Brain cancer treatment in Germany: diagnosis, therapy and surgery

Brain cancer treatment in Germany means an exceptional professional level of medical personnel, innovative technologies and affordable prices.

Neoplasms of the brain and spinal cord are very demanding for technical equipment, so the survival rate in the developing countries is critically low.

For example, patients with the glioblastoma multiforme stage IV survive only a few months after diagnosis.

Tumors of the central nervous system may be primary or secondary (metastatic).

The primary ones arise from the brain cells and make up about 20% of all cases. The rest are metastases from other organs (lungs, bowel, kidney, breast cancer).

Each type of cancer has its own molecular and genetic characteristics and requires a unique approach to treatment. Most often we diagnose gliomas (50%), meningiomas (20%) and pituitary adenomas (15%).

The disease is very rare affecting about 0.7% of people at some point of their life. Therefore, classic symptoms of intracranial neoplasm – such as headache, blurred vision, nausea - we rarely associate with deadly disease.

Meanwhile, persistent chronic headache is the leading symptom of brain tumors. Pain is present in almost half of the patients. This symptom, which is caused by the increasing pressure of the tumor on surrounding tissue, can't be ignored.

Early diagnosis of brain cancer is the key

Regardless of the type of neoplasm, the earlier an accurate diagnosis has been made, the higher the chances of a complete cure. The longer you can live. The lower the risk of severe neurologic deficits after treatment.

Diagnostic options in German cancer clinics:

1. MRI: magnetic resonance scanning allows obtaining detailed 3D images of soft tissues. German radiologists use MR-angiography, MR-venography, MR perfusion imaging, MR-spectroscopy and functional studies (fMRI).
2. CT: computed tomography of the brain and spine column helps assessing the condition of the bone structures adjacent to the tumor.
3. PET: the positron emission tomography method using radioactive sugar (FDG) expands diagnostic opportunities of other imaging studies.
4. Chest X-ray: secondary CNS tumors are often the result of metastatic lung cancer (stage IV), which wasn’t detected in time.
5. Tumor biopsy: a stereotaxic (needle) biopsy or open procedure called craniotomy is required for genetic tests and choosing further treatment.
6. Lumbar puncture: the search for cancer cells in cerebrospinal fluid (CSF) is especially important in such cases as primary CNS lymphoma.
7. Urinalysis and blood tests: these lab tests are used in the planning of treatment, before and after surgery, during chemotherapy.

Top-12 best brain cancer clinics in Germany

If the disease is not treated aggressively and in a timely manner, some cancers kill a patient in two or three months after the diagnosis. Modern surgical equipment, high-precision radiation therapy and the latest drugs allow German cancer clinics to demonstrate surprisingly high survival rates.

In some cases, you can achieve complete cure of the disease and return to normal life. You probably heard such stories from friends, neighbors or doctors. Even in the most hopeless situations, German oncologists ask people not to give up and fight for their relatives to the last opportunity.

Recently, we heard an inspirational story of the brave 4-year-old Australian girl Alexia Keeping. She was diagnosed with a diffuse brain stem glioma (DIPG).

Surgeons could not remove the tumor. Her prognosis was grim: the two-year survival rate for this type of disease is 10%, and the five-year survival rate hardly exceeds 1%. Starting with a slight strabismus, neurologic symptoms quickly progressed. Motor and cognitive functions - everything collapsed. High dose radiation therapy was ineffective. Parents gathered 90 thousand euros, and went to Germany. There the girl underwent an intensive course of radiation and chemo, immunotherapy and hyperthermia.

The illness began to recede, giving the child another chance.

Cancer diagnosis and treatment abroad is a very expensive and requires mobilizing all available resources. Numerous trips take money and time that patients do not have. Therefore it is extremely important to study the profile of the medical institution and choose only those clinics that offer maximum chances and opportunities.

Best centers for brain cancer treatment in Germany:

1. Universitätsklinikum Erlangen
2. Universitätsklinikum Magdeburg
3. Krankenhaus Nordwest Frankfurt am Main
4. Universitätsklinikum Koln
5. Universitätsklinikum Düsseldorf
6. Universitätsklinikum RWTH Aachen
7. Universitätsklinikum Essen
8. Universitätsklinikum Jena
9. Nord Klinikum Allianz Bremen
10. Charité – Universitätsmedizin Berlin
11. Asklepios Kliniken
12. Helios Kliniken

Cost of brain cancer treatment in Germany

The effectiveness of therapy and prognosis depend largely on the correct and timely diagnosis. Consultation of the highest class German specialist (neurosurgeon, oncologist, and neurologist) will cost around 500-600 euros. After contacting the clinic, doctors will ask you to undergo some diagnostic tests. This can be required even if you have already passed the tests at home (for recheck).



