Brain Cancer

DRG Category:	27
Mean LOS:	3.6 days
Description:	SURGICAL: Craniotomy and Endovascular Intracranial Procedures Without CC or Major CC
DRG Category:	54
Mean LOS:	5.7 days
Description:	MEDICAL: Nervous System Neoplasms With Major CC

Primary brain tumors develop from various tissue types within the intracranial cavity and are named for the tissue in which they originate (e.g., astrocytomas originate in the astrocytes). Tumors are customarily described as benign or malignant; however, all brain tumors may be considered malignant because without treatment, the patient dies. Even tumors that are well contained may lead to serious consequences because they compress or invade neighboring structures within the enclosed skull. Brain tumors cause their symptoms directly by destroying neurons or indirectly by exerting pressure, displacing brain structures, and increasing intracranial pressure. Besides primary tumors arising from intracranial tissue, metastatic tumors may also migrate to the area by hematogenous spread. Common sources for brain metastases are the lung, breast, and colon. Advances in diagnosis, surgical techniques, and adjunctive therapy have greatly improved the outlook for patients with brain cancer. About 50% are treatable with a hopeful prognosis.

Statistics from the American Cancer Society in 2013 indicated that there were 23,130 cases of brain and spinal cord tumors diagnosed: 12,770 in men and 10,360 in women. In 2013, 14,080 people died from this disease: 7,930 males and 6,150 females. A person’s lifetime risk of developing a brain and spinal cord malignancy is 1%.

Brain and spinal cord malignant tumors account for 1.4% of all cancers and 2.4% of all cancer-related deaths. Because of the difficulty with pathological discrimination and absence of metastasis, the clinical staging method is not used to describe brain cancer. Rather, tumors are classified as low grade or high grade. Although there are a wide variety of histologic types (Table 1), a small number of tumor types account for most morbidity and mortality. Average survival time for persons with a low-grade astrocytoma is 6 to 8 years; the average survival time for a person with a glioblastoma is 12 months.

Primary Intracranial Tumors

Table 1. Primary Intracranial Tumors
Tumor	Percentage of Cases	Mean Age at Diagnosis (Years)	Clinical Manifestations	Treatment and Prognosis
Glioblastoma multiform (spongioblastoma)	40	54	Twice as common in males; increased intracranial pressure (ICP) with nonspecific mental and behavioral changes at first; later focal signs depending on location	Surgery where possible; poor response to radiation; course is rapidly progressive with poor prognosis
Astrocytoma	16	37	Presentation similar to glioblastoma but slower; headache, decreased motor strength and coordination; seizures or altered vital signs	By time of diagnosis, total excision is usually not possible unless there is a cerebellar lesion; variable prognosis
Medulloblastoma	< 5	5	Seen frequently in children, males more than females; nonspecific symptoms of increased ICP; local signs vary with location	Surgery combined with radiation and chemotherapy
Ependymoma	< 5	< 20	Similar to oligodendroglioma; increased ICP, hand hydrocephalus if tumor obstructs cerebrospinal fluid (CSF) pathway	Surgical excision; usually not radiosensitive
Oligodendroglioma	< 5	45	More common in middle-aged women; slow growing with gradual development of symptoms; decreased visual acuity and other visual disturbances	Surgical excision, which is usually successful
Meningioma	18	35	More common in females; originates from dura or arachnoid; compresses rather than invades structures; headache, vomiting, seizures, mental and behavioral changes	Surgery; may recur if excision is incomplete
Schwannoma (acoustic neurinoma, neurilemma)	2	57	Higher incidence in women; ipsilateral hearing loss is most common; later may be accompanied by tinnitus, headache	Excision by translabyrinth surgery, craniotomy, or both; usually favorable outcome
Pituitary adenoma	12	39	As tumor grows, it replaces endocrine gland cells, leading to endocrine symptoms such as hypopituitarism, addisonian crisis, or diabetes insipidus; conversely, they may produce excesses of the hormone; may also lead to visual symptoms, headaches, increased ICP	Surgery (frontal or transphenoidal) or radiation for small tumors
Lymphoma	2	46	Growing incidence, perhaps because of the growing incidence of immunosuppressed patients, such as those with AIDS and post–solid-organ or bone marrow transplant patients; may have no symptoms or focal ones	Usually brain radiation; chemotherapy may have an adjunctive role

