Treatments for Childhood Central Nervous System Tumors

Executive Summary

The different types of standard treatments for childhood central nervous system tumor are explained in detail. Standard treatments are used along with the integration of effective treatment planning. Clinical trials are used as an innovative treatment approach that combines different therapies and drugs for treating central nervous system tumor in children. The child’s care plan includes treatment for symptoms and side effects, which is essential for medical care. In the case of low-grade Astrocytoma, surgery, radiation therapy, chemotherapy, or combinations of these treatments are used. Surgery and chemotherapy or limited radiation therapy are the options for younger children. For older children, radiation therapy without surgery is used.

Surgery with radiation therapy and chemotherapy is given in case of high-grade Astrocytoma. Radiation therapy is given to children with Brain stem glioma. Treatment options for ependymoma include surgery and radiation therapy. For infants and very young children having ependymoma, chemotherapy is used. Surgery, chemotherapy, and radiation therapy are typically used to treat a germ cell tumor. Treatment options for medulloblastoma include surgery, chemotherapy, and radiation therapy. Palliative care is provided to the patients to cope with mental, physical or financial issues while involving medication, nutritional changes, emotional and spiritual support and other relaxation therapies.

Treatments for Childhood Central Nervous system Tumors

In general, tumors are uncommon in children. It means it can be challenging for doctors to plan treatments for Central Nervous system tumors unless they know what is most effective in other children. More than 60% of children are treated as part of a clinical trial.

Children with a Central Nervous system tumor should be treated at a specialized cancer Centre. Doctors at these Centres have extensive experience treating children and access to the latest research. 

“Standard to care” refers to the best-known treatment. In cancer care, different doctors work together to bring out an overall treatment plan for the patient. It is called a multidisciplinary team. 

Treatments for Central Nervous system tumors recommendations depend on many factors:

• The size, grade and type of tumor
• Whether the tumor is applying pressure on vital parts of the brain
• If the tumor has increased to other parts of the Central Nervous system or body
• Possible side effects
• The patient’s preferences and overall health

For example, radiation therapy is often limited to children younger than three years old because extensive radiation therapy can cause memory and learning problems in the future. The child’s care plan may also include treatment for symptoms and side effects, which are essential for medical care.

Details of the common treatments used for specific Central Nervous system tumors in children are mentioned below, followed by more information on each primary type of treatment ^​1​.

• Astrocytomas: Treatment options usually depend on the grade of the tumor. For low-grade astrocytoma, options include surgery, radiation therapy, chemotherapy, or combinations of these treatments. The treatments for Central Nervous system tumors depend on the tumor’s location, how easy it is removed with surgery, and a child’s age. Surgery and chemotherapy or limited radiation therapy may be an option for younger children. For older children, radiation therapy without surgery can be used. For high-grade astrocytoma, surgery with radiation therapy and chemotherapy is usually given ^​2​.
• Brain stem glioma: Treatment options for brain stem glioma typically include radiation therapy. Presently, chemotherapy does not appear to lengthen the lives of children with brain stem glioma. However, in clinical trials, new drugs are being researched for brain stem glioma. 

• Ependymoma: Treatment options for ependymoma include surgery and radiation therapy. For infants and very young children having ependymoma, chemotherapy may be used ^​3​. It is used for a short duration to help shrink a tumor removed entirely with surgery.

• Germ cell tumor: Surgery, chemotherapy, and radiation therapy are typically used to treat a germ cell tumor.

• Medulloblastoma: Treatment options for medulloblastoma include surgery, chemotherapy, and radiation therapy ^​4​.

Surgery

Surgery is the removal of the tumor and some nearby healthy tissue during an operation. The purposes of surgery are to remove tissue to make a diagnosis, remove the tumor to improve the prognosis and relieve symptoms caused by the tumor compressing normal functioning nerves. Sometimes, a tumor spreads and grows between healthy nerve cells, making surgery difficult. Surgery may be limited, and other treatments are suggested in this situation.

In specific situations, surgery can damage parts of the brain near the tumor, affecting breathing, swallowing, eye movement, arm and leg movement, or other functions. Before surgery, talking to the health care team about the possible side effects of your child’s specific surgery is essential ^​5​.

