The document provides information about brain metastasis including: - Brain metastasis are cancer cells that have spread to the brain from primary tumors elsewhere in the body. Lung cancer, breast cancer, melanoma, and renal cancer are common sources. - Symptoms depend on the location of metastases and can include headaches, nausea, focal weakness, seizures, and alterations in consciousness. Diagnosis is typically made through MRI or CT imaging. - Treatment involves steroids, anticonvulsants, surgery to remove solitary metastases, stereotactic radiosurgery for a small number of lesions, whole brain radiation, and occasionally chemotherapy. The prognosis is generally poor with a median survival of 4-5 months.

1. DR. AFIA FARHANA
MD Resident (Phase-A)
Dept. of Oncology, RMCH
BRAIN METASTASIS

2. INTRODUCTION
 Brain metastasis are cancer cells that have spread
to brain from primary tumors in the body.
 Brain metastasis is much more common
intracranial tumor in adults, accounting for
significantly more than one-half of brain tumor.
 In patients with systemic malignancies, brain
metastasis occur in 10 - 30% of adult and 6 to
10% of children.

3. EPIDEMIOLOGY
• Brain metastases are 10 time more common than
primary malignant CNS tumor. In the Caucasian
population, approximately 1,00,000 patients have
symptomatic intracranial metastasis annually, a number
that is six times more than the 17,000 patients with
malignant primary brain tumor.
• Some Autopsy series show that 25% of patient who die
of cancer have intracranial metastases, among this 15%
have brain dural metastasis.

4. Most patients develop involvement of the brain late
during the course of metastatic cancer. In some types
of cancers, brain metastases may occasionally be the
first presenting features.
Among the patient of brain metastases two third of
them become symptomatic. The Global Prevalence of
brain metastases in patients with cancer is around 10 -
30%.

5. Pathophysiology
1) Tumor dissemination to the CNS is usually through the
haematogenous route.
2) For metastasis cells to reach the brain, the
primary tumor usually access to the circulation
either by invading the venules or lymph
channels.
3) Before reaching the brain such circulating
tumor cells necessarily pass through the right
side of the Heart and the first capillary bed they
encounter is the lung.

6. 4)The most common metastasis - intraparenchymal (May
also involve the cervical nerve, the blood vessels, the
dura, the leptomeninges).
5)The distribution of lesions parallel to the distribution of
arterial blood flow of brain metastasis,
80% Cerebral Hemispheres
15% Cerebellum
5% Brainsteam.

7. Etiology
 The most common sources of brain metastasis are-
1. Lung cancer  30 - 40%
2. Breast cancer  15 - 20%
3. Melanoma  10%
4. Renal  10%
5. CUP  15%
6. Gastrointestinal cancer (Colorectal)  3%
7. Uncommon - Ovary, Uterus, thyroid

8. Risk factors for brain metastasis
 Young age (< 50 yrs)
 > 2 metastasis sites
 High tumor grade
 Tumor size > 2 cm
 HER-2 positive
 Triple negative breast cancer

9. Clinical Presentation
The signs and symptoms of brain metastasis are
related to the involved brain area.
Metastasis can cause focal or global cerebral
dysfunction at presentation.
Symptoms usually develop insidiously and progress
over a few weeks.
However haemorrhage into the metastases can result
in a more dramatic presentation (malignant
melanoma, renal cell carcinoma)

10. 1 Global signs & symptoms - Symptoms of brain
metastasis occur by the expansion of lesions and raised ICP.
 Headache - Headache occur in roughly half of brain
metastasis patients,especially in those with many tumor.
Nausea & Vomiting –
It is more common in children than in adult. In children,
vomiting may be especially dramatic or forceful, so much so
that it may be labeled as projectile in nature.
 Alteration in consciousness
 Papilloedema

11. 2.Focal signs & symptoms -
Ataxia- when metastasis occurs to the cerebellum,
patients will experience various difficulties with spatial
awareness and coordination.
Paresthesia - Patient after present with hemiparesis
(weakness on only one side of the body) which is after a result
of damage to neighbouring brain tissues.
 visual field defect
 Aphasia
 Neck stiffness

