Brain Tumor

By Dr. Ravindra Patil
Brain Tumor

A brain tumor is a mass or growth of abnormal cells in your brain. There are many different types of brain tumors. Some brain Tumors are noncancerous (called benign) while the other brain tumors are cancerous (called malignant).

Brain Tumors can begin in your brain (called primary brain Tumors), or cancer can begin in other parts of your body and spread to your brain (called secondary, or metastatic, brain Tumors).

Types of brain tumors

Acoustic neuroma
Astrocytoma
Brain metastases
Choroid plexus
Carcinoma
Craniopharyngioma
Embryonal Tumors
Ependymoma
Glioblastoma
Glioma
Medulloblastoma
Meningioma
Oligodendroglioma
Paediatric brain
Tumors
Pineoblastoma
Pituitary Tumors

How quickly a brain Tumor grows can greatly vary. The growth rate as well as location of a brain Tumor determines how it will affect the function of the patient’s nervous system.

Treatment choices for brain tumors are determined on the type of tumor, its size, and its location.

Brain tumor symptoms

People with a brain Tumor may or may not experience symptoms and signs. Sometimes, people with a brain Tumor do not have any of these signs and symptoms. Also, symptoms and signs similar to a brain tumor symptoms and signs may also be because of other disease conditions.

Pressure symptoms

Every tumor may exert pressure on the brain or the spinal cord. Here are brain tumor early symptoms:

Headache.
Blurred vision.
Feeling less alert than usual.
Nausea, Vomiting.
Fatigue.
Drowsiness, lack of energy, sleepiness.
Weakness or problems with moving or talking.
Sleep problems.
Behaviour changes.

Specific symptoms

These occur when a specific part of the brain is not working well because of the tumor. Obviously, the specific symptoms of a brain tumor depend on the location of the tumor in the brain.

Perhaps the most complex organ of the body, the brain controls our body and each small portion of the brain coordinates the limbs, taste, eyes, movement, hearing and so on. Thus if a tumor grows in the portion of the brain controlling eyesight and eye movements, then sight or eye movements will be affected. Some examples of specific symptoms are:

Pressure or headache near the Tumor. Often called as brain tumor headache.
Loss of balance and difficulty with fine motor skills is linked with a Tumor in the cerebellum or the small brain.
Changes in judgment, including loss of initiative, sluggishness, and muscle weakness or paralysis is associated with a tumor in the frontal lobe of the cerebrum or the large brain.
Partial or complete loss of vision is caused by a Tumor in the occipital lobe or temporal lobe of the cerebrum, the hind brain or the side of the brain.
Changes in speech, hearing, memory, or emotional state, such as aggressiveness and problems in understanding or recollecting words result due to a tumor in the frontal and temporal lobe of the cerebrum.
Altered perception of touch or pressure, arm or leg weakness on one side of the body, or confusion with left and right sides of the body occur when there is a tumor in the frontal or parietal lobe of the cerebrum.
Inability to look upward can be caused by a pineal gland Tumor.
Secretion of breast milk and altered menstrual periods may occur in women with a pituitary Tumor.
Growth of the hands and feet are affected when the growth hormone production is affected, that also happens because of a tumor in the pituitary gland.
Difficulty swallowing, facial weakness or numbness, or double vision are symptoms of a brain stem tumor.
Vision changes, including loss of part of the vision or double vision may occur because of a tumor in the temporal lobe, occipital lobe, or brain stem.

If you are concerned about any changes in yourself or your near and dear ones, you must consult your doctor. He/she take a detailed history of your symptoms and figure out the cause of the problem, and come to a diagnosis.

Many brain tumor patients are diagnosed when they consult their doctor after experiencing specific brain symptoms.

Seizures or Fits

Seizures are prevalent in brain tumors, with 40% to 60% of patients experiencing them.Loss or change in sensory functions like the vision, smell, hearing, touch and taste may occur.

Personality and/or Memory changes

Inability to sleep or excessive sleep, loss of memory, change in behaviour etc occur when the higher centres of the brain are affected. Patients may also experience changes in their ability to walk or perform daily activities.

Treating Brain Tumor

The best treatment for a tumor is obviously removing the tumor. However, because of the complex brain structure and the possibility of spread of a malignant [cancerous] tumor, it is not always possible to remove the tumor.

