Updated: 12/11/2018

Metastatic Brain Cancer

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Snapshot
  • A 67-year-old woman presents to the emergency department by her daughter due to an observed seizure-like event. The daughter states that this is the first time she has ever had a seizure. The daughter also reports that for the past few weeks she has had progressively worsening diffuse headaches, which are more severe in the morning, and accompanied by nausea. Medical history is significant for breast cancer. On physical exam, there is right-sided weakness in both upper and lower extremities. A head CT was obtained which showed hyperdense lesions with surrounding vasogenic edema.
Introduction
  • Most common intracranial malignancy in adults
    • most commonly carcinomas such as
      • lung
      • breast
      • kidney
      • colorectal
      • melanomas
  • In children, most common sources are
    • sarcomas
    • neuroblastomas
    • germ cell tumors
  • Pathogenesis
    • hematogenous spread (most commonly)
      • usually found at gray-white matter junction
  • Epidemiology
    • > 50% of all intracranial tumors
Presentation
  • Highly variable clinical presentation
    • must be suspected in patients with a history of malignancy who present with neurologic symptoms or behavioral abnormalities
  • Symptoms
    • headache
    • morning headache is highly suggestive
      • although it is uncommon
    • nausea and vomiting
    • cognitive dysfunction
      • e.g., personality changes and altered mental status
    • seizure
      • of new onset
    • stroke
      • patients with malignancy are at risk of being hypercoagulable
      • may hemorrhage into the metastasis
      • tumor may compress artery
  • Physical exam
    • focal neurologic deficit
      • e.g., hemiparesis
      • location dependent
    • papilledema
Evaluation
  • Contrast-enhanced MRI
    • preferred for diagnosing brain metastasis
    • features suggestive of metastasis
      • multiple lesions
      • lesions at grey-white matter junction
      • vasogenic edema
        • large when compared to lesion size
  • Brain biopsy
    • when diagnosis is unclear
Differential
  • Primary brain tumor
  • Intracranial abscess
  • Progressive multifocal leukoencephalopathy (PML)
  • Cerebral infarction or hemorrhage
 
Treatment
  • Increased intracranial pressure
    • dexamethasone
  • Seizures
    • phenytoin
  • Radiation therapy
  • Surgery
    • stereotactic radiosurgery
    • surgical resection
      • neurosurgical resection is the standard for a single or limited number of metastases in a surgically accessible location
Prognosis, Prevention, and Complications
  • Prognosis
    • if untreated, the median survival from solid tumors of brain metastases is ~ 1-2 months

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(M2.ON.15.41) A 45-year-old female is admitted to the hospital after worsening headaches for the past month. She has noticed that the headaches are usually generalized, and frequently occur during sleep. She does not have a history of migraines or other types of headaches. Her past medical history is significant for breast cancer, which was diagnosed a year ago and treated with mastectomy. She recovered fully and returned to work shortly thereafter. CT scan of the brain now shows a solitary cortical 5cm mass surrounded by edema in the left hemisphere of the brain at the grey-white matter junction. She is admitted to the hospital for further management. What is the most appropriate next step in management for this patient?

QID: 106285
1

Chemotherapy

10%

(2/20)

2

Seizure prophylaxis and palliative pain therapy

5%

(1/20)

3

Irradiation to the breasts

0%

(0/20)

4

Irradiation to the brain mass

20%

(4/20)

5

Surgical resection of the mass

60%

(12/20)

M 7 E

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