Brain Surgery and Neurosurgical Oncology
Center for Advanced Brain Tumor Surgery
Dr Christian Brogna is an international expert in brain tumor surgery, including techniques as awake surgery, intraoperative mapping, neuronavigation, Gliolan.
He also performs MRI guided laser interstitial thermal therapy in collaboration with the London Neurosurgery Partnership.
Dr Christian Brogna has a recognised wide international experience, being ablle to acquire the most advanced neurosurgical techniques and to advance them. In partnership with several institutions around the globe, Dr Christian Brogna allows patients to have access to cutting edge treatments for brain tumors.
A brain tumor is made up of neoplastic tissue in the brain or skull, the cells of which grow and multiply uncontrollably, escaping normal cellular control mechanisms.
There are more than 150 types of brain tumors divided into two large groups:
- primary brain tumors;
- metastatic tumors.
Primary brain tumors include tumors that originate from brain cells or from tissues found inside the skull (gliomas, ependymomas, meningiomas).
Primary tumors are distinguished into glial and non-glial tumors. Brain tumors can be benign or malignant in nature.
Metastatic brain tumors are tumors that form in other parts of the body, such as in the breast, lungs, skin (melanomas), kidneys, gastrointestinal tract, etc., and which migrate to the brain mostly through arterial vessels.
Metastatic brain tumors are malignant tumors. Today, one in four cancer patients develops metastatic brain cancer.
Although in the past the survival of patients diagnosed with metastatic brain tumor was rather short, typically a few weeks, fortunately this is no longer the case today. More sophisticated diagnostic techniques combined with surgical techniques and innovative radiotherapy approaches have greatly lengthened the survival of patients with metastatic brain tumors and above all they have improved their quality of life.
There is an important consideration to make when it comes to brain tumors: the subdivision between benign and malignant tumors, while taking into account their histopathological and molecular nature and their future behavior, are elements that must not be considered alone. The clinical status of the patient, the presence or absence of epilepsy, the presence of neurological deficits, the location of the tumor, the way in which they grow, all these elements determine the patient’s clinical history. Even brain tumors that are benign by nature can in fact cause serious neurological problems and risk to life.
Benign brain tumors
Meningioma: Meningiomas are the most common benign intracranial tumors and comprise 10 to 15% of all brain neoplasms. Only a small percentage of meningiomas have malignant features. These tumors originate from the brain meninges, a complex of membranes that lines both the brain and the spinal cord. Only 5% of meningiomas have a malignant character.
Chordoma: Chordomas are slow-growing benign tumors that occur mostly in patients between 50 and 60 years of age. They are most frequently located at the base of the skull or in the lowest portion of the vertebral column. Although these tumors are benign they can invade the adjacent bone tissue and therefore cause compression of the nervous tissue with severe neurological deficits. They represent only 0.2% of all primary brain tumors.
Craniopharyngioma: Craniopharyngioma is benign in nature, but complex to remove totally due to its location near critical structures. It generally originates from a portion of the pituitary gland, which is responsible for regulating many hormones in our body.
Gangliocytoma, ganglioglioma: these are rare tumors, which generally occur in young people and are mainly made up of well-differentiated neoplastic nerve cells.
Glomus jugular tumors: These are mostly benign tumors produced just below the skull base and above the jugular vein. The most common form is glomus tumor. They are very rare tumors which represent only 0.6% of head and neck neoplasms.
Pineocytoma: These are generally benign tumors that originate from the cells of the pineal gland. They manifest in adulthood, are generally well defined, homogeneous non-invasive and low-growing.
Pituitary adenoma: Pituitary adenomas are the most common intracranial tumors after gliomas, meningiomas and schwannomas. Most pituitary gland adenomas are benign and generally slow-growing. There are more malignant forms. Adenomas represent the most common disease affecting the pituitary gland, generally in people between 30 and 40 years of age. They can rarely be diagnosed in children.
Schwannoma or neuroma: Schwannomas are fairly common benign tumors that originate along the nerves, specifically from the Schwan cells that constitute the electrical insulation of the nerve cells themselves. Schwannomas generally tend to displace normal tissue rather than invade it. Neurinomas of the acoustic-vestibular nerve are the most common and originate from the eighth cranial nerve or vestibular-cochlear nerve which runs from the brainstem to the inner ear (see facial nerve). Neurinomas can also occur in other locations such as in the spine and more rarely along the nerves of the arms and legs.
Malignant brain tumors
Gliomas are the most common primary adult brain tumors. They originate from glial cells which are part of the brain structure. Glial cells are divided into astrocytes, oligodendroglial cells and ependymal cells.
Astrocytomas: These are the most common gliomas, and represent about half of all primary brain and spinal cord tumors. Astrocytomas originate from star-shaped glial cells called astrocytes that take part in the constitution of the brain. Astrocytomas can occur anywhere in the brain, most commonly in the cerebral hemispheres. Even though astrocytomas can affect people of all ages, they are more common in older adults. The astrocytomas of the cerebellum and brain stem are more common in children and adolescents and are part of the constitution of most pediatric brain tumors.