Causes

Most brain tumors are not associated with any risk factors. Evidence suggests that therapeutic radiation for other purposes (e.g., leukemia) may predispose one to later development of a brain tumor. Brain tumors are also more common in the immunosuppressed population.

Genetic considerations

Some rare genetic conditions, including von Hippel-Lindau disease, Turcot’s syndrome, tuberous sclerosis, Li-Fraumeni, and neurofibromatosis, increase the risk of developing a brain tumor. Abnormalities in over a dozen chromosomal regions have been associated with gliomas, and combinations of both genetic and environmental factors seem to increase susceptibility. Medulloblastomas are associated with germ line mutations in SUFU and BRCA2 and somatic mutations in PTCH2, CTNNB1, and APC. Neuroblastomas are associated with germ line mutations in PHOX2B, KIF1B, ALK, and SDHB genes.

Gender, ethnic/racial, and life span considerations

Brain tumors may occur at any age and are fairly common in both children and adults, with about 100,000 symptomatic brain tumors, including metastatic brain tumors, diagnosed per year. They are common in children less than age 1 year and then again between ages 2 and 13 years. In children, primary tumors of the brain and spinal column are the second most common (after leukemias) type of childhood cancer—that is, the most common solid tumor. However, most central nervous system (CNS) tumors occur in patients over age 45, with the peak incidence found after age 70. More than 50% of these CNS tumors those are metastatic rather than primary. Gender considerations depend on tumor type. The 5-year survival rate decreases with age. For persons ages 15 to 44, it is 55%; for those ages 45 to 64, it is 16%; and for those over age 65, it is 5%. African Americans, especially African American women, have a slightly higher incidence of meningiomas and pituitary adenomas.

Global health considerations

The global incidence of brain and nervous system cancer is 3.5 per 100,000 males and 2.6 per 100,000 females. Developed nations have rates approximately three times that of developing nations.

Assessment

History

Symptoms produced by tumors vary by cell type and location and may cause generalized or focal symptoms. Although clearly every case of headache or dizziness is not a sign of brain tumor, it must always be considered. Any of the following indicate the possibility of a brain tumor: headache, progressive neurological deficit, convulsions (focal or generalized), increased intracranial pressure (ICP), and organic mental changes.

The generalized symptoms are usually caused by increased ICP from the tumor, obstruction of the CSF pathways, or cerebral edema. Headache and vomiting are the most common first symptoms of increased ICP. Typically, headache is worse in the morning and may wake the patient from sleep. The patient or significant others may also report personality changes (irritability initially, progressing to apathy and forgetfulness), increased fatigue, decreased endurance, visual disturbances, and a tendency toward social withdrawal. Generalized seizures are the presenting symptoms in 15% of adults and 30% of children.

Focal signs and symptoms result from local pressure or damage to limited parts of the brain and depend on the area of the brain affected. Tumors in the dominant hemisphere produce communication difficulties (aphasia); tumors near an optic tract will produce changes in visual fields. A lesion in the temporal lobe may lead to temporal lobe seizures that are exhibited by unexplained olfactory sensations, visual auras, or psychomotor seizures, all of which may be misdiagnosed as psychological problems or mental illness.