Relieving symptoms of a brain tumor is perhaps the most important part of treating brain tumors. This is called palliative care or supportive care. It is often started soon after diagnosis and continued throughout treatment.

Diagnosis of Brain Tumor

Many tests help diagnose a brain tumor and its type. It is very important to know if the tumor is benign [non-cancerous] or malignant [cancerous]. It is important to know if the tumor had originated in the brain itself or it has spread to the brain [metastasis] from another tumor in another part of the body. It is also vital to check if the brain tumor has spread to other parts of the body. However, the good news is that primary brain tumors rarely metastasize or spread.

Physical examination and history

Although the brain cannot be ‘examined’ for tumors with mere hands and eyes and touch, there are many indirect tests done by a physician or a neurologist to help in the diagnosis of a brain tumor. Physical examination includes a detailed medical history and examination of the whole body for sensations, movement and reflexes. A detailed assessment of major brain functions like storage and retrieval of memory, expressive and receptive language abilities, calculation, dexterity, and the overall well-being of the patient are done.

Imaging tests

These tests are done with X-Rays, MRI or Ultrasonography. As the name suggests, the tests show the shadow or computer generated three dimensional [3-D] image of the skull, brain, spinal chord and the vertebral column.

Most brain tumors are not diagnosed until after symptoms appear, hence a brain tumor is initially often suspected and diagnosed by general practitioner or a physician and then referred to a neurologist.

MRI of brain tumor

It means Magnetic Resonance Imaging. MRI is a very sharp and accurate means of ‘viewing’ inside the brain and it shows tumors which are but 2-3 mm in diameter. As MRI uses no X-Rays, it is considered to be a much safer means of diagnosis.

To enhance accuracy in MRI imaging, a special dye called a ‘contrast medium’ is injected or given orally before the MRI scan to give a clearer picture.

The MRI may be of the brain, spinal cord, or both, depending on the type of tumorsuspected and the likelihood that it will spread in the Central Nervous System.

There are different types of MRI scans, which is the best for the patient is decided by the treating doctor.

CT Scan

This similar to MRI but it uses X-Rays. Contrast medium can also be injected for CT Scan studies. Generally MRI is considered to be more precise than CT scans for brain and spine examinations. But a CT scan is the only choice of imaging if the patient cannot undergo MRI testing, for example patients with a pacemaker for their heart or any other steel implants in their bones cannot be tested with MRI scans.

A CT scan can help find bleeding and enlargement of the fluid-filled spaces in the brain, called ventricles. Changes to bone in the skull can also be seen on a CT scan, and it can be used to measure a Tumor’s size.

Biopsy

The best test for diagnosing a brain tumor is biopsy, that is, taking a sample of the tumor and examining it in the pathology laboratory. Biopsy also helps in finding if the tumor is a primary brain tumor or is a metastatic tumor from another part of the body.

Biopsy is usually done through surgery. A small sample of tissue is taken for testing. But a biopsy is many a times not possible for fear of damaging the brain and so other tests are done.

PET Scan

Its full form is Positron emission tomography. A small amount of a radioactive substance is injected into the patient’s body. This substance is taken up by cells that are actively dividing, that is tumor cells. Tumor cells absorb more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. Thus, PET scans during treatment over weeks or months can show whether the tumor is regressing in size. The PET scan machine can also take a CT Scan and often the two tests are combined.

Cerebral Angiography

It is also called Cerebral arteriogram or a cerebral angiogram. It is a series of X-Rays or videography of the head after a radio opaque contrast dye is injected into the carotid arteries.

Lumbar puncture

It is a procedure in which a needle is inserted between two lumber vertebrae and a sample of the fluid inside the spinal cord, called the cerebrospinal fluid [CSF], is taken for examination. Microscopic examination of the CSF of some brain tumor patients shows tumor cells and their type, and greatly help in reaching the diagnosis. CSF show presence of blood or tumor markers or biomarkers, which are substances found in higher than normal amounts in the blood, urine, spinal fluid, plasma or other bodily fluids of patients with certain types of Tumors.

Myelogram

A myelogram is an X-Ray taken after injecting a dye around the spinal cord. The dye shows up on an X-Ray and can outline the spinal cord to doctors look for a tumor. It helps diagnose the tumor which has spread to the spinal fluid, other parts of the brain, or the spinal cord. However, a myelogram is rarely done, a lumbar puncture is more common.

