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How We Treat Brain Tumors

  • The treatment of all brain tumors is determined on a case-by-case basis. At Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC), we believe that you and your family are key members of the care team, and that while we understand your illness, you understand your own body. We work with you and your family to develop a treatment plan that is right for you.

    Treatment options and prognosis depend on the grade and location of the tumor, your general health, and whether or not the tumor can be removed by surgery. If any cancer cells remain after surgery, treatment options and prognosis will depend on whether there are certain changes in the chromosomes and whether the cancer was newly diagnosed or had recurred (come back).

    Our multidisciplinary approach ensures that you and your family will be provided with all available and appropriate treatment options. Your neuro-oncologists provide you with access to continual care, confidentially, 24 hours a day. Our dedicated nurses and physician assistants will guide you and your family throughout the treatment process.

    Treatment options

    There are several treatment options for patients with adult brain and spinal cord tumors. The response to treatment in each individual is unique. Some treatments are based on the standard of care, and some are new approaches through clinical trials to aid in the development of more effective therapies.

    Five standard types of treatment can be used:

    Watchful waiting

    Watchful waiting is closely monitoring a patient's condition without giving any treatment until signs or symptoms appear or change.

    Surgery

    In most cases, treatment begins with surgery. While not all brain cancers can be treated with surgery, (depending on the location, size, and shape of the tumor), neurosurgery is often the best approach to the treatment of a brain tumor.

    One of the most important steps in your brain tumor care is choosing where to have your surgery

    If you are considering surgery for a brain lesion that may be a tumor, or is the recurrence of a previously removed tumor, our physicians can advise whether surgery and treatment at our hospital may make sense for your situation. Having surgery at DF/BWCC from the beginning can maximize the amount of tumor available for sequencing and genomic testing, to help determine what options you have later in your care. Our team of specialists coordinates with surgeons and pathologists from their first contact with you, to ensure that valuable opportunities for your treatment are not missed.

    AMIGO: Advanced Image-Guided Treatment

    Our team has over 30 years of experience in minimally-invasive image-guided therapy. The first intraoperative MRI scanner was invented at Brigham and Women's Hospital, paving the way for the advancement of imaging technology during a surgical procedure. Our expert neurosurgeons use advanced techniques to treat tumors that other treatment centers often consider inoperable or untreatable.

    Our Advanced Multimodality Image-Guided Operating (AMIGO) Suite opened in 2012, with over 1,000 surgeries completed to date. The AMIGO Suite is a state-of-the-art medical and surgical research operating suite that is home to advanced imaging equipment and interventional surgical systems that guide the intra-operative removal of brain tumors. Neurosurgeons and neuroradiologists at the Center for Neuro-Oncology may use this equipment to efficiently and precisely guide treatment with imaging before, during, and after a surgical procedure without the patient or medical team ever leaving the operating room.

    AMIGO operating suite

    We perform the following surgical procedures for the treatment of brain tumors:

    illustration of a craniotomy
    • Awake craniotomy: In this procedure, an opening is made in the skull and a piece of the skull is removed to expose the brain. You will receive anesthesia and medication to numb your body, but you will remain awake through certain parts of the procedure to ensure that there is no loss of speech or functional motor skills while the tumor is being removed.
    • Skull base surgery: The skull base is the bottom portion of the skull that supports the undersurface of the brain and protects many vital structures. This area includes the roof of the eye sockets, cheek bone, top of the palate, the deep structures of the ear canals, and the bottom portion of the skull behind the head. The skull base contains cranial nerves and multiple arteries that control complex senses, including hearing, vision, and balance.

      Our skull base surgery team, using the latest imaging technology, can reach all areas of the skull base to treat a wide variety of cranial disorders. Our surgical approaches for skull base disorders allow for faster pathological diagnosis, decompression of critical structures, and often, a cure. Our innovative, minimally-invasive surgical techniques – through the side or underneath the skull base – help minimize injury to the brain, resulting in a faster procedure with fewer complications and a more timely recovery.

      Our approaches include:

      • Expanded endonasal endoscopic approaches (EEA): Minimally-invasive procedures that use an endoscope to remove tumors through the nose.
      • Anterior craniofacial surgery: The tumor is removed through the front of the skull base (near the hairline).
      • Posterior skull base surgery: The tumor is removed through the back or the side of the skull base.
      • Skull base radiosurgery: Uses targeted radiation to reduce a tumor.
      • Vascular decompression: Treats trigeminal neuralgia or hemifacial spasm.
       

    Even if the neurosurgeon removes all the cancer that can be seen at the time of the surgery, some patients may be given chemotherapy or radiation therapy after surgery to eliminate any remaining cancer cells and lower the risk that the cancer will return. Treatment given after the surgery is called adjuvant therapy.

    Radiation therapy

    Radiation therapy is a cancer treatment that uses high-energy X-rays or other types of radiation to eradicate cancer cells or keep them from growing. The method of radiation therapy depends on the type of tumor and its location in the brain or spinal cord. Our radiation oncologists are experts in radiation techniques; if radiation therapy is indicated for your specific brain tumor, they will discuss the neuro-cognitive effects of radiation therapy with you and your family.

