Treatment of brain cancer requires a broad and multi-system approach, hence the need for specialist doctors from different fields. Israeli Neurosurgeons (brain surgeons) are responsible for surgeries, biopsies and any surgical procedure that is required, neurooncologists (brain cancer specialists) in Israel are the ones who perform chemotherapy, radiation, biological treatments and other advanced treatment methods, while radiosurgeons, using an advanced device called SBRT, are responsible for performing high-intensity focused radiation that treats the tumor site. A professional and precise combination of all of these gives the patient the best chance of recovery.
It is important to emphasize that the Neurosurgery and Oncology specialists of Tel Aviv Medical Clinic are considered the best specialists in Israel in the field of treatment of brain tumors and work in a multidisciplinary team in which all doctors decide how to properly treat the patient.
Tumors can appear anywhere in the brain, in some cases these are benign tumors, but there are also malignant tumors. Unlike tumors in other organs of the body, there are areas in the brain where the tumor cannot be completely removed and sometimes, even a low-grade tumor may become malignant and continue to grow. Cancerous tumors can form in the brain for two reasons:
- Primary tumors that originate in brain cells.
- Secondary tumors (metastases) that come from another organ in the body. Most brain tumors are secondary and their incidence is 10 times higher than primary tumors.
Primary and metastatic brain tumors
The most common primary brain tumors are glioma, medulloblastoma, meningioma, hypophyseal adenoma, and acoustic neuroma:
- Glioma: Low-grade glioma, such as astrocytoma, is more common in young adults, with an annual incidence of 5.4 cases per 100,000. The five-year survival rate after surgery is 0-25%, with a median survival of 6-8 years. High-grade glioma, such as anaplastic astrocytoma or glioblastoma multiforme, is more common in people aged 40–50 years, with a 5-year survival rate of 2–16% after treatment including resection and radiation.
- Medulloblastoma: A tumor belonging to the group of primitive neuroectodermal tumors, which accounts for 7–8% of all brain tumors in adults and about 30% of brain tumors in children. The tumor can occur at any age, but is more common in children (3/4 of cases are discovered in children, average age 9 years). Approximately 350 new cases of medulloblastomas are diagnosed each year in the United States, with 1.5–2 cases per 100,000. The tumor is very aggressive, metastasizes in 10-20% of cases, and the disease usually recurs about two years after treatment. The average five-year survival is 60-80%, and depends on several factors such as the patient’s age, the time of recurrence, and the response to treatment.
- Pituitary gland tumors: Usually benign, with a wide range of clinical manifestations due to changes in the production of gland hormones. They account for about 10-25% of all brain tumors. The mortality rate is very low, due to the high effectiveness of surgical treatments and hormonal treatments.
- Meningioma: A benign tumor with an annual incidence rate of about two cases per 100,000 in the United States, more common in women than in men, grows slowly and can cause many complications and even death. The five-year survival rate is 73-94%. Incidence increases with age and is very common in African countries.
Primary tumors must be distinguished from metastatic tumors, which constitute the majority of brain tumors. The most common tumors that metastasize to the brain are lung cancer (17%), kidney cancer (10.5%), breast cancer (5.2%), and melanoma (8%). In the United States, approximately 150,000 cases of metastatic brain tumors are diagnosed each year in 10–40% of patients with some extracerebral tumor. Autopsies performed on patients who died from various tumors have shown that intracranial metastases were found in 18–24% of patients.
Classification of tumors
Tumor classification is based on malignancy grade, cellular origin, and extent of neurological involvement. Malignant tumors grow very quickly, penetrate the surrounding tissues and cause destruction and disruption of brain function. In contrast, benign tumors grow slowly and do not penetrate the surrounding tissues. However, a benign tumor located in a critical area of the brain may still pose a life-threatening risk, and is therefore no different from a malignant tumor. Since the brain is located inside a closed box, each process takes place accompanied by pressure on healthy tissues and disruption of the drainage of spinal fluid, and ultimately, creates disruption of various functions of the brain.