Some tumors cannot be removed by surgery because of their location. These Central Nervous system tumors are called inoperable. In these cases, the doctor will suggest other treatment options.

Radiation therapy

Radiation therapy uses high-energy X-rays or particles to destroy cancer cells. Doctors use radiation therapy to slow or stop the growth of a brain tumor. It is typically given post-surgery and possibly along with chemotherapy.

The most common radiation treatment type is external-beam radiation therapy, in which radiation is given from a machine outside the body. A radiation therapy schedule consists typically of a specific number of treatments offered over a set period.

Internal radiation therapy or brachytherapy is when radiation treatment is given using implants.

Stereotactic radiosurgery is a method to deliver high doses of radiation therapy directly to a tumor and not to healthy tissue. This technique forms detailed, 3-dimensional maps of the brain and tumor so doctors can point out where to direct the radiation treatment.

Another type of radiation therapy used for a Central Nervous system tumor is proton therapy. Proton therapy is an external-beam radiation therapy that uses a proton particle rather than an x-ray. Proton therapy does not go entirely through the body (and does not have an “exit dose”), so it may cause minor damage to healthy tissue. In the past two decades, proton therapy has become more widely available in the United States.

Side effects from radiation therapy may include mild skin reactions, upset stomach, fatigue, headaches, and loose bowel movements. Most side effects go away after treatment ends. However, in the long term, radiation therapy can cause problems with the development and growth of the child’s brain. Hence, the doctor may choose to treat the tumor in another way.

Chemotherapy

Chemotherapy uses medicine to kill or stop the growth of cancerous cells which are in Central Nervous system. Depending upon the stage, different chemotherapy is given. The point that makes a difference is how the chemotherapy enters the body and which cells it affects.

Systemic chemotherapy enters the bloodstream to reach cancerous cells all over the body. 

Standard methods for chemotherapy include an intravenous (IV) tube placed into a vein using a needle or by capsule or pill taken orally.

A chemotherapy schedule usually consists of a certain number of cycles over a fixed period. A patient can be given one drug at a time, or a combination of different medications given simultaneously.

Chemotherapy may be given directly into the spinal canal to treat tumor cells on the brain and spine surface. This process, called intrathecal chemotherapy, is still being researched in clinical trials and may not be available everywhere.

Chemotherapy may be effective for various types of brain tumors. Depending on the tumour type, chemotherapy can be given immediately after a biopsy or surgery or after radiation therapy. In some instances, chemotherapy is used simultaneously as radiation therapy.

The side effects of chemotherapy depend on the patient and the drug and dose used. Still, they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite, and diarrhoea. These side effects usually go after treatment ends.

Palliative Care

Cancer and its treatment have side effects that can be mental, physical or financial and managing the effects are palliative or supportive care.

Palliative care includes medication, nutritional changes, emotional and spiritual support and other relaxation therapies. 

Palliative care focuses on alleviating how you feel during treatment by managing symptoms and supporting patients and their families with other non-medical needs. Regardless of type and stage of Cancer age, any person may receive this type of care.

Remission and the chance of recurrence

When cancer can’t be detected in the body and there are no symptoms, this is known as remission. It may also be called having ‘no evidence of disease’ or ‘NED.’

A remission can be temporary or permanent. Many people worry about the recurrence of cancer.

If the tumor returns after the original treatment, it is called a recurrent tumor. It may return in the same place (local recurrence), nearby (regional recurrence), or in another place (distant recurrence).

The doctor performs another round of tests to know the extent of the recurrence.

Mainly the treatment plan includes the treatments for Central Nervous system tumors explained above, like surgery, chemotherapy, radiation therapy, and targeted therapy. Still, they are used in a different combination or given at a different pace. 

For a recurrent Central Nervous system tumor, the treatment options depend on three factors:

• The type of tumor
• The type of treatment given for the original tumor
• Whether the tumor recurred where it originally started or in another part of the brain or body

If cancer can’t be treated or controlled, it leads to advanced or terminal cancer. It is vital to have straightforward conversations with your health care team to express your feelings, preferences, and concerns. The health care team has unique skills, knowledge, and experience to assist patients and their families. Ensuring that a person is physically comfortable, free from pain, and emotionally supported is extremely important. 

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