is usually the best option.

Temozolomide, carmustine (BCNU), and lomustine (CCNU) are commonly used chemo drugs. Combinations of drugs, such as the PCV regimen (procarbazine, CCNU, and vincristine), may also be used. All of these treatments may shrink or slow tumor growth for some time, but they are very unlikely to produce a cure.

If standard chemo drugs are no longer effective, the targeted drug bevacizumab (Avastin, other brand names) may be helpful for some people, either alone or with chemo.

In general, these gliomas can be very hard to control for long periods of time. Because these tumors are so hard to cure with current treatments, clinical trials of promising new treatments may be a good option.

Glioblastomas or GBMs (grade IV astrocytomas)

Surgery is often the first treatment if an imaging test shows what is likely a glioblastoma, although the specific type of tumor might not be known until after the operation. As much of the tumor is removed as is safely possible, although these tumors are almost never removed completely because of the way they grow into nearby areas. Radiation therapy is then given in most cases. This may be given with or followed by chemotherapy if a person is healthy enough. For some people who are older or in poor health, or whose tumor cells have certain gene changes found on lab tests, just one of these treatments (chemo or radiation therapy) might be used.

For tumors that can’t be treated with surgery, radiation therapy along with chemo is usually the best option.

Temozolomide is the chemo drug used first by most doctors because it crosses the blood-brain barrier and it’s convenient because it can be taken as a pill. It is sometimes given along with radiation therapy and then continued after the radiation is completed.

Carmustine (BCNU) and lomustine (CCNU) are other commonly used chemo drugs. Combinations of drugs, such as the PCV regimen (procarbazine, CCNU, and vincristine), may also be used. All of these treatments may shrink or slow tumor growth for some time, but they are very unlikely to cure the tumor.

If standard chemo drugs are no longer effective, the targeted drug bevacizumab (Avastin, other brand names) may be helpful for some people, either alone or with chemo.

Another option might be tumor treating fields therapy (TTF), also known as alternating electrical field therapy with the Optune Gio device. This can be used along with chemo (after surgery and radiation) as part of the initial treatment, or it can be used by itself (instead of chemo) for tumors that come back after treatment. 

In general, these tumors can be very hard to control for long periods of time. Because glioblastomas are so hard to cure with current treatments, clinical trials of promising new treatments may be a good option.

Oligodendrogliomas

Oligodendrogliomas are grade II tumors. (Treatment of anaplastic oligodendrogliomas, which are grade III tumors, is discussed above.)

If possible, surgery is typically the first treatment for oligodendrogliomas. Surgery usually doesn’t cure these tumors, but it can relieve symptoms and prolong survival. Many oligodendrogliomas grow slowly, especially in younger people, and may not need further treatment right away. Surgery may be repeated if the tumor grows back in the same spot.

Radiation therapy and/or chemo (most often with temozolomide or the PCV combination regimen - procarbazine CCNU, and vincristine,) may also be options after surgery. Another option after surgery might be a targeted therapy drug such as vorasidenib, if the tumor cells are found have an IDH1 or IDH2 gene mutation.

Oligodendrogliomas tend to respond better to chemotherapy than some other brain tumors.

Radiation therapy and/or chemotherapy may be helpful for tumors that can’t be treated with surgery.

Ependymomas and anaplastic ependymomas

These tumors usually do not grow into nearby normal brain tissue, and surgery to remove the tumor is typically the first treatment. Sometimes, patients may be cured by surgery alone if the entire tumor can be removed, but often this is not possible. Spinal cord ependymomas have the greatest chance of being cured with surgery, but treatment can cause side effects related to nerve damage.

Radiation therapy is given after surgery, especially if only part of the tumor was removed (or if it is an anaplastic ependymoma). If surgery cannot be done, radiation therapy is typically the main treatment.

Sometimes the tumor cells can spread into the cerebrospinal fluid (CSF). Patients typically get an MRI of the brain and spinal cord (and possibly a lumbar puncture) a few weeks after surgery if it is done. If either of these tests shows that the cancer has spread through the CSF, radiation therapy is given to the entire brain and spinal cord.

Chemotherapy isn't usually helpful for these tumors, so it often isn't given unless the tumor can no longer be treated with surgery or radiation.

Meningiomas

Most meningiomas tend to grow slowly, so small tumors that aren’t causing symptoms can often be watched rather than treated, particularly in the elderly.

If treatment is needed, these tumors can usually be cured if they can be removed completely with surgery. Radiation therapy may be used along with, or instead of, surgery for tumors that can’t be removed completely.

For meningiomas that are atypical/invasive (grade II) or anaplastic (grade III), which tend to come back after treatment, radiation therapy is typically given after surgery even if all of the visible tumor has been removed.

For meningiomas that recur after initial treatment, further surgery (if possible) or radiation therapy may be used. If surgery and radiation aren’t options, drug treatments (such as chemotherapy, targeted drug therapy, immunotherapy, or hormone-like drugs) may be tried, but it’s not clear how much benefit they offer.

Schwannomas (including acoustic neuromas)

These slow-growing tumors are usually benign and are cured by surgery. In some centers, small acoustic neuromas are treated with precise radiation therapy techniques such as stereotactic radiosurgery (SRS) or proton beam therapy (see Radiation Therapy for Adult Brain and Spinal Cord Tumors). For large schwannomas where complete removal is likely to cause problems, tumors may be operated on first to remove as much as is safe, and then the remainder is treated with radiation.

Spinal cord tumors

Different types of tumors can start in the spinal cord. If a spinal cord tumor is small and not causing symptoms, it might not need to be treated right away. When spinal cord tumors do need treatment, it’s often similar to what’s done for the same type of tumor in the brain.

Astrocytomas of the spinal cord usually cannot be removed completely. They may be treated with surgery to obtain a diagnosis and remove as much tumor as possible, and then by radiation therapy, or with radiation therapy alone. Chemotherapy might also be an option at some point, if needed.

Meningiomas of the spinal canal are often cured by surgery, as are some ependymomas. If surgery doesn’t remove the tumor completely, radiation therapy is often given.

Primary CNS lymphomas

Treatment of central nervous system (CNS) lymphomas generally consists of chemotherapy (given into a vein or through a ventricular access catheter, or both) and/or radiation therapy. Treatment is discussed in more detail in Non-Hodgkin Lymphoma.

Brain tumors that occur more often in children

Some types of brain tumors that are seen more often in children can also occur occasionally in adults. Some examples include:

• Brain stem gliomas
• Germ cell tumors
• Craniopharyngiomas
• Choroid plexus tumors
• Medulloblastomas and other embryonal tumors

Treatment of these tumors is described in Brain and Spinal Cord Tumors in Children.