12. 3. Seizures - When present, often indicates disease involvement
of the cerebral cortex
4. Cranial nerve deficit
5. Cognitive disturbance
6. Loss of consciousness: Which may be gradual or rapid
7. HTN & Bradycardia
No symptoms - 7% patient with brain metastasis

13. Symptoms of brain metastasis by
percentage-
Symptom Patient %
 Headache 42
Cognitive dysfunction 31
Focal weakness 22
 Seizure 20
Ataxia 17
Speech problem 10
Sensory disturbance 06

15. Neurological examination –
 Neurological exam may include among
other things.
 Checking vision, hearing, balance
coordination, strength & reflexes.
Difficulty in one or more areas may provide
clues about the part of the brain that could
be affected by a brain tumor.

16. Imaging Test -
Magnetic resonance imaging (MRI) - MRI makes clean pictures
of the brain using powerful magnet and Radio wave. It is the
Gold standard in testing, provides information about the
location, size, characteristics and pressure effects of the tumor.
There are some other imaging tests -may include Computerized
Tomography (CT) and Positron Emission Tomography (PET) ,
plain skull radiograph or radionuclide study, LP (not routinly
done)
Other routine examination should be done.

17. • Superior sensitivity and specificity
• Soft tissue contrast
• Spatial resolution
• Multi planar localization and
• Absence of beam hardening artifact in the
posterior fossa and at the skull base.
MRI
(Imaging modality of choice)

18. • A hyperdense lesion suggests the presence of hemorrhage,
calcium or high nuclear-to cytoplasmic ratio.
• Hemorrhage would focus the differential diagnosis on
small cell lung, renal, thyroid, choriocarcinoma and
melanoma metastases.
• Calcium would favour lung, breast or gastrointestinal
metastases.
CT SCAN

19. • CECT failed to identify multiplicity in 31% of cases when
compared to contrast-enhanced MRI.
• When MRI is contraindicated it is reasonable to perform CECT
to detect metastasis but the protocol should be optimized to
include double-dose and delayed imaging.
• On non-contrast CT, metastasis are typically iso-dense.
• Double-dose contrast-enhanced CT is still inferior to contrast
MRI.

20. MRI
HEMORRHAGIC CHORICARCINOMAMETASTASIS
A.Shows heterogeneous signal in the mass including subtle T1 shortening that represents
blood products. The vasogenic edema (arrows) is subtle
B.The mass is moderately hypointense suggestive of blood. Highlights the vasogenic
edema.
C. Demonstrates hypo-intensity in the mass indicative of blood products.

21. POORLY DIFF. ADENOCARCINOMA METASTASIS TO BRAIN
A, T2-weighted shows left parietal subcortical lesion (arrow) slightly
hyperintense relative to the normal- appearing white matter.
B, On contract-enhanced T1-weighted image, the lesion is well enhanced
(arrow).
C, On DWI, the lesion is slightly hyper intense relative to the normal-
appearing cortical gray matter (arrow).

23. • Non-contrast axial CT scan
• Hypo-dense mass with Hyper-
density indicate mass is either
hemorrhagic or highly
cellular.
CT SCAN of Brain Metastasis

24. Rounded isodense mass with a
rim of hypodensity.
The mass is either hemorrhagic or
highly cellular.
Hypointensity related to the mass.
The vasogenic edema is less conspicuous in T1W.
The vasogenic edema does not enhance.
Tumor hypointensity
represents microcalcification
in this mucinous metastasis.

25. Differential Diagnosis
1. Primary brain tumor
2. Infection process
3. Metabolic encephalopathy
4. Drug induced encephalopathy
5. Demyelination
6. Paraneoplastic syndrome
7. Cerebral infarction or bleeding
8. Nutritional deficiency

26. Management
 The aim of management for patients with brain metastasis is to relieve
neurological symptoms, significant improvement in quality of life and
prolong survival.
A. Symptomatic Therapy.
1.Steroids - In patients who are symptomatic with raised ICP.
Pain or neurological dysfunction are likely to benefit from the use of
steroids.
Dexamethasone is the drug of choice. Dose of
Dexametheasone is 10 - 20 mg I/V followed by 4 - 8 mg PO 4 times
daily. Higher dose (> 32 mg/day) usually not given for more then 48 to
72 hours.