    Our radiation and medical oncologists work together to approach radiation therapy as a treatment option. We are committed to providing the safest approaches to radiation and are careful in adopting new treatment technologies. At our Center, radiation therapy is moving away from whole-brain radiation as a standard, and whenever possible, toward techniques that target specific areas of concern in the brain without harming the surrounding healthy tissue.

    We often use the following radiation therapy approaches, which cause less damage to the healthy tissue surrounding the tumor:

    • 3-dimensional conformal radiation therapy: A procedure that uses a computer to create a three-dimensional (3-D) picture of the brain or spinal cord tumor. This allows doctors to give the highest possible dose of radiation to the tumor, with the least possible damage to normal tissue. This type of radiation therapy is also called three-dimensional radiation therapy, or 3D-CRT.
    • Intensity-modulated radiation therapy (IMRT): A type of 3-D radiation therapy that uses a computer to make pictures of the size and shape of the brain or spinal cord tumor. Thin beams of radiation of different intensities are aimed at the tumor from many angles. This type of radiation therapy causes less damage to healthy tissue near the tumor.
    • Stereotactic radiosurgery (SRS): A procedure that uses radiation and computer targeting to direct focused radiation to specific targets in the brain that may be difficult to reach through conventional neurosurgery. This minimizes injury to surrounding structures that are not affected by the tumor. The procedure is performed under local sedation, with patients fitted with a face mask to guide targeting; neither a head frame nor a surgical incision is needed.

      At DF/BWCC, we are moving towards the implementation of a smaller, more comfortable face mask for patients and reducing the time it takes to complete the treatment. Patients who receive SRS usually return home the same day.
    • Stereotactic radiotherapy: A radiation treatment that is used in some instances for larger brain tumors and is divided, or fractionated, over several days.

    Chemotherapy and targeted therapy

    At the Center for Neuro-Oncology, precision cancer medicine helps us determine which form of chemotherapy is best for you. We analyze the genetic profile of your individual tumor type and may recommend a combination of therapies for optimal results.

    Chemotherapy is a cancer treatment that uses drugs to stop the growth of cancer cells, by either eliminating the cells or stopping them from dividing. The way chemotherapy is given depends on the type of tumor and where it is located:

    • In systemic chemotherapy, the chemotherapy agents are given intravenously and attack cancer cells throughout the body.
    • In regional chemotherapy, cancer-fighting agents are injected into the brain or cerebrospinal fluid, where they target cancer cells locally. Because of the brain's natural blood-brain barrier (BBB), not all drugs are able to pass through and attack cancer cells.

    Learn more about targeted therapies for brain tumors.

    Immunotherapy

    Our clinical experts at the Center for Neuro-Oncology are constantly investigating promising new therapy options for patients with all types of brain cancers.

    One promising new area is immunotherapy, which harnesses the power of the body's immune system to detect and combat tumors. Where targeted chemotherapy drugs disable proteins that cancer cells need to grow, immunotherapy drugs stimulate the patient's own immune system to recognize and kill cancer cells.

    Monoclonal antibody therapy is often made from an individual patient's tumor cells, or parts of them, which are processed in the laboratory and returned to the patient to stimulate a strong immune response. This unique approach combines immunotherapy with precision cancer medicine.

    At the Center for Neuro-Oncology, we have a tremendous array of immunotherapy clinical trials – including vaccines, novel tumor-targeting therapeutics, and anti-angiogenic therapies in recurrent glioblastoma.

    Learn more about immunotherapies for brain tumors.

    Clinical trials

    Clinical trials are scientific studies in which drugs, diagnostic procedures, and other therapies are tested in patients to determine if they are safe and effective. Participating in a clinical trial can help advance your own treatment, and can also improve the way cancer will be diagnosed and treated for patients in the future. Dana-Farber/Brigham and Women's Cancer Center is a leader in initiating clinical trials that have resulted in breakthroughs for cancer treatment.

    At the Center for Neuro-Oncology, we conduct continuous research into the diagnosis and treatment of brain tumors, offering a wide array of therapeutic options:

    • Our research and clinical trials for gliomas are ongoing.
    • We develop and lead ongoing clinical trials for the treatment of:
      • CNS lymphoma
      • Brain metastases
      • Many other primary brain cancers
       

    The multidisciplinary experts at the Center for Neuro-Oncology can help you determine if taking part in a clinical trial is best for you.

    Researchers at the Center for Neuro-Oncology work with the Adult Brain Tumor Consortium, the National Cancer Institute, the Ivy Foundation Early Phase Clinical Trials Consortium, and pharmaceutical companies to develop new approaches to the treatment of brain and spinal cord tumors. We offer clinical trials for patients with:

    • Newly diagnosed brain tumors
    • Recurrent glioblastoma
    • Non-glioblastoma brain tumors

    Treatment by tumor type

    Glioblastoma

    Between 200 and 300 patients are treated for glioblastoma at the Center for Neuro-Oncology each year. The treatment of glioblastoma may include surgery, followed by radiation therapy with or without chemotherapy, targeted chemotherapy during surgery, or simultaneous radiation therapy and chemotherapy.

