Brain metastases

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Epidemiology and Pathogenesis

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Clinical Features

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Investigations

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CT imaging

Cerebral metastasis causing left arm weakness.jpg

  • Image above - A CT scan from a man with cancer who developed left arm weakness over 24 hours and was found to have upper motor neuron signs in his left arm

MRI

MRI brain - metastatic lung cancer with dysarthria - frontal metastasis.jpg

  • Image above - An MRI from a man with metastatic lung cancer who developed confusion and an expressive dysarthria. MRI showed multiple cerebral and leptomeningeal metastases

Management

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Steroids

Neurosurgery

Radiotherapy

Treating symptoms and complications

Headache

Nausea and vomiting

Speech disturbances

Mobility issues

Seizures

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Seizure prophylaxis

In general, there is no good evidence that seizure prophylaxis is beneficial. Numerous trials have demonstrated increased adverse effects without any reduction in seizures with phenobarbitone, phenytoin and valproate, and as such seizure prophylaxis is usually not recommended. There is some evidence however that in patients with melanoma seizure prophylaxis may be beneficial, especially when a deposit is associated with a cerebral haemorrhage or if there are multiple supratentorial lesions. In one analysis, about 20% of patients with CNS melanoma metastases who were not on seizure prophylaxis went on to have a seizure within the following 3 months; in the same analysis, none of a small number of patients who were given prophylaxis suffered seizures over a 3 months period.[1]

Drowsiness and end of life care

Prognosis

The development of cerebral metastases almost always is a terrible emotional blow to patients and their families as most people understand that metastases hear indicates that time is short and the prognosis is poor. The 3 key prognostic characteristics in patients with cerebral metastases are:

  1. Age
  2. Functional status
  3. Extra-cranial disease status

In one series of 1,200 patients, three prognostic groups were determined:

Group Features Median Survival
Class I KPS >= 70 + Age < 65 + Controlled Primary Disease + No Other Metastases 7.1 months
Class II Not class I or III 4.2 months
Class III KPS < 70 2.3 months

Life expectancy also has been noted to correlate with cancer type plus other more general features (GPA = graded prognostic instruments).

Cancer type Overall median survival GPA 0-1 median survival GPA 1.5-2 median survival GPA 2.5-3 median survival GPA 3.5-4 median survival
All cancers 7.2 months 3.1 months 5.4 months 9.6 months 16.7 months
Non-small cell lung cancer 7 3 5.5 9.4 14.8
Small cell lung cancer 4.9 2.9 4.9 7.7 17.1
Breast cancer 13.8 3.4 5.4 9.6 16.7
Melanoma 6.7 3.4 4.7 8.8 13.2
Renal cell cancer 9.6 3.3 8.3 11.3 14.8
Gastrointestinal cancers 4.5 3.1 7.7 15.1 25.3

In the above study, the higher the GPA the better the prognosis. GPA was determined by adding up the following prognostic factors, which varied depending on the cancer type.

For lung cancer:

Score Age KPS Extra-cranial metastases Number of brain metastases
0 > 60 < 70 Present > 3
0.5 50-60 70-80 2-3
1 < 50 90-100 Absent 1

For melanoma or renal cell cancer:

Score KPS Number of brain metastases
0 < 70 > 3
1 70-80 2-3

For breast cancer:

Score KPS ER/HR/Her2 Age
0 < 60 Triple negative > 70
0.5 50 < 70
1 70-80 ER/PR positive, Her2 negative
1.5 90-100 ER/PR negative, Her2 positive
2 Triple positive

For gastrointestinal cancers:

Score KPS
0 < 70
1 70
2 80
3 90
4 100

These above prognostic tools are helpful in counselling patients and guiding them in treatment decisions. When the prognosis is very short, e.g. only a couple of months, supportive care alone is probably most appropriate, whereas if the prognosis is longer then whole brain radiotherapy and surgical resection (if a solitary lesion) is worth considering.

References

  1. Goldlust et al. Seizure prophylaxis and melanoma brain metastases. J Neurooncol. 2012 May;108(1):109-14.

Authors

Graham Llewellyn Grove