27. 2.Anticonvulsant therapy
should be administered only to the patients who have a
seizure.
Levetiracetam, Locosamide are the best options. As they
do not induce Hepatic microsomal system
Phenytoin is the another choice for control epilepsy.
3.Mannitol: Inj. mannitol 50 to 100 mg IV over 30 mins
If there are severe cerebral oedema or brainstem
herniation.

28. B. Surgery
Provides a significant survival advantage for patients with a
solitary brain metastasis.
Median survival for surgically treated patients is 9 to 16 months
and 12% of patient live 5 years a longer.
Candidates for surgical resection should have a single or possible
two brain metastases and limited or controlled systemic disease.

29. C. Stereotactic Radiosurgery (SRS)
Delivers a single large dose of radiation to well-defined target by
gamma knife, cyberknife or linear accelerator.
The steep dose curve of this technique ensures that little radiation
is delivered to surrounding tissue.
It is the treatment option for patients with one to there or
possibly more intracranial lesion.

30. • Non invasive procedure that
gives a high dose of radiation
to the tumor or target while
sparing normal tissue.
Stereotactic radiosurgery (CYBER KNIFE)

31. D. Radiation Therapy (RT)
Whole Brain Radio therapy (WBRT) is the standard
treatment for multiple or unresectable metastasis and for
lesions too large for Radiosurgery.
It is palliative and can be useful when both CNS and
Systemic disease are progressing.
The Recommend dose is 3000 cGy in 10 daily fractions or
37.5 Gy in 15 fractions.

32. E. Chemotherapy has a limited role and is rarely used for the treatment of
brain metastasis, as Chemotherapeutic agents penetrate the BBB poorly.
However, metastasis brain lesions from germ cell tumor, breast cancer and
small cell lung cancer may be chemo-sensative. Although the role of
Chemotherapy for brain metastasis still remain controversial, a new
generation of Chemotherapy agent have ability to cross an intact BBB.
• (1) Temozolomide
• (2) Topotecan
• (3) Etoposide
• (4) Cisplatin
• (5) Carboplatin
• (6) Ifosfamide
• (7) Fotemustine

33. • Individualised approach taking into account:
1. Karnofsky performance scale (KPS) score
2. Medical comorbid conditions
3. Systemic disease status
4. Number of metastases
5. Size and location of metastases and
6. Symptoms.
Furthermore treatment of the brain metastases may have little impact on
overall survival.
CHOICE OF THERAPY

34. • Large cerebral metastases greater than 3 cm are generally
considered too large to be treated with radiosurgery and are best
treated with surgical resection.
• Small cerebral metastases less than 5 mm are typically treated
with radiosurgery.
• Treatment decision is usually based on the patient’s
neurological function, extent of systemic disease, and surgical
risk.
• Lesions located deep within the brain, such as the thalamus,
basal ganglia, and brainstem are generally not considered to
surgical resection.
Decision making

35. • Chemoradiosensitive: Lymphoma, small cell lung cancer, and
germ cell tumors
• Rx: fractionated radiation and chemotherapy.
• Radioresistant: Melanoma, renal cell carcinoma, and
sarcomas
Rx: Excision
Moderately radiosensitive; Breast and non–small cell
lung cancer: Surgery is often a component of
multimodality treatment.
DECISION AFTER HISTOLOGY OF BIOPSY

36. • A surgical resection followed by whole-brain
radiotherapy (WBRT) is currently the standard
treatment
for resectable solitary cerebral metastases.
• The presence of brain metastases with an untreated
or undetected primary tumor is not a
contraindication for surgery

37. Prognosis
Prognosis of the patient of Brain metastasis is poor, with a median
survival of 4 - 5 months
1 year survival of approximately 10% cases.
Prognosis depends on the type of primary cancer, the age of patient,
the absence or presence of extra cranial metastasis & number of
metastatic sites in the brain. KPS score is used for specific prognosis.

38. 
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