A biopsy of the tumor will cost 2000 euros, a blood test and tests for oncomarkers around 300-500 euros. Magnetic resonance imaging (MRI) starts from 1000 euros for one area, PET / CT - from 2300 euros, scintigraphy - from 850 euros.

When it comes to treatment, the cost of chemotherapy with modern drugs will cost between 2 and 4 thousand euros for 1 course. Craniotomy can cost about 25 thousand, removal of the tumor (glioma, glioblastoma) - from 20 thousand, and subsequent radiation therapy – up to 12 thousand euros.

Brain cancer treatment options in Germany

After this terrible diagnosis it is recommended to visit several specialists and get a second opinion in different clinics. Each case requires a unique approach. The doctor's recommendations depend on the features of the disease (type, stage, location), the overall health and age of the patient.

Surgical treatment of brain and spinal tumors

Surgical resection is the main option, and usually the first step towards recovery. Surgery allows removing the maximum amount of tumor tissue and collecting samples for lab testing. For inoperable cases, surgical interventions can alleviate the symptoms of the disease and prevent complications.

Surgery in combination with radiotherapy is the current “gold standard” for glioma, astrocytoma, ependymoma, meningioma and other localized tumors in the early stage.

Sometimes this is enough for a complete cure. If the cancer has penetrated surrounding tissues and the vital areas of the brain, the surgery will not cure it completely. Surgery is not effective enough for lymphoma.

But even in these situations, a successful combination of chemotherapy, immunotherapy and radiation can significantly prolong life and improve health.

Craniotomy

This surgery is the removal of a small fragment of the skull to gain access to the tumor and surrounding tissues. An MRI or CT scan is required before the surgery to accurately determine the borders of the lesion.

Thanks to new technologies, sometimes a patient is awakened during surgery to evaluate neurological functions (memory, speech, movement). When access is ready, the neurosurgeon can remove it with a scalpel or vacuum device. Sometimes doctors use ultrasound that destroys the neoplasm before extraction.

During surgery, German neurosurgeons use fluorescence microscopes, ultrasound scanners and even compact tomographs. Intraoperative visualization allows doctor to determine the location and size of the tumor, clearing the brain of cancer cells. To minimize the risk to vital nervous structures, doctors extensively use cortical mapping, functional magnetic resonance imaging, fluorescent biomarkers.

After successful removal, the skull fragment is attached using titanium plates or screws. Don’t worry. These material is biocompatible and 100% safe. MR-scanners don’t react to titanium, so you can safely get MRI after treatment. During first few days after the procedure you may require drainage – a special plastic tube that removes excess cerebrospinal fluid. A follow-up MR or CT scan is performed in a couple of days to confirm the success of the surgical procedure,. If everything goes according to plan, you may be discharged from the hospital for further therapy in 3-7 days.

Full recovery takes several weeks.

In some cases, a safe and less traumatic procedure called endoscopic craniotomy can be used. This surgery requires a tiny opening in the skull to insert a flexible probe with a camera and miniature instruments on the end.

Unfortunately, this method is not suitable for removing large tumors.

Shunt procedure

This type of surgery may be required to normalize intracranial pressure. Growing neoplasm blocks the outflow of the cerebrospinal fluid, headaches, lethargy, nausea develop. Increased intracranial pressure may become life-threatening.



To remove excess cerebrospinal fluid, German neurosurgeons perform ventriculoperitoneal (VP) or ventriculoatrial (VA) shunting. In the first case, the liquor is transferred into the peritoneal cavity, in the VA – into the heart through the veins.

Such kind of intervention may be required for delivery of chemotherapy directly to the brain. In these situations surgeons implant the Ommaya reservoir under the scalp. The reservoir allows injecting drugs and taking samples of the cerebrospinal fluid. The shunt procedure has different purposes; therefore shunts may be temporary or permanent. This surgical intervention takes about an hour, and in most cases is well tolerated. After the procedure you can expect a rapid improvement of symptoms.

You should know that a long-term treatment requires periodic shunt replacements. The problem is that the old shunt can eventually get clogged. In addition, after this procedure patients should be monitored by neurologist and neurosurgeon.