Molecular Laboratory Testing

It is done on a tumor sample to identify specific genes, proteins, and other factors, such as tumor markers, unique to the tumor. Some biomarkers may help doctors in determining a patient’s fate, that is the prognosis, meaning whether the patient’s tumor will regress or not.

Neurological, Vision, and Hearing Tests

These tests help determine if a Tumor is affecting the brain functions. An eye examination can detect changes to the optic nerve, as well as changes to a person’s field of vision.

EEG

Short for Electroencephalography, it is a non-invasive test in which electrodes are attached to the patient’s skull to measure electrical activity of the brain. It is specially useful to monitor for possible seizures.

Diagnosis

After all the diagnostic tests are done the doctor will review and discuss the test results with the patient and his/her family and plan the treatment.

Brain Tumor Grades and Prognostic Factors

A staging or grading system is used for most types of tumors in other parts of the body. The staging system describes where a tumor is located, if or where it has spread, and whether it is affecting other parts of the body.

However, there is no systemic staging system for adult brain tumors because most primary brain tumors do not usually spread beyond the central nervous system.

The grading system for brain tumors only determines how cancerous it is and how likely it is to grow.

Functional neurologic status

The doctor will test how well a patient is able to function and carry out everyday activities by using a functional assessment scale, such as the Karnofsky Performance Scale (KPS), outlined below. A higher score indicates a better functional status. Typically, someone who is better able to walk and care for themselves has a better prognosis.

Metastatic spread

A Tumor that starts in the brain or spinal cord, even if cancerous, rarely spreads to other parts of the body in adults, but may grow within the Central Nervous System. For that reason, with few exceptions, tests looking at the other organs of the body are typically not needed. A Tumor that does spread to other parts of the brain or spinal cord may result in a poorer outcome.

Brain Tumor Treatment

In brain tumor care, different types of doctors work together to create a patient’s overall treatment plan that combines different types of treatment. This is called a multidisciplinary team.

Treatment options depend on several factors:

The size, type, and grade of the Tumor
Whether the Tumor is putting pressure on vital parts of the brain
If the Tumor has spread to other parts of the CNS or body
Possible side effects. Read about side effects of brain tumor treatment here.
The patient’s preferences and overall health

Some types of brain tumors grow rapidly; other tumors grow slowly.

Treatment options

For a low-grade brain Tumor , surgery may be the only treatment needed especially if all of the Tumor can be removed.
If there is visible Tumor remaining after surgery, radiation therapy and chemotherapy may be used.
For higher-grade tumors, treatment usually begins with surgery, followed by radiation therapy and chemotherapy.

Successfully treating brain tumors can be challenging. The body’s blood-brain barrier normally protects the brain and spinal cord from harmful chemicals. However, this barrier also keeps out many types of chemotherapy. Surgery can be difficult if the Tumor is near a delicate part of the brain or spinal cord. Even when the surgeon can completely remove the original tumor, parts of the Tumor may remain that are too small to be seen or removed during surgery. Radiation therapy can also damage healthy tissue.

Physical, Emotional, and Social Effects of a Brain Tumor

A brain Tumor and its treatment cause physical symptoms and side effects, as well as emotional, social, and financial effects. Managing all of these effects is called palliative care or supportive care. It is an important part of your care that is included along with treatments intended to slow, stop, or eliminate the tumor.

Palliative Care

Palliative care focuses on improving how you feel during treatment by managing symptoms and supporting patients and their families with other, non-medical needs. Any person, regardless of age or type and stage of Tumor , may receive this type of care. And it often works best when it is started right after a brain Tumor diagnosis. People who receive palliative care along with treatment for the Tumor often have less severe symptoms, better quality of life, and report that they are more satisfied with treatment.

Palliative treatments vary widely and often include medication, nutritional changes, relaxation techniques, emotional and spiritual support, and other therapies. You may also receive palliative treatments similar to those meant to get rid of the Tumor , such as chemotherapy, surgery, or radiation therapy.

