Radiation

The majority of high-grade gliomas (WHO grade 3 and 4) require radiotherapy following surgery. Although radiotherapy rarely cures glioblastoma, studies show that it doubles the median survival of patients, compared to supportive care alone. A recent important study (known as the 'Stupp' trial) showed a benefit for chemotherapy using temozolomide in patients with glioblastoma multiforme. In the study, the median survival of patients who received temozolomide in addition to radiotherapy was increased by 2.5 months and two-year survival by 16 percent. For grade 3 gliomas the options for treatment following surgery would involve radiotherapy alone or chemotherapy alone followed by surveillance (i.e. keeping an eye with regular scans). Following surgery to obtain tissue for biopsy or to resect a grade 4 glioma (or glioblastoma), the patient is scored on their general well being (WHO performance status) and those with performance status of 0 or 1 are offered high dose radiotherapy treatment along with Temozolomide tablets during the treatment.

Further details about radiotherapy can be obtained by viewing this booklet which has been designed specifically for patients treated at the University Hospitals Bristol NHS Foundation trust:

Chemotherapy

Chemotherapy is an integral part of the treatment of Cancer and the decision on when to use it is dependant again on the type of tumour, but also on the clinical status of the patient (i.e. how well is the patient and will he/she be able to tolerate the treatment). For grade I gliomas no chemotherapy is currently indicated. For grade 2 gliomas, the role of chemotherapy is limited and is currently restricted to clinical trials. For grade 3 gliomas (Astrocytomas, Oligo-astrocytomas amd Oligodendrogliomas) the options for treatment include either initial radiotherapy followed by chemotherapy with either Temozolomide or PCV (Procarbazine, CCNU and Vincristine). The exact management plan is arrived at after the Clinical Oncologist is able to have a full and complete discussion with the patient and family about the pros and cons of each treatment. For grade 4 gliomas, following surgical resection of the tumour where appropriate, a decision about additional treatment is made by the Clinical Oncologist depending on the general fitness level of the patient (see links to WHO performance status above). The current standard of treatment in a fit patient would be Radiotherapy to the tumour bed and concomitant administration of Temozolomide (i.e. Temozolomide taken orally during the administration of Radiotherapy) followed by a few cycles of adjuvant Temozolomide orally over a period of time. Additional information about Temozolomide can be found here:

Awake Craniotomy

This is a highly specialised procedure performed when tumours are present very close to areas of the brain that control movement, speech and language, to minimise injury to these areas and preserve function. An important part of the brain, which controls voluntary movement of the opposite side of the arm, leg, face and tongue, is called the motor cortex. (See fig below)

The anatomical region of the brain known as Area 4 (coloured red in the figure above) was given the name primary motor cortex after the Canadian Neurosurgeon Dr Wilder Penfield showed that focal stimulations in this region elicited highly localized muscle contractions at various locations in the body. The motor cortex also includes Area 6, which lies in front of Area 4 and is divided into the premotor area (or premotor cortex) and the supplementary motor area. The premotor cortex is believed to help regulate posture by dictating an optimal position to the motor cortex for any given movement. The supplementary motor area, for its part, seems to influence the planning and initiation of movements on the basis of past experience. The mere anticipation of a movement triggers neural transmissions in the supplementary motor area. Tumours in the Premotor and supplementary motor areas can be removed in most instances without any significant loss of function to the patient, though there may be some temporary weakness on the opposite side of the body if these areas are removed on the dominant side (i.e. in the majority of people (both right and left handed) the left half of the brain is dominant). However tumours in the primary motor cortex are difficult to remove without loss of function of the opposite side of the body. Any injury to the primary motor cortex is in most instances likely to lead to irreversible loss of function of the arm, hand , leg or face of the other side of the body.