Depending on the extent of the damage, two groups are distinguished:
- Tumors located above the tentorium (Supratentorial): constitute 2/3 of brain tumors in adults.
- Infratentorial tumors: These account for 2/3 of brain tumors in children.
Brain Tumor Symptoms
Israel is a global leader in advanced neurosurgical and oncological care. At our leading medical centers in Tel Aviv, patients receive expert diagnosis and customized treatment plans from some of the country’s top specialists.
The first signs appear depending on the rate of tumor development, its penetration into nearby tissues and degree of pressure on areas of the brain that include vital centers.
In most cases, the signs are not unique to brain tumors and include headaches, nausea, vomiting, general weakness, ataxia and changes in coordination. In many cases, the first signs that appear can be a decrease in visual acuity, hearing, speech disorders or sensory changes in the extremities. In a more advanced stage, cognitive impairment, seizures and a change in the level of consciousness can appear.
In rare cases, there is a sudden onset of stroke-like symptoms due to intracranial hemorrhage, especially in metastases of lung tumors, melanoma, and choriocarcinoma, or a sudden onset of headache, fainting, altered consciousness, vomiting, ataxia, or even sudden death due to obstruction of the drainage of the third ventricle by an intraventricular tumor. In addition, a sharp increase in intracranial pressure may cause a life-threatening condition, such as herniation.
There are characteristic signs depending on the location of the tumor:
- Changes in mental status, memory loss, apathy, and prolonged sleep can indicate a tumor in the frontal lobe.
- When the tumor affects the temporal region, emotional changes, behavioral disorders, and depersonalization may occur.
- Acoustic neuroma is accompanied by progressive hearing loss, tinnitus, and imbalance.
- Posterior fossa tumors are accompanied by irritability, ataxia, headache, and vomiting.
- Tumors above the cerebellum in children are usually accompanied by seizures, hemiparesis, speech disorders, and decreased hearing.
Headache
Although it is commonly thought that headache is the main complaint in patients with brain tumors, in reality the pain appears in more advanced stages of the disease, and only in 50% of patients will headache be a serious problem.
A detailed history of headache should be taken, emphasizing the following details:
- Headache is the main complaint in children with intracerebral tumors.
- Most common in patients with tumors in the posterior fossa.
- Most patients will suffer from nonspecific headaches or tension headaches.
- A red flag would be a change in the nature of the headaches in people with chronic headaches or the appearance of new pain in older or elderly people.
- The location of the pain usually indicates the affected side, but not the exact location of the brain tumor.
- The headache is usually worse in the morning and may resolve during the day, and is sometimes accompanied by vomiting or nausea, with worsening upon standing up from a lying position or with the Valsalva maneuver.
Seizures
Seizures, often the first sign of a brain tumor, are typically focal or generalized. Jacksonian pattern seizures are typical, in which seizures begin as focal seizures in one limb and spread throughout the body to become generalized seizures.
Seizures appear as the first sign of a brain tumor in 20-40% of patients. While metastatic brain tumors are more common than primary brain tumors, the chance of developing seizures in metastatic tumors is less than 10%.
Treatment for brain tumors in Israel – Tel Aviv Medical Clinic
Brain tumor treatments include surgery, chemotherapy, radiation, symptomatic treatment with steroids or anticonvulsants, combinations of the various treatments and immunotherapy for brain tumors. For these reasons, patients from around the world come to Israel for cutting-edge brain cancer care.
Surgical treatment in Israel
If the tumor can be resected, surgery is the preferred treatment. It is generally accepted to consider surgical intervention for primary tumors, but there is a place for surgery also for metastatic tumors in the brain, even when there are multiple metastases. Surgical treatment has been shown to have a great advantage in terms of survival and quality of life among patients with metastatic brain tumors who have undergone early diagnosis and were found to be suitable in terms of age, extracerebral diseases, and functional status.