Brain tumor cryosurgery

Unlike the United States, where cryosurgery develops primarily in the direction of treating skin, prostate, cervical cancer and retinoblastoma, German cancer clinics successfully apply this innovative method to spinal and brain tumors. Cryosurgery, also known as cryotherapy, is based on the use of extremely low temperatures to destroy malignant cells.

The main surgeon's weapon in these cases is liquid gas (nitrogen, argon). Thanks to modern intraoperative visualization, the cryoprobe is injected into the brain very accurately, without causing excessive damage to surrounding healthy tissues.

This method is largely experimental, but it is useful in the treatment of primary and metastatic neoplasms, especially in the functionally active areas of the brain.

Brain cancer radiotherapy in Germany

Thanks to the use of modern linear accelerators, irradiation has become one of the most effective and popular forms of treatment for CNS neoplasms. In most cases, surgery is the first stage to remove visible tumors. But some neoplasms are able to penetrate into the surrounding tissues without being seen on MRI and directly by neurosurgeon during the operation.

Not all tumors can be completely removed surgically, but even after the successful procedure there is a remained tissue capable of giving rise to new cancer.

Radiation therapy (Strahlentherapie) solves the problem in two ways.

External beam radiation therapy is the "shelling" of malignant cells with gamma rays or accelerated particles from an external source. Internal radiation (called brachytherapy) means the introduction of a radioisotope directly into the tumor.

Classification of external radiotherapy:

1. Irradiation of the "extended tumor site" is widely used in treatment of craniopharyngioma, ependymoma, low- and high-grade gliomas
2. Whole brain irradiation, including meninges: prophylactically for systemic malignant diseases (leukemia), secondary (metastatic) tumors
3. Total irradiation of the entire CNS with cerebrospinal fluid: medulloblastoma, other neoplasms that spread through the cerebrospinal fluid.

The goals of radiotherapy are to enchance surgical treatment or replace it in cases of inoperable cancer. Usually German radiologists recommend irradiation of the "extended tumor site" (erweiterte Tumorregion), including areas of possible infiltration.

During so-called external irradiation, the patient is placed in a virtual 3D coordinate system, while computer focuses the rays directly on the tumor. Each procedure lasts from a few seconds to several minutes.

To minimize the damage to healthy tissues, the patient is usually fixed with special straps and mask (modern computers do not require fixation of the head).

Modern types of external radiotherapy:

- Image guided Radiotherapy (Bildgeführte Strahlentherapie)
- Radiotherapy of modulated intensity (intensitätsmodulierte Strahlentherapie)
- 3D-conformal radiotherapy (3-dimensional konformale Strahlentherapie)
- Proton therapy (Protonentherapie) etc.

The leading role in the planning belongs to diagnostic imaging. The results of computed tomography, MRI and PET allow doctor to differentiate tumor and normal tissue.

Stereotactic Radiosurgery (SRS)

The innovative method of stereotactic radiosurgery and radiotherapy (stereotaktische Radiotherapie) is based on the high-precision delivery of radiation to the tumor in one or more sessions. Radiosurgery in Germany is extensively used to treat inoperable malignant neoplasms located in vital areas of the brain.

One of the options is the famous Gamma knife. This technology uses the simultaneous irradiation of the target with hundreds of rays from different angles. Each of them is weak and does not have a serious damaging effect on the healthy tissue, but at the point of their convergence the tumor literally "burns up".

Another approach is the mobile linear accelerator (called CyberKnife). This machine moves around the head and irradiates the tumor from different sides. Thanks to smart machines, some clinics stopped fixing the patient's head – computers control the movements and correct the direction automatically.

What dose of radiation is required?

The dose required to destroy the tumor depends on the sensitivity. For high-grade glioma, a dose of up to 60 grays may be required, for low-grade gliomas - 45 Gy. Secondary tumors usually require irradiating the entire brain with a dose of up to 30 Gy. Ependymoma requires at least 55 Gy, preventive irradiation in leukemia – 12 Gy.

After the end of the therapy, a medical examination is required. This is the best time to discuss therapeutic result, side effects and future plans.

Just be sure: to prevent radiation damage to normal tissue, radiologists will use the minimum effective dose of radiation and deliver radiation exactly to the target.

Possible consequences of brain cancer radiotherapy:

• Hair loss
• Weakness and fatigue
• Worsening of the symptoms
• Hormonal imbalance
• Thinking and memory problems
• Development of other cancers

Long-term side effects of central nervous system irradiation are more common in children. As their brain continues to grow, it is more sensitive to radiation damage.