Physical examination

While symptoms vary with brain tumor type or location, common symptoms include headache, visual changes, dizziness, and seizures. Inspect the child suspected of a brain tumor before the sutures are closed; there may be head enlargement or bulging of the fontanelles from increased ICP. In rare cases, an adult with meningioma may have skull bulging. The appearance of the optic disk may change; if the tumor compresses the optic nerve, it will remain flat or atrophy. If ICP is increased, papilledema is possible. Perform a thorough neurological examination to identify changes in vision, hearing, sensation, and movement. A tumor may exert local pressure causing apraxia (an inability to use objects), paresthesia (numbness and tingling), paresis (partial or incomplete paralysis), or hyperreflexia.

Psychosocial

Assess for the presence of irritability and personality changes. Changes in a person’s mental status and ability to perform various roles are extremely disturbing to patients and significant others. Families and patients often display profound grief, extreme anxiety, and disbelief upon receiving the diagnosis of a brain tumor.

Diagnostic highlights

Test	Normal Result	Abnormality With Condition	Explanation
Computed tomography and magnetic resonance imaging	No space-occupying lesions	Locates size, location, and extent of tumor	Used for initial evaluation as well as response to treatment

Other Tests: Cerebral angiogram; electroencephalography; lumbar puncture; myelogram; brain scan; positron emission tomography.

Primary nursing diagnosis

Diagnosis

Decreased intracranial adaptive capacity

Outcomes

Neurological status; Neurological status: Consciousness; Fluid balance

Interventions

Cerebral perfusion promotion; Cerebral edema management; Neurological monitoring; Surveillance; Surveillance: Safety; Positioning: Neurological; Vital signs monitoring; Medication management

Planning and implementation

Collaborative

The type of treatment used for brain cancer depends on the type of tumor (see Table 1). The primary modes of treatment include surgery, radiotherapy, and pharmacologic therapy.

surgical.

Surgery remains the primary treatment modality. A craniotomy is done to remove larger tumors. This involves making a surgical opening in the cranium to remove the tumor and inspect various areas of the brain; reconstruction is required. Stereotactic surgery involves insertion of a needle through a small opening in the skull to “suction out” the small tumor. The goals of surgery are (1) total removal of the tumor, (2) subtotal removal to relieve symptoms, or (3) procedures to protect the brain from damage, such as placement of a shunt to relieve hydrocephalus. Other modalities are used in combination. After the surgery, the patient needs careful monitoring for increased ICP. Notify the surgeon if the bone flap becomes elevated, which is a sign of increased ICP. The physician usually manages cerebral swelling and elevated ICP with fluid restriction (usually 1,500 mL or less in 24 hours), steroids, shunt placement, and osmotic diuretics such as mannitol.

radiation.

For tumors that are not accessible to surgical removal, radiation may be used. Locally contained tumors receive direct-beam radiation focused on the lesion. For multiple lesions, especially metastatic brain lesions, whole-brain radiation therapy (WBRT) is used. Radiation is not used usually in children under age 2 because of the long-term effects, such as panhypopituitarism, developmental delay, and secondary tumors.

Pharmacologic highlights

Medication or Drug Class	Dosage	Description	Rationale
Chemotherapy	Varies by drug	Some germ cell tumors respond well to a combination of vincristine, bleomycin, methotrexate, and cisplatin	Chemotherapy plays a very minor role in the treatment of brain metastases; the blood-brain barrier prevents delivery to the tumor of the cytotoxic agents in high concentrations

Independent

The first priority is to ensure that the airway is patent. Keep equipment to manage the airway (endotracheal tube, laryngoscope, nasal and oral airway) within easy access of the patient. Make sure that working endotracheal suction is at the bedside. Note that an obstructed airway and increased levels of carbon dioxide contribute to increased ICP in patients with a space-occupying lesion. Keep the patient comfortable but not oversedated. If the patient is awake, encourage him or her to avoid Valsalva’s maneuver and isometric muscle contractions when moving or sitting up in bed to limit the risk of increased ICP. Perform a serial neurological assessment to watch for sudden changes in mental status. To reduce ICP and optimize lung expansion, place the patient in the semi-Fowler’s position. Keep the head in good alignment with the body to prevent compression on the veins that allow for venous drainage of the head. Avoid hip flexion. Assist the patient to turn in bed and perform coughing, deep breathing, and leg exercises every 2 hours to prevent skin breakdown as well as pulmonary and vascular stasis. As soon as allowed, help the patient get out of bed and ambulate in hallways three to four times each day. If the patient has sensory or motor deficits, work with the rehabilitation team to encourage activities of daily living and increased independence.