Since not every surgery in a patient with metastatic brain tumors can bring benefit and improve prognosis, the situation must be carefully examined before making the decision, and several criteria must be taken into account. Indicators that will support surgery include:
- Patient age less than 65 years.
- Karnofsky performance status scale score greater than 70.
- Single brain tumor.
- Absence of metastases outside the nervous system.
- Tumor size less than 3 centimeters.
- Easy access to the tumor.
- Control for extracranial disease.
- No leptomeningeal involvement.
To assess prognosis, the Radiation Treatment Oncology Group (RTOG) in Israel has classified patients with metastatic brain tumors into three groups:
- The group with the best prognosis, which includes approximately 16-20% of all patients with brain tumors, includes patients younger than 65 years of age, without evidence of extra-nervous system metastases, and with a Karnofsky performance status score greater than 70. In this group, survival after treatment is approximately 7.7 months.
- The group with the worst prognosis, which includes approximately 10-15% of all patients with brain tumors, includes patients with a Karnofsky performance status score less than 70. In this group, survival after treatment is approximately 2.3 months.
- The remaining patients belong to the intermediate group with a survival after treatment of approximately 4.5 months.
The main surgical approach is craniotomy with removal of the tumor or part of it. If the tumor cannot be removed in its entirety, it is necessary to reduce pressure on the vital area or on the area that leads to seizures. It is also necessary to improve fluid drainage. Before surgery, preparation is necessary, which includes the administration of high-dose steroids, such as Dexacort (Dexamethasone) up to 40 milligrams, in order to prevent the development of cerebral edema and improve the postoperative course.
Radiation therapy in Israel – Tel Aviv Medical Clinic
Brain metastases – Radiation therapy treatment in Israel
Radiation has been used for more than 30 years as an alternative to surgery, mainly for tumors such as meningioma and acoustic neuroma. In the last 15 years, radiation therapy has become the treatment of choice for metastatic brain tumors. Radiation therapy includes whole-brain radiotherapy or stereotactic radiosurgery.
Whole-brain radiotherapy is used primarily for tumors that cannot be removed, such as large tumors with invasion of vital tissues, widespread brain metastases, a Karnofsky performance status score of less than 70, and a survival of less than 3 months. The effectiveness of treatment depends on the histology of the tumor. Small-cell lung tumors and germ-cell tumors are very sensitive to radiation. Other lung tumors and breast tumors are less sensitive, and melanoma and kidney tumors are not sensitive at all. Postoperative radiation therapy is indicated to reduce the risk of disease recurrence. It should be noted that radiation therapy does not improve prognosis and is accompanied by side effects, such as hair loss, nausea, vomiting, memory problems, and decreased libido.
Stereotactic radiosurgery in Israel allows radiation to be directed more precisely and carefully at the tumor. The median survival after treatment is approximately 11 months. As a result of cerebral edema, approximately 7-10% of patients develop an acute reaction within 2 weeks after treatment. The reaction includes nausea, headache, vomiting, deterioration in neurological symptoms, and seizures.
What types of Radiotherapy are there in Israel?
- SBRT with 4D CT (Stereotactic Radiofrequency Surgery)
- SIRT (selective internal radiotherapy) – liver cancer treatment
- IORT (intraoperative radiotherapy INTRABEAM)
- IGRT (3D confocal radiotherapy)
Why do patients choose to undergo Radiotherapy in Israel?
The progress of technology has not bypassed medicine and today we can proudly say that Israel is in the top countries where it is very safe and without unnecessary side effects to undergo irradiation of any organ without harming other organs and this became possible thanks to the new technologies.
One of the biggest challenges in modern oncology is delivering radiation precisely to cancerous tissue while protecting surrounding healthy structures. At Tel Aviv Medical Clinic, we address this challenge with two of the most advanced radiotherapy systems in the world: Elekta Unity MR-Linac and the ETHOS AI-powered Adaptive Radiotherapy System.
