A short presentation about patients with cancer that has metastasized to the brain.

1. BRAIN METASTASES
Herb Engelhard, M.D., Ph.D.
Department of Neurosurgery
The University of Illinois at Chicago

2. Case discussion
Note: for patient confidentiality, this details are for illustrative purposes only
• 48 yo male comes into the ER with dizziness, and
“something’s not right”. Suffered a fall about 3
months ago – did not hit his head.
• PMH: Appendectomy age 26 GSW leg – age 18.
• NKA Meds: none Occas recreational drug use
• Habits: has smoked 1 ppd since age 15 + ETOH
• FH: Father died of a heart attack; mother recently
had a stroke and is in a nursing home.
• Exam: Afebrile P 72 BP 140/86 Alert and
oriented to PPTS Speech & memory – normal
HEENT normal Neck supple CN screen nl Motor
5/5; normal tone Slight difficulty on tandem gait
Possible mild tremor Reflexes 2+ all
Neurosurgery consulted
(dizziness). Head CT scan
read as normal.
Options?

3. “Miliary brain lesions”
Need for biopsy?
Differential diagnosis?
A different patient
Note: Some images used in this
presentation are freely available from
the Internet.

4. Here, chest CT was positive for a mass and
lymphadenopathy – mediastinoscopy revealed
adenocarcinoma of the lung.
MILIARY LESIONS:
Metastatic cancer
TB TB TB TB
Other infections
Sarcoidosis
Other very rare

5. BRAIN METASTASES from Lung CA:
 First manifestation in 10% of cases
 The most frequent cause of death
 Fewer solitary metastases
 If solitary - surgery rapidly improves
function in 75%
 Longest term survivors received surgery and
whole brain radiation therapy

6.  What are the prognostic factors for patients with
brain mets?
 What are the options for treatment?
 How often will I see these patients in my practice?
 Which types of tumors are most common?
 Which ones hemorrhage?
 What can be done to prevent recurrence?

7. BRAIN METASTASES IN GENERAL
Prognostic factors:
 Histology and site of origin
 Extent of primary disease / other metastatic sites
 Number of brain metastases
 Pt. age / functional status / general medical condition
 Interval between time of diagnosis of primary and
metastatic disease (longer is better)

8. Factors influencing choice of surgical /
radiosurgical treatment:
 Projected quality of life / prognosis – as above
 Surgical risks – such as infection
Rationale for local therapy  probability of local recurrence
Still an option Intra-cavitary radiation: no longer available
Gliadel, Gliasite etc.

9. Scope of the Problem:
 Cancer is the #2 cause of death in the U.S.
 Brain mets are present up to 30-40% of patients
with cancer (Kotecha et al., 2018)
 >100,000 deaths per year due to brain mets, and
their incidence is increasing (improved imaging,
aging population)
 As cancer treatments improve, CNS is a common
site of failure/recurrence (behind the BBB)
 New emphasis: Neurocognitive side effects of Rx
Neurosurgeons never see the vast majority of
patients with brain mets

10. BRAIN METS
 2/3 of patients having them are asymptomatic (?)
 Constitute 10 - 30% of brain tumors in classic
neurosurgical series
 Usually present in 4th - 7th decades of life –
median age: 60 years and median overall survival:
6.4 months (Kotecha et al., 2016).
 Multiple in 35 - 50% of patients (depends how
hard you look … )
 In autopsy series, 60 – 85% of patients with brain
metastases have multiple lesions
 Initial seeding involves multiple cells – but they
proliferate in more discrete patches and are not
as invasive as glioblastoma

11.  Primary unknown in 15 - 35%
 Other organs involved in 50% of patients
 Usually respond to dexamethasone
 Survival if untreated: a few months!
 With treatment, survival is highly variable
 “Classic” 2 year survival 5 - 10%, with surgery + radiation
producing the “long term” survivors
 Role / importance of radiosurgery … see previous lecture …
 Radiosurgery has been used for up to 20 mets!

12. Tumors with highest
tendency toward brain
metastasis:
1. Melanoma
2. Choriocarcinoma
3. Undifferentiated lung CA
4. Breast
5. Renal cell carcinoma
6. Head and neck
Most common sources of
brain mets:
1. Lung
2. Breast
3. Melanoma
4. Colorectal, renal, thyroid
= incidence + tendency

13. Hemorrhage in brain
metastases:
1. Melanoma
2. Choriocarcinoma
3. Lung CA
4. Kidney CA
Mets to the posterior fossa:
 More dangerous location
 More commonly cystic
 Relatively more from GI,
bladder, uterus
 Higher operative mortality
 Postoperative survival
shorter

14. BRAIN METASTASES:
“Classic” indications for open surgery:
 Need for diagnosis
 Neurologic deterioration / impending
herniation
 Accessible lesions limiting life
expectancy
New: Molecular data – even at recurrence?

15. Specific cancer type: Melanoma
 5 year risk of brain mets: 7%
 CNS is first site of recurrence in 20%
 Often multiple; 5% miliary = poorest prognosis
 30% of melanoma brain mets contain no
melanin! “Great imitator”
 HMB-45 is most specific marker for
melanoma
 Surgical resection yields longest survival

16. Breast cancer
 CNS metastases in 30% of
patients (brain /
leptomeningeal seeding)
Colon cancer
 Brain metastases often
markedly hypo-intense
on T2-weighted MRI
Breast

17. Surgical issue: Postoperative
recurrence patterns in brain mets:
Should we cauterize the tumor bed?
 It’s complicated
 Depends on histology & time from dx
My current preference:
Follow-up MRI: positive  radiosurgery
Classic study: surgery alone – 46%
recurrence at operative site

18. KEY ARTICLE:
Mahajan et al. Lancet Oncology 18(8), 2017.
“Post-operative stereotactic radiosurgery versus
observation for completely-resected brain metastases: A
single-centre, randomised, controlled, phase 3 trial.”
Patients had complete resection of 1-3 brain metastases
(maximum diameter: 4 cm), followed by SRS vs. observation
alone (no external beam radiation).
12 month freedom from local recurrence was 43% in the
observation group and 72% in the SRS group. However,
overall survival was similar.