    Traditional drugs, and even targeted chemotherapy agents, have had little success in treating glioblastoma, which is the most serious type of brain tumor. The addition of a clinical trial for a new treatment can be added to standard treatment and can be beneficial.

    At the Center for Neuro-Oncology, we have a large volume and diverse spectrum of clinical trials for malignant gliomas. We conducted the first successful randomized clinical trial of immunotherapy to show a benefit in glioblastoma patients. These are the first types of drugs to be related to attacking the genetic abnormalities of the tumors. A new vaccine, rindopepimut, given along with the anti-angiogenic drug Avastin, has shown promise in significantly improving the survival of patients whose tumors carry the mutation known as EGFRvIII, which is found in about one-third of glioblastoma tumors.

    Dana-Farber researchers have helped to develop targeted molecular drugs for glioblastomas, and are identifying the most promising and best combination for our patients. Immunotherapy drugs stimulate the patient's immune system to recognize and eradicate cancer cells. Clinical trials of new drugs that target P13 kinase (one of the most critical pathways in glioblastomas) and IDH1 (one of the most common mutations in grade II and III glioma) are ongoing.

    We have a large research program studying the biology of tumor stem cells, which are resistant to treatment, and finding the best drugs to eliminate them. Another area of great excitement is the development of therapies that stimulate the immune system to fight brain tumors. Several trials involving novel checkpoint inhibitors and tumor vaccines recently opened. We offer clinical trials for patients who are newly diagnosed with glioblastoma and clinical trials for those with recurrent glioblastoma.

    Lower-grade gliomas

    The standard approach to treating lower-grade gliomas includes surgery, radiation therapy, and sometimes chemotherapy. Immunotherapy is also an evolving approach for low-grade gliomas. Surgery is a key component of the treatment of lower-grade gliomas, which, like high-grade gliomas, can be infiltrative and difficult to remove. Based on the location of the brain tumor, surgeons will remove as much of the tumor as possible and work with your medical oncologist and radiation oncologist to determine subsequent treatment with chemotherapy and/or radiation therapy.

    CNS lymphoma

    The treatment of CNS lymphoma has evolved over the past several decades, resulting in a reduction in the rate of disease recurrence. Treatment for CNS lymphoma includes low-dose radiation and high-dose methotrexate, an anti-cancer drug given systemically (intravenously). High-dose methotrexate is an inpatient chemotherapy treatment; our experienced medical oncology nurses administer the drug and carefully monitor patients throughout their treatment.

    Clinicians at the Center for Neuro-Oncology have pioneered the treatment of CNS lymphoma through a number of clinical trials:

    • Combinations of low-dose radiation, high-dose methotrexate, and myeloablative or non-myeloablative transplants are promising therapy options now being tested through clinical trials.
    • We are currently conducting a clinical trial that compares myeloablative therapy versus non-myeloablative therapy.
    • We also have a clinical trial combating the recurrence of CNS lymphoma using a drug called Pemetrexed.

    We hope to offer clinical trials that use targeted therapy and immunotherapy to further advance the treatment of CNS lymphoma.

    Brain metastases

    Although treatments of primary cancers of the body continue to progress with better, more effective therapies, the drugs given to kill these cancer cells often cannot cross the brain's natural defense system, the blood brain barrier, which prevents the penetration of these cancer cell-killing drugs. This makes it easier for cancer cells in the body to migrate and metastasize to the brain (secondary tumor), even though you may have responded well to your primary cancer's treatment.

    Our expert neuro-oncology team works with the medical oncology group responsible for your primary cancer. The treatment of brain metastases is surgery- and radiation-centric, and depends on the number of metastatic brain tumors. Our neurosurgeons and radiation oncologists collaborate to determine the approach to surgery and radiation – which may include whole brain radiation, stereotactic radiosurgery, or a combination of both. Chemotherapy may also be a part of your treatment plan.

    Meningiomas

    Meningiomas are diagnosed in about 18,000 patients annually in the United States and account for about one-third of primary brain tumors. They are twice as common in women and have a high chance of recurrence. Meningiomas are generally slow-growing, and watchful waiting can be an initial treatment if there are no signs or symptoms. Depending on the location of your meningioma, the standard treatment is surgery, radiation therapy, or stereotactic radiosurgery.

    Our world-class neurosurgeons are known for their innovative and groundbreaking approaches to removing meningiomas. If surgery is indicated, they will assess the safest approach to removing the tumor, based on its location.

    Neurosurgeons and researchers at the Center for Neuro-Oncology and the Broad Institute have successfully completed large-scale genomic sequencing that has revealed two DNA mutations that appear to drive about 15 percent of all meningiomas. With the results of this research, medical oncologists at the Center for Neuro-Oncology are working on the first immunotherapy clinical trial for the effective treatment of meningiomas.