- Elekta Unity – Real-Time MRI-Guided Radiation Therapy
The Elekta Unity system represents a breakthrough in personalized radiation treatment. Unlike conventional linear accelerators that rely on X-ray imaging, Unity integrates real-time magnetic resonance imaging (MRI), allowing for ultra-precise visualization of tumors during every session.
Thanks to its sub-millimeter resolution and superior soft-tissue contrast, the Unity system enables continuous adjustment of the radiation plan to match daily variations in tumor size, shape, and position, as well as surrounding anatomy. This adaptability ensures optimal dose delivery exactly where it’s needed — while dramatically reducing exposure to nearby healthy tissue.
These capabilities make Unity especially valuable in treating difficult, anatomically complex tumors, and in pediatric cases, where minimizing the number of treatment sessions under anesthesia can prevent long-term complications.
- ETHOS – Adaptive Radiotherapy Powered by Artificial Intelligence
The ETHOS system, newly installed at our center, introduces an entirely new era of AI-assisted cancer care. As the first linear accelerator of its kind, ETHOS uses a high-resolution 3D X-ray imaging system to scan the patient before each session and dynamically adapt the radiation treatment plan in real-time.
By identifying anatomical shifts from day to day, ETHOS can reshape the dose distribution with exceptional accuracy — significantly reducing the safety margins traditionally used to compensate for organ movement. This means a lower dose to healthy organs, fewer side effects, and shorter treatment regimens.
Crucially, ETHOS enables higher daily dosing to the tumor, improving the biological effectiveness of treatment without increasing risk to surrounding tissues. It also allows more patients to return to their normal lives sooner — with less disruption and better outcomes.
Setting a New Global Standard in Cancer Care
With both the Unity and ETHOS systems fully operational, Tel Aviv Medical Clinic’s Radiotherapy Institute now stands as one of the most technologically advanced cancer treatment centers worldwide. Our center offers a full spectrum of radiotherapy options, allowing us to customize each patient’s care plan with unparalleled precision and safety.
By integrating cutting-edge imaging, artificial intelligence, and adaptive treatment planning, we are redefining what’s possible in radiotherapy — offering new hope, improved outcomes, and fewer side effects for cancer patients in Israel and beyond.
The role of steroids in the treatment of brain tumors
Steroids significantly reduce signs associated with cerebral edema, with Dexacort being the preferred steroid. The main mechanisms by which steroids work are stabilization of brain cell membranes, reduction of edema, and reduction of intracranial pressure. Steroids also reduce the blood supply within tumors. The main effects of treatment are improvement in headache, decreased seizure frequency, improvement in motor functions, and improvement in cognition. Several types of tumors, such as metastatic brain tumors, have high levels of steroid receptors, and therefore respond better to treatment. In contrast, tumors such as meningiomas do not respond well due to low receptor levels.
It is common to start treatment with Dexacort in high doses of up to 40 milligrams before surgical treatment or radiation therapy, and it is also common to continue treatment in the postoperative period, with a gradual decrease in doses. In urgent situations, such as when there is a risk of rupture or the need to stabilize the patient’s condition before urgent brain surgery, Dexacort is used in high doses of up to 100 milligrams per day. Several reports indicate that high doses of Dexacort of up to 60-100 milligrams per day can improve the general condition of terminally ill oncological patients. Improvement in daily functioning, general weakness, pain and mood have been mainly reported.
Dosage for adults: You can start with 4-10 milligrams per day intravenously and continue until improvement, and then switch to the lowest effective dose – 4-16 milligrams per day orally, intramuscularly or intravenously.
Dosage for children: 0.25-0.5 milligrams per kilogram per day administered orally, intramuscularly, or intravenously.
Principles of Anticonvulsant Therapy
Patients who develop seizures can be treated with anticonvulsants. First-line drugs, such as Carbamazepine, Valproic acid, or Phenytoin, are usually used. There is no clinical evidence that shows a preference for one drug over another.
Treatment should be started at low doses while monitoring the drug level in the blood, in order to reduce the toxic effects of the drugs.