Patients who have been newly diagnosed with brain cancer are often in emotional shock, especially when the disease is diagnosed in the advanced stages or is inoperable. Encourage the patient and family to verbalize their feelings surrounding the diagnosis and impending death.

Assist family members in identifying the extent of home care that is realistically required by the patient. Arrange for visits by a home health agency. Suggest supportive counseling (hospice, grief counselor) and, if necessary, make the initial contact. Local units of the American Cancer Society offer assistance with home care supplies and support groups for patients and families. Also refer patients to the American Brain Tumor Association, the Brain Tumor Society, and the National Brain Tumor Foundation. Instruct the patient to use the pain scale effectively and to request pain medication before the pain escalates to an intolerable level. Consider switching as-needed pain medication to an around-the-clock dosing schedule to keep pain under control.

Evidence-Based Practice and Health Policy

Repacholi, M. H., Lerchl, A., Roosli, M., Sienkiewicz, Z., Auvinen, A., Breckenkamp, J., Vecchia, P. (2012). Systematic review of wireless phone use and brain cancer and other head tumors. Bioelectromagnetics, 33(3), 187–206.

The proliferation of cell phone use worldwide has prompted epidemiologists to examine if there are implications for increased brain cancer risk.
Cell phones emit radiofrequency (RF) energy and operate between 450 and 2,700 MHz compared with cordless phones, which operate between 1,880 and 1,900 MHz. International guidelines limit the specific energy absorption rate (SAR) in the head to 2 W/kg. SAR values from cell phones generally range between 0.2 and 1.5 W/kg compared with cordless phones in which values range between 0.0008 and 0.06 W/kg.
A systematic review of two case-only studies, two cohort studies, and seven ecological studies revealed inconclusive results regarding the association between increased cell phone use and brain cancer risk. In several studies, long-term cell phone use increased the odds of brain cancer by as much as 2.4 times (95% CI, 1.4 to 4.1). However, other investigators found no statistically significant associations.
There are no data on the effects of cell phone use in children or the effects of body weight on SAR exposure.

Documentation guidelines

Response to the diagnosis of cancer, the diagnostic tests, and recommended treatment regimen
Physical responses: Patency of airway, neurological assessments, vital signs, signs of increased ICP or seizure activity, description of all dressings and wounds, appearance of incision
Response to and tolerance to therapy: Radiation, surgery, chemotherapy
Presence of complications: Increased ICP, hemorrhage, infection, pulmonary congestion, activity intolerance, unrelieved discomfort
Activity level, progress in rehabilitation if appropriate, ability to perform independent activities of daily living

Discharge and home healthcare guidelines

follow-up.

Consult with occupational and physical therapists to develop an appropriate rehabilitation plan if one is needed. Discuss aids for self-care and mobilization such as wheelchairs, bathroom rails, and speech aids and where and how they can be obtained. Evaluate the home situation before discharge to determine if wheelchair access is available if it is necessary.

Teach the patient and family strategies to avoid exposure to infection. If the patient develops an infection or notes increased bleeding, teach the patient to notify the primary healthcare provider immediately. Teach the patient and significant others the early signs of tumor recurrence so that they can notify the primary healthcare provider if they occur. Instruct the patient on care of the skin in the external radiation field.

Stress the need to maintain a schedule for follow-up visits as recommended by the physician.

medications.

Explain the purpose, action, dosage, desired effects, and side effects of all medications prescribed by the physician.