Brain cancer chemotherapy in Germany

"Chemo" is a highly toxic drug therapy that destroys tumor cells or at least prevents their further reproduction. Depending on the cancer type, chemotherapeutic agents are given alone or in combination. They are administered intravenously (IV), orally or directly into the CSF (for example, through the Ommaya reservoir). The delivery method depends on whether the drug molecule can cross the blood-brain barrier.

"Chemo" is especially useful in rapidly growing tumors. Some cancers (medulloblastoma, lymphoma) respond better to treatment. Others, such as tumors of the spine cord, are much more resistant to traditional chemotherapeutical agents.

Since tumor cells do not fundamentally differ from normal ones in terms of growth and proliferation, fast-growing healthy tissues suffer from side effects (blood). The dose of chemotherapy is limited only by the toxicity. When the risk of side effects becomes unacceptable, you need to choose other treatment options.

Modern drugs in neurooncology

Most chemotherapeutic drugs damage the genetic material (DNA) of cancer cells. These are nitrosoureas (carmustine, lomustine), temozolomide, procarbazine. Other drugs interfere with the metabolism of tumor cells, especially the formation of genetic structures. This is methotrexate, cytarabine.

Inhibitors of topoisomerase I (topotecan) and topoisomerase II (etoposide) play a secondary role in brain cancer chemotherapy. German oncologists usually combine them with other pharmacotherapeutic groups.

Vincristine is widely used in neurooncology, especially in the context of polychemotherapy of high-grade glioma (glioblastoma) and lymphoma.

Consequences of chemotherapy

Among the most common side effects of “chemo”: nausea, hair loss, weakness and fatigue, poor appetite, immune suppression, bleeding.

Some drugs (vincristine) damage the peripheral nerves. Others cause hormonal imbalance and increase the risk of developing new cancers in future.

Targeted therapy of the brain and spinal cord tumors

High-specific targeted drugs appeared recently, when scientists uncovered the secrets of cellular physiology. These agents are aimed at specific molecules and mutant genes that distinguish cancer cells from healthy ones. The use of targeted drugs against the brain and spinal cord tumors is limited. Occasionally German doctors prescribe bevacizumab (Avastin) and everolimus (Certican) in the complex therapy of some cancers.

What is bevacizumab (Avastin)?

This is a specific immune system protein, aimed against the growth factor of the vascular endothelium (VEGF). Bevacizumab disrupts angiogenesis - the ability to develop a vasculature. It is prescribed for some types of glioma, if the tumor did not respond to previous therapy or recurred. Applying bevacizumab in different combinations, German doctors can significantly prolong life of people with metastatic brain cancer (stage IV) and reduce the need for other potentially toxic drugs.



Most common side effects include: hypertension, weakness, fatigue, bleeding, loss of appetite, leukopenia. Heart problems, thrombosis, ulcers, perforations of the intestine are less common complications.

The drug is administered intravenously every 2 weeks.

What is everolimus (Certican)?

This drug blocks the cellular protein mTOR, disrupting the growth and division of malignant cells. It is used in certain types of inoperable astrocytomas (subependymal Riesenzellastrozytome). Due to a decrease in the tumor size such patients live longer. Among side effects: ulceration of the mucous membranes of the mouth, weakness, hyperglycemia, elevated cholesterol, skin rash, and swelling.

Obvious advantage of the Everolimus is a very convenient dosage form - tablets for oral administration (prescribed once a day).

German science defeats brain cancer

Almost half a million new cases of oncological diseases are diagnosed in Germany each year. This is a fairly strong argument for the government and private companies to invest more funds and resources in the development of oncology.

German scientists have presented to the world hundreds of amazing discoveries in this field. Discovering the role of the human papillomavirus (HPV) in the development of cervical cancer. Or inventing fluorescence microscopy for cancer surgery. A real outpost in this war is the German Cancer Research Center (Deutsches Krebsforschungszentrum). This is one of the largest biomedical research centers in Europe. More than 1300 employees, 90 research groups, and hundreds of projects.

Germany is the home of technologies that probably will save your life tomorrow. Technologies that defeat brain cancer and other deadly diseases of XXI century.

«Brain tumor survivors: don't become hopelessly discouraged if you are experiencing deficits. You in a war and you are bound to have a few battle wounds» - Rachel Grady, American film director.

© Analytical reviews and oncology news by K. Mokanov: clinical pharmacist and professional medical translator