If the patient is being treated with chemotherapy, drugs such as Levetiracetam should be considered. Studies have shown that Levetiracetam was as effective as Phenytoin in preventing seizures in patients who have undergone brain surgery, with fewer unwanted effects. It has been reported that treatment with Levetiracetam resulted in a reduction of up to 48.3% in the frequency of seizure attacks and a change in the timing and nature of seizures (more simple seizures).
Treatment with a single drug should be preferred over treatment with multiple drugs, in order to reduce drug interactions. In the event of a lack of improvement, the dose of the drug should be gradually increased, while monitoring the level of the drug in the blood. Only if there is no benefit at the optimal dose should another drug be chosen.
Prophylactic treatment with anticonvulsants
One of the fundamental questions regarding the treatment of a patient who has recently been diagnosed with a primary or metastatic brain tumor and has not yet developed seizures is whether prophylactic treatment with anticonvulsants is necessary. Patients with primary brain tumors have a very low risk of developing seizures. This risk is especially low in patients with tumors located below the meninges, and therefore it is not recommended to give prophylactic treatment for seizures to these patients. Patients with tumors located above the meninges often need to be given prophylactic treatment due to a high risk of developing seizures or due to anticipated surgeries.
The following situations have a high risk of developing seizures:
- Involvement of areas that are particularly at risk for seizures, such as the motor cortex.
- Tumors that frequently invade the cerebral cortex, such as melanomas.
- Metastasis that invades both the brain and the thin meninges.
A meta-analysis of five studies examining the use of anticonvulsants for prophylaxis in patients without a history of seizures did not provide additional information regarding the efficacy of treatment in these patients. Prophylaxis was not shown to reduce the frequency of first seizures, and there was an increase in treatment-related complications among those receiving prophylaxis (20-40% of patients) compared with those not receiving prophylaxis (7%). In six studies, serious adverse events were reported in 23.8% (5-38%) of patients receiving prophylaxis, leading to discontinuation of anticonvulsant therapy. Complications included rash (14%), nausea and vomiting (5%), encephalopathy (5%), bone marrow suppression (3%), ataxia, and worsening liver function [7]. A Cochrane review found no difference between placebo and anticonvulsant therapy such as carbamazepine, valproic acid or phenytoin for preventing a first seizure. Another study initiated prophylactic treatment in 100 patients with newly diagnosed brain tumors, 40 with primary brain tumors and 60 with metastatic tumors. 26% of patients developed seizures while receiving prophylactic anticonvulsant therapy regardless of tumor type, primary or metastatic. The results of this study are limited by both the small number of patients and the fact that 45% of patients had low blood levels of the drugs.
Medications and Dosages
Levetiracetam:
- Adult dosage: 1,000 milligrams per day orally, divided into two doses, with the possibility of increasing to a dose of 3,000 milligrams per day.
- Pediatric dosage: For partial onset seizures in children aged 4-15 years, you can start at 20 milligrams per kilogram per day orally, with the dose increasing as needed up to 60 milligrams per kilogram per day. For children older than 15 years, the doses are the same as for adults. For tonic–clonic seizures, you can start at 10 milligrams per kilogram per day orally, with the dose increasing as needed up to 20 milligrams per kilogram for two weeks, but not to exceed 30 milligrams per kilogram per day.
Phenytoin: Effective in various types of seizures.
- Adult dosage: Can be started at 15 milligrams per kilogram (1,000 milligrams) orally or intravenously, divided into two to three doses. Maintenance dose of 5 milligrams per kilogram per day (300 milligrams) orally or intravenously, while monitoring the drug level in the blood.
- Pediatric dosage: Same as adult dosage. Can be given in four doses per day.
Carbamazepine: Effective in various types of seizures.
- Adult dosage: 200-600 milligrams orally, divided into three to four doses per day. The drug level in the blood should be monitored.
- Pediatric dosage: 15-25 milligrams per kilogram orally, divided into three to four doses per day.
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