Oligodendrogliomas: they are part of cerebral gliomas and derive from oligodendrocytes, cells that supply myelin to brain neurons, allowing their isolation from the world and a more effective conduction of electrical impulses.
Glioblastoma multiforme: is the most invasive glial brain tumor. This tumor tends to grow very rapidly, infiltrating different areas of the brain. It generally occurs in people between 50 and 70 years of age and is more common in men than in women.
Ependymomas: these are brain tumors that result from the neoplastic transformation of the ependymal cells that line the cerebral ventricles. They account for approximately 3% of all brain tumors.
Medulloblastomas: they generally originate in the cerebellum and are more common in children. They are high-grade tumors.
Hemangioblastomas: these are slow-growing tumors normally located in the cerebellum. They originate from the arterial vessels of the brain, can be quite bulky and are often accompanied by cysts. These tumors are more common in patients between the ages of 40 and 60 and more frequent in men than in women.
Rhabdoid tumors: they are very rare highly aggressive tumors that tend to invade the central nervous system. They often occur in multiple areas of the body, especially in the kidneys, and are more common in children.
Pediatric tumors
Brain tumors that affect children are different than those of adults. The treatment strategy must also take into account the developmental age in which they occur. For example, treatments that are often well tolerated in adults such as radiotherapy, however, can have a negative impact on a child brain especially if he is less than 5 years of age.
In children, brain tumors are most commonly located in the posterior cranial fossa or the posterior and basal part of the brain, including the brainstem and cerebellum. Brain tumors in children often present with hydrocephalus, which is the pathological increase of fluid (CSF) within the brain.
The most common brain tumors in children are medulloblastoma, low-grade astrocytoma, pilocytic astrocytoma, ependymoma, craniopharyngioma, and brainstem gliomas.
What are the most common symptoms of brain tumors?
The symptoms with which brain tumors occur depend both on their location within the skull and brain and on their growth rate.
Early diagnosis of brain tumors is crucial for the success of the various treatment strategies.
People with brain tumors can present with acute or worsening symptoms within 2-3 months.
The most common symptoms are:
- Headache: headache that clearly worsens over days or weeks and is associated with other symptoms, headache that wakes up in the night or is associated with vomiting, nausea or confusion;
- Seizures: a patient who has a seizure should go to the emergency room immediately;
- Weakness of one half of the body / face / of an arm or leg: it can occur suddenly, like a stroke, or over several weeks;
- Speech disorders: the patient cannot find words, cannot speak properly using words without meaning or out of context, or simply cannot speak at all or understand;
- Difficulty reading or interpreting words: in recent weeks the patient has difficulty reading emails, sending messages, or despite being able to see words, cannot detect their meaning;
- Personality change: brain tumor patients may become confused, have difficulty performing daily tasks, working, or using cell phones;
- Impaired vision: impaired ability to see objects from one side. Patients begin bumping into doors, unable to see anyone sitting next to them, rub the car alongside;
- Nausea and vomiting;
- Confusion and disorientation.
How are brain tumors diagnosed?
Diagnosis of brain tumors is done with imaging techniques such as CT or MRI. In particular, magnetic resonance imaging is essential to characterize a brain tumor: it allows the use of specific sequences to study both the metabolism of the tumor and the functionality of the brain surrounding the tumor itself.
Thus the spectroscopic magnetic resonance allows to give a first evaluation on the chemical profile and the nature of the tumor; the magnetic resonance with tractographic sequences allows to study the bundles of white fibers that constitute the elements of connection between several cerebral areas and that underlie the same cerebral functions such as language; functional magnetic resonance makes it possible to establish which cerebral cortical areas are activated during the execution of some specific functions. More advanced radiomics techniques can extrapolate advanced quantitative datas.
It is important to note that the definitive diagnosis of a brain tumor is performed with the histological and molecular analysis of the tumor itself.
Brain tumors’ treatments
The treatment of brain tumors must be framed in a strategic plan that takes into account all the available therapeutic modalities, such as surgery, radiotherapy, radiosurgery, chemotherapy, treatments with monoclonal antibodies, and eventually other treatments under investigation.
The surgical treatment plays a major role in almost all brain tumors. Its role has in most cases a fundamental prognostic value.
The surgical strategy takes into account many factors: anatomical site of the tumor, histological nature, infiltrated brain functional areas, compressed cranial nerves, clinical status of the patient, neurological functions at risk and their need to be preserved, type of job performed by the patient, patient’s wishes.
The neurosurgical treatment of brain tumors requires a deep knowledge of both brain anatomy and the distribution of brain functions and neuronal networks underlying various functions, such as motor, language, memory, coordination … . It is essential that the surgical strategy takes into account the uniqueness of the patient, since the brain of each of us is profoundly different from one another.
The surgical treatment of brain tumors also makes use of a series of advanced intraoperative technologies, essential for the accurate execution of the surgery:
- microneurosurgery;
- intraoperative monitoring;
- awake surgery;
- minimally invasive neurosurgery;
- neuroendoscopy;
- neuronavigation;
- 5-ALA.