Some of the symptoms of a brain Tumor can be severe and have an enormous impact on the daily lives of patients and their family caregivers. However, symptoms can often be managed with the use of certain medicines. Supportive care for people with a brain Tumor includes:

Drugs

Corticosteroids: Used to reduce swelling in the brain
Anti-seizure medicines: Help control seizures or fits
The treating doctors will also discuss side effects of the above medicines

Surgery

Brain tumor operation include surgical removal of the Tumor and some surrounding healthy tissue during an operation. It is usually the first stage treatment for a brain tumor. It is often the only treatment needed for a low-grade brain tumor. Removing the Tumor can improve neurological symptoms, provide tissue for diagnosis and genetic analysis, help make other treatments of brain tumor more effective, and, in many instances, improve the prognosis of a person with a brain tumor.

Surgery is done mostly by neurosurgeons. They use complex machinery like operating microscopes and Ultrasonic Coagulation and Cutting Devices, computer navigation and image intensifier television [IITV] to operate on the brain. The cost of brain surgery in india depends on all these factor.

Surgery to the brain requires the removal of part of the skull, a procedure called a craniotomy. After the surgeon removes the tumor, the patient’s own bone will be used to cover the opening in the skull. Sometimes the patient’s skull bone is stored in the operation theatre or implanted in the patient’s abdomen for safe keeping.

Newer technologies have made brain surgery much safer and more successful. The top neurosurgon, Dr. Ravindra Patil, Samarth Hospital gives the best brain surgery.

Sometimes, surgery cannot be performed because the Tumor is located in a place the surgeon cannot reach, or it is near a vital structure. These tumors are called inoperable or unresectable. If the Tumor is inoperable, the doctor will recommend other treatment options that may also include a biopsy or removal of a portion of the Tumor.

Radiation therapy

Radiation therapy is the use of high-energy X-Rays or other particles to destroy Tumor cells. Doctors may use radiation therapy to slow or stop the growth of a brain Tumor. It is typically given after surgery and possibly along with chemotherapy.

Doctors who specialize in giving radiation therapy to treat a Tumor is called a radiation oncologist.

The most common type of radiation treatment is called external-beam radiation therapy, where radiation given from a machine outside the body.

When radiation treatment is given using implants, it is called internal radiation therapy or brachytherapy.

A radiation therapy schedule usually consists of a specific number of treatments given over a set period of time.

There are many types of radiation therapies, with these different techniques, doctors are trying to be more precise and reduce radiation exposure to the surrounding healthy brain tissue. Depending on the size and location of the tumor, the radiation oncologist may choose the most suitable radiation technique. In certain situations, a combination of multiple techniques may work best.

Short-term side effects from radiation therapy may include fatigue, mild skin reactions, hair loss, upset stomach, and neurologic symptoms, such as memory problems. Most side effects go away soon after treatment is finished. Also, radiation therapy is usually not recommended for children younger than 5 because of the high risk of damage to their developing brains. Longer term side effects of radiation therapy depend on how much healthy tissue received radiation and include memory and hormonal problems and cognitive (thought process) changes, such as difficulty understanding and performing complex tasks.

Chemotherapy

This is drug therapy to destroy tumor cells. This type of medication is given intravenously to reach Tumor cells throughout the body. Chemotherapy is prescribed by a medical oncologist, a doctor who specializes in treating a Tumor with medicines.

Common ways to give systemic therapies include an intravenous (IV) tube placed into a vein using a needle or in a pill or capsule that is swallowed (orally). It may also be given through a catheter or port, which are used to make IV injections easier.

Patients are monitored with a brain MRI every 2 to 3 months while receiving chemotherapy to check for progress.

The side effects of chemotherapy depend on the individual and the dose used, but they can include fatigue, risk of infection, nausea and vomiting, hair loss, loss of appetite and diarrhoea. These side effects usually go away after treatment is finished. Rarely, certain drugs may cause some hearing loss. Others may cause kidney damage. Patients may be given extra fluid by IV to protect their kidneys.

Targeted therapy

In addition to standard chemotherapy, targeted therapy is a treatment that targets the Tumor’s specific genes, proteins, or the tissue environment that contributes to a Tumor ’s growth and survival. This type of treatment blocks the growth and spread of Tumor cells and limits the damage to healthy cells.

Not all tumors have the same targets, and some tumors may have more than 1 target. To find the most effective treatment, your doctor may run tests to identify the genes, proteins, and other factors in your tumor. This helps doctors better match each patient with the most effective treatment whenever possible. In addition, research studies continue to find out more about specific molecular targets and new treatments directed at them. Learn more about the basics of targeted treatments.