If a glioma is present very close to the primary motor cortex then an 'Awake craniotomy' can be performed to minimise injury to this area. In this procedure the patient is awake (but pain free) during parts of the operation to remove the tumour. The surgeon and his team are able to talk to the patient while the operation is in progress. The surgeon stimulates various areas of the brain and looks for muscle contractions in the patient and sometimes correlates with electrical recordings obtained from specific muscle groups in the arm and leg. The patient is also asked to move the arm, hand, and leg repeatedly to observe for any decrease or loss of function while removal of the tumour is underway. In this way the surgeon is able to obtain a map of the opposite side of the body on the brain surface and is able to avoid injury to areas of the brain that he/she knows is responsible for movement. This is known as 'Cortical mapping'. This procedure is also performed when tumours that are very close to the speech / language areas of the brain have to be removed. In this case the patient is asked to repeat a variety of small simple tests (like naming objects, counting numbers etc) while the operation is underway to help prevent any injury to the speech & language areas of the brain. The risk of developing a neurological disability like weakness of arm / leg or difficulty in speech can be significantly reduced by performing this procedure where appropriate, but the risk can never be completely eliminated.

Gliadel

Carefully selected patients with a suspected malignant glioma on an MRI scan may be eligible for application of Gliadel wafers in the tumour cavity at the time of surgery to resect the tumour. A team of experts at the Multi disciplinary meeting will make the decision about the suitability for this treatment. If the patient is assessed and found suitable for this treatment then the Neurosurgeon will discuss this in detail with the patient and family at the initial consultation. Gliadel is a form of topical chemotherapy containing the drug called Carmustine (or BCNU), which has shown some benefit in clinical trials. NICE has approved this treatment in selected cases of newly diagnosed malignant glioma. 

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For further queries please email NBTCommunications@nbt.nhs.uk

The NHS Equality Delivery System (EDS) is designed to help NHS organisations improve equality performance and embed equality into mainstream NHS business so that we can provide a better service that meets the requirements of people from diverse communities. North Bristol NHS Trust has worked through the framework to provide evidence to support our grading.

This was used to devise our Equality Objectives.

NBT aims to work in partnership with a wide range of local communities including marginalised and seldom-heard groups.

The Trust works closely with other NHS partners to deliver the EDS and engages with them to gather feedback from communities on the quality of our service delivery.  This offers local stakeholders the opportunity to be fully involved in the process where important decisions are made about the planning, developing, commissioning, management and delivery of health services.

We also engage with staff to ensure they can help to plan, develop and manage working environments and activities that aim to improve their working lives.

At North Bristol NHS Trust, we respect and value the diversity of our workforce, patients, service users, relatives, carers and visitors and are committed to:

• Serving our community in a way that is appropriate, accessible and responsive
• Making best use of the range of talent and experience available within our workforce and potential workforce
• Ensuring that our legal obligations are fulfilled

It is recognised that individual and institutional discrimination obstruct the fundamental aims and objectives of NBT as a public service provider.

We are mainstreaming equality into all our functions and policies with the intention of achieving a fully inclusive organisation. A zero tolerance policy towards harassment and bullying towards anyone on Trust premises is endorsed throughout the organisation.

The Trust is committed to taking positive action for disabled people and has been awarded the Two Tick disability symbol. We have also signed up to the Mindful Employer charter as we are positive about mental health and take steps to increase awareness of mental health at work. For more details about the charter visit www.mindfulemployer.net

Equality & Diversity Committee

The Equality and Diversity Committee is the main forum through which progress on equality, diversity and human rights is managed. It’s principle function is to ensure that the Trust Board is informed of its legal duties and to promote the mainstreaming of equalities in all of our activities for patients, visitors and staff. It provides direction on equality for the Trust including strategies to develop consultation and involvement.

The Equality and Diversity Committee is made up of members of senior staff, including those from equality groups and others from the community.

Donations are welcome for supporting research into brain tumours at Bristol. Current work in progress is looking at a particular molecular marker in malignant glial tumours in collaboration with the University of Bristol.

Please make cheques payable to 'The Brain Box Fund' and send it to:

'The Brain Box Fund'
c/o Jackie Scholes
Secretary to Mr V Iyer
Consultant Neurosurgeon
Southmead Hosptial
Westbury-on-Trym
Bristol, BS10 5NB.

Please contact Jackie Scholes if you require any further information.

To contact the MDT co-ordinator for all MDTs with any queries about patient referrals please ring Rachael Eldridge on 0117 4140531. Working hours are Monday to Friday 8.00am to 4:00pm. Please leave a message on the answer machine outside these hours, or if the issue is more urgent please contact the On-call Neurosurgical Registrar at Southmead Hospital through the Switchboard (0117 950 5050) and ask for extension 45726.

If there are any questions about specific disease conditions please refer to 'Meet the Team' Page to contact the appropriate specialist.