Download brain metastases

BRAIN METASTASES
FREQUENCY
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The most common intracranial tumors among
adults occurring up to 10 times as frequently as
primary tumors
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The most frequent metastatic neurologic
complication of systemic cancer
- 20-40% of adult cancer patients
- 6-10% of pediatric group patients
PATHOPHYSIOLOGY
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The most common metastases – intraparenchymal
(may also involve the cranial nerves, the blood vessels (including the
dural sinuses), the dura, the leptomeninges, the inner table of the skull)
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80% cerebral hemispheres
15% cerebellum
5% brain stem
* Single (1/4-1/3 of patients; colon, breast, renal cell carcinoma) or
multiple (malignant melanoma, lung cancer)
PRIMARY TUMOR TYPES
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Lung
Breast
Melanoma
Colon
Other known primary
Unknown primary
48%
15%
9%
5%
13%
11%
Patients less than 21 years old – mainly sarcomas
(osteogenic sarcoma, rhabdomyosarcoma, Ewing’s sarcoma) and
germ cell tumors
CLINICAL MANIFESTATION
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> 80% of brain metastases are discovered
after the diagnosis of systemic cancer
Progressive neurologic dysfunction is related to the
gradually expanding tumor mass, associated edema
or to the development of obstructive hydrocephalus.
A more acute onset may occur after a seizure, a hemorrhage
into a metastasis, an invasion or compression of an artery by
tumor, or a stroke caused by embolization of tumor cells.
SYMPTOMS
* Headache (42%) – more common in patients with multiple metastases
in the posterior fossa;
may become more intense with postural changes or straining;
may be associated with other symptoms of increased intracranial pressure –
vomiting, vissual blurring, confusion, syncope
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Focal weakness (27%)
Mental change (31%) – memory problems, mood or personality
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changes, cognitive dysfunction
Seizure – usually focal or secondary generalized after a focal onset
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Gait ataxia
Sensory disturbance
Speech problems
SIGNS
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Altered mental status
Hemiparesis
Hemisensory loss
Papilledema
Gait ataxia
Aphasia
Visual field cut
Depressed level of consciousness
DIAGNOSIS
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Contrast enhanced MRI
- presence of multiple lesions
- gray-white junction location
- lesser degree of margin irregularity
- associated vasogenic edema (not all metastatic tumors)
** enables to differentiate among other conditions (primary
brain tumors, abscesses, cerebral infarcts, hemorrhages,
demyelinating disease)
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CT
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Searching for primary focus (chest radiographs, CT or MRI of the
abdomen)
TREATMENT
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Corticosteroids (dexamethasone)
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Surgery
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Radiotherapy
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Radiosurgery
Brachytherapy
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Chemotherapy
SURGERY
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Therapeutic and diagnostic
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Surgical considerations are based mainly on
accessibility and resectability
* superiority of surgery and whole-brain rth
to whole-brain rth alone in survival, local
tumor control and neurologic performance!
SURGERY
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Prognostic factors:
- status of systemic disease
- extent of neurologic deficit
- time between the first diagnosis of cancer and the
diagnosis of brain metastasis
- location of the lesion
- type of primary tumor
*
31-48% of surgically treated patients experience
recurrence in the brain
SURGERY - COMPLICATIONS
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Herniation due to edema and increased intracranial
pressure
Hemorrhage
Uncontrolled systemic cancer
Thromboembolic phenomena (pulmonary embolism)
Hematomas
Wound infection
Surgery-induced neurologic impairment
RADIOTHERAPY
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Remains an important treatment modality
When used promptly can reverse neurologic deficits
Postoperative whole-brain rth reduces the local
recurrence rate
New techniques:
- radiosurgery (external irradiation that uses stereotactically
directed beams to deliver a high single dose of radiation to a small
volume)
- brachytherapy
WHOLE-BRAIN RTH – LATE COMPLICATIONS
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Brain atrophy
Necrosis
Endocrine dysfunction
Leukoencephalopathy with neurocognitive deterioration
* the incidence of late complications is related to: total dose,
fraction size, performance status, extent of CNS disease,
preexisting neurologic impairment, concurrent
chemotherapy