For a brain tumor, there are 2 types of targeted therapy that may be used:

Remission and the chance of recurrence

A remission is when the Tumor cannot be detected in the body. A remission can be temporary or permanent. For most primary brain tumors, despite imaging tests showing that the Tumor growth is controlled or there are no visible signs of a tumor, it is common for a brain Tumor to recur.

Patients will often continue to undergo MRI scans to watch for a recurrence. This uncertainty causes many people to worry that the Tumor will come back. It is important to talk with your doctor about the possibility of the Tumor returning. Understanding your risk of recurrence and the treatment options may help you feel more prepared if the Tumor does return. Learn more about coping with the fear of recurrence.

If the Tumor returns after the original treatment, it is called a recurrent tumor. A recurrent brain tumor generally comes back near where it originally started. Rarely, it may come back in another place or in several areas, which is called a multifocal recurrence.

When this occurs, a new cycle of testing will begin again to learn as much as possible about the recurrence. After this testing is done, you and your doctor will talk about the treatment options. Often the treatment plan will include the treatments described above such as surgery, radiation therapy, chemotherapy, and targeted therapy, but they may be used in a different combination or given at a different pace. Options may include:

Clinical trials studying new treatments

There is no single approach to treating a recurrent brain tumor, and your treatment plan will be based on many factors. Whichever treatment plan you choose, palliative care will be important for relieving symptoms and side effects. Your doctor may suggest clinical trials of new drugs that are being created and tested to treat brain tumors that may help with recurrent tumors. Many of these new drugs are called “molecular targeted therapies” because they are small in size, which means they can be taken by mouth and/or can target specific parts of the brain Tumor cells (see Targeted therapy, above). These new drugs are being tested either alone or in combination with standard chemotherapy. Learn more about clinical trials on brain Tumor in the Latest Research section.

People with a recurrent brain Tumor often experience emotions such as disbelief or fear. For most people, a diagnosis of a recurrent brain Tumor is very stressful and, at times, difficult to bear. You are encouraged to talk with the health care team about these feelings and ask about support services to help you cope. It may also be helpful to talk with other patients, including through a support group. Learn more about dealing with a recurrence.

Metastatic cancer

If cancer spreads to the brain or CNS from where it started, doctors call it metastatic cancer or a secondary brain tumor. If this happens, it is a good idea to talk with doctors who have experience in treating it. Doctors can have different opinions about the best standard treatment plan. Clinical trials might also be an option. Learn more about getting a second opinion before starting treatment, so you are comfortable with your chosen treatment plan.

Treatment plan may include a combination of surgery, radiation therapy, targeted therapy, and immunotherapy, which is a type of treatment designed to boost the body’s natural defenses to fight the tumor. Learn more about immunotherapy below and in the Latest Research section of this guide.

Treatment of brain metastases

If cancer spread to the brain from another part of the body, it is called a brain metastasis. Brain metastases have traditionally been treated with surgery or radiation therapy. Chemotherapy is not often used because the blood-brain barrier keeps many drugs from reaching the brain. In the past, chemotherapy was mostly used only if radiation therapy did not work. Current options for treating brain metastases include surgery. Surgery is generally only an option for patients who have a single area of cancer in the brain. Radiation therapy is often given afterwards.

Surgery for spinal tumors

Both children and adults can get spinal tumors. But unlike adults, children have not achieved complete skeletal growth, which surgeons must take into account when planning treatment.

Other factors to consider before surgery for spinal tumors are spinal stability, surgical versus nonsurgical interventions and preservation of neurological function.

Basically, most of the spinal surgeries aim at ‘decompression’ because it reduces the ‘compression’ that is increased pressure around the spinal cord because of the tumor. The entire tumor or a part of it may be surgically removed. If a small part of the tumor is removed, it is called debulk (make smaller) surgery. Excision means the complete removal of the tumor. While resection means partial removal. These types of procedures decompress or relieve pressure to the spinal cord and nerve roots, thereby helping to reduce pain and other symptoms.

Surgery from front or the back?

If surgery is considered, the approach to the tumor is determined by the tumor’s location within the spinal canal. The posterior approach [meaning that the surgery is done with the patient lying supine or face down on the operation theatre] allows for the identification of the dura mater and exposure of the nerve roots. This approach is commonly used for tumors in the posterior aspect of the spinal column or to expose tumors inside the dura. Multiple levels can be decompressed, and multilevel segmental fixation can be performed if necessary.

The anterior approach [meaning that the surgery is done with the patient lying prone or face up on the operation theatre] is excellent for tumors in the front of the spine. This approach also allows for the reconstruction of defects caused by removal of the vertebral bodies. This approach also allows placement of short-segment fixation devices.

Some thoracic and lumbar spinal tumors that affect both the anterior and posterior vertebral columns can be a challenge to resect completely. So, both the above type of surgeries are done in tow stages. A posterior (back) approach followed by a separately staged anterior (front) approach helps the treatment of these complex lesions.

Pre-operative Embolization

This is done in benign tumors where surgical resection is possible. The aim to minimize bleeding during surgery as all nerve tissue has abundant blood supply and is likely to bleed profusely during surgery. Embolization means blocking. Preoperative embolization may be used to enable an easier resection. This procedure involves the insertion of a catheter or tube through an artery in the groin. The catheter is guided up through the blood vessels to the site of the tumor, where it delivers a glue-like liquid embolic agent that blocks the vessels that feed the tumor. When the blood vessels that feed the tumor are blocked off, bleeding can often be controlled better during surgery, helping to decrease surgical risks.

Risks in spinal tumor surgery

There is a slight risk of damage to the spine during to surgery. But if surgery is not performed, there’s definite risk of catastrophic nerve or spine injury.

If the patient refuses surgery and the tumor/s continue to grow, that patient may end up paralyzed because of the tumor’s growth. Such patients also face risks like blood clots and other serious health complications.

Chemotherapy for spinal tumors

Chemotherapy drugs destroy cancer cells throughout the body. They are rarely used to treat spinal cord tumors unless the tumors are cancerous and fast-growing, increasing their risk of spreading outside of the spinal cord. When prescribed, these drugs are often given after surgery or radiation therapy.

Most chemotherapy is given through a vein with several intravenous (IV) infusions. Chemotherapy is usually delivered in cycles; one cycle involves a treatment followed by a period of rest.

Outlook of spinal tumors treatment

Outcome depends greatly on the age and overall health of the patient and on whether the spinal tumor is benign or malignant, primary or metastatic.
In the case of primary tumors, both benign and malignant, the goal is to remove the tumor completely. This leads to cure of the tumor, the malignancy if present, and the symptoms and loss of function.

In some primary tumors, particularly those that arise inside the spinal [cord-intramedullary tumors], complete resection is not possible without significant neural damage. Hence surgery may not be advised or the outcomes may not be as expected.

In the case of metastatic tumors [tumors which have spread to the spine from the other parts of the body], the goal is almost always palliative, with treatment aimed at providing the patient with an improved quality of life and possibly prolonged life expectancy.

While spine surgery has the risks associated with any surgery like infections, blood clots in veins and so on, spine surgery in adults for a variety of spinal tumors has been associated with a risk for major complications. It may be noted that post-operative complications are more common in patients who have significant co-morbidities [presence of other diseases like diabetes, high blood pressure and use of steroids].

Through the top neurosurgon, Dr. Ravindra Patil, Samarth Neuro and Superspeciality Hospital gives the best spine surgery.

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Brain Tumor

Table of Contents

Types of brain tumors

Brain tumor symptoms

Pressure symptoms

Specific symptoms

Seizures or Fits

Personality and/or Memory changes

Treating Brain Tumor

Diagnosis of Brain Tumor

Physical examination and history

Imaging tests

MRI of brain tumor

CT Scan

Biopsy

PET Scan

Cerebral Angiography

Lumbar puncture

Myelogram

Molecular Laboratory Testing

Neurological, Vision, and Hearing Tests

EEG

Diagnosis

Brain Tumor Grades and Prognostic Factors

Functional neurologic status

Metastatic spread

Brain Tumor Treatment

Treatment options

Physical, Emotional, and Social Effects of a Brain Tumor

Palliative Care

Drugs

Surgery

Radiation therapy

Chemotherapy

Targeted therapy

Remission and the chance of recurrence

Clinical trials studying new treatments

Metastatic cancer

Treatment of brain metastases

Surgery for spinal tumors

Surgery from front or the back?

Pre-operative Embolization

Risks in spinal tumor surgery

Chemotherapy for spinal tumors

Outlook of spinal tumors treatment

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