Brain mets video


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Brain mets video

  1. 1. Brain Metastases Robert Miller MD Brain metastases or primary brain tumors (glioma) Treatment options Side effects of treatment
  2. 2. Brain metastases: cancerthat started elsewhere in thebody (e.g. lung or breast)and spread to the brainBrain primary: a normalbrain cell (glial cell)becomes malignant and iscalled a glioma
  3. 3. Brain Metastases Most common intracranial tumors in adults In patients with stage IV disease , 10 – 30% will have brain mets
  4. 4. The odds of developing brain metastases based on the primary type of cancer  Lung: 16 to 20%  Melanoma: 7%  Kidney: 7 to 10%  Breast: 5%  Colorectal: 1 to 2%
  5. 5. The most common causes of brain metastases in adultswith their approximate frequency are: Lung — 50 percent Breast — 15 to 20 percent Unknown primary 10 percent Melanoma — 10 percent Colon and rectum 5 percentThe distribution of metastases roughly follows the relativeweight of and blood flow to each area. Cerebral hemispheres — 80 percent Cerebellum — 15 percent Brain stem — 5 percent
  6. 6. SYMPTOMS OF BRAIN METASTASESSymptom Patients %Headache 42Focal weakness 27Mental change 31Seizure 20Gait ataxia 17Sensory disturbance 6Speech problems 10
  7. 7. Note that tumors may cause symptoms onthe opposite side of the body
  8. 8. Brain Swelling – brain tumor often cause swelling oredema which creates pressure on the brain, with headachesand nausea, steroids like Decadron (dexamethasone) willdecrease this pressure
  9. 9. Brain Imaging
  10. 10. GlioblastomaCertain braintumors .e.g.glioma have adistinctappearance onMRI scan . Withirregular bordersand necroticcenter
  11. 11. Glioblastomacells in green,spread diffuselythrough the brainand are hard totarget accurately
  12. 12. Brain Metastasis as seen on an MRI Scan, thesharp margins may make this a better case forhighly targeted radiation
  13. 13. Normally the radiologist can tell the differencebetween a brain tumor and a stroke (if notsometimes a biopsy is necessary)
  14. 14. Other Brain Tumors that are NOT cancer Both of these are examples of a brain abscess
  15. 15. Multiple Brain MetastasesMRI suggests that in 66 to 75% of the cases, there are multiple metastasesMetastases from breast, colon, and renal cell carcinoma are more often single,while lung cancer and malignant melanoma have a greater tendency to produce multiple metastases
  16. 16. Brain Metastases are usually Multiple (66 – 75% of the cases)
  17. 17. Brain Metastases are Usually Multiple
  18. 18. PET Scans and the BrainBecause a PET measures uptake of glucose and the brain uses a lot ofglucose, the normal brain looks very active on a PET scan
  19. 19. PET Scans and the BrainPET scan showed an abnormal area in the left frontal lobe and MRIconfirmed this as a brain metastasis from breast cancer
  20. 20. Brain RadiationDepending on the type and number of braintumors, the patient may receive radiation tothe whole brain, or partial brain or havehighly targeted radiation (called radiosurgery,e.g. Cyberknife or gamma knife)
  21. 21.
  22. 22. Whole brain irradiation
  23. 23. Whole brain radiation
  24. 24. The response or benefitfrom whole brain radiationmay take several weeks tomonths
  25. 25. Typical Response to Whole Brain Radiation
  26. 26. The smalllesion is nolongervisible andthe largelesion ismuchsmaller
  27. 27. Typical response for whole brain radiation
  28. 28. Typical response for whole brain radiation, small cell lung cancer
  29. 29. Typical response for whole brain radiation
  30. 30. Radio resistant cancer (renal cell) MRI appearance two months after whole brain radiation (small lesions gone and large lesion much smaller)
  31. 31. Radiosurgery for Cancer
  32. 32. Typical timeinterval toregression afterradiosurgeryCyberknife orGamma Knife)
  33. 33. For a single lesion, radiosurgery alone may be used,but there is a higher risk of a new lesion showing up inthe brain Jan 2011 - Radiosurgery Aug 2012 – Treated tumor is virtually gone, but there is a new tumor on the opposite side of the brain
  34. 34. Radiation Doses Whole brain: 20 – 40 Gy in 5 to 20 fractions Radiosurgery: 15Gy (3.1 – 4cm), 18Gy (2.1 to 3cm) or 24Gy (2cm or less)
  35. 35. How often does whole brain radiationhelp?• 70 -90% initial response• > 50% of symptoms of headache, CSF pressure have complete response• 50 -60% have functional improvement moderate dysfunction: 1/3 near normal at median time of 3 weeks severe dysfunction: 2/3 improve at median of 1-2 weeks
  36. 36. Side Effects of Whole Brain Radiation1. Hair loss (usually takes two or three weeks to happen)2. Mild skin itching or irritation3. Short term more fatigue or slightly more confusion or memory problems4. Mild headache or nausea is uncommon but may require medication (Decadron)5. Occasionally hearing problems (fluid behind the ear drums)
  37. 37. Long Term Effects of Radiation on the BrainThis patient had no symptoms, but radiation may effectmemory
  38. 38. Long Term Effects of Radiation on the Brain This patient had no symptoms
  39. 39. Long Term Effects of Radiation on the Brain This patient had no symptoms
  40. 40. Long Term Effects of Radiation on the Brain This patient had no symptoms
  41. 41. Risk of white matter changes (leukoencephalopathy) 1year after whole brain radiation for brain mets U Pitt Study E Monaco (AANS 2012, Medscape Med News 2012-05-01) WB+SRS SRS 1 year 97.3% 3.2%So by one year 97% has some changes andby 2 years 70% had grade 3 changes on theMRI (but no symptoms)
  42. 42. Radiosurgery for Brain Metastasis Local control Rates of 73 to 94% Risk of radiation necrosis of 5 to 10%Better than whole brain if single lesion and good performance patient in theRTOG 95-08 Trial
  43. 43. Complications of Radiosurgery Short term side effects are uncommon (2%) with worsening symptoms or new seizures About one third mild swelling (headaches, nausea) Radionecrosis in 5% to 10%
  44. 44. Sometimes the MRIwill look worse afterradiosurgery due toradionecrosis of thecancer but with timethis should fade away
  45. 45. Survival and Prognosis for People with Brain Metastases1. Do best if the cancer is confined to the brain only2. Do better if they are young (< 65y)3. Do better if they have a good performance score (i.e. a high Karnofsky score of 70 or better)Karnofsky Score (KPS) 70 = Cares for self; unable to carry on normalactivity or do active workKPS 60 = Requires occasional assistance, but is able to care for mostpersonal needs
  46. 46. Median Survival Based on RTOG Class for People with Brain Metastases I (KPS =70, age < 65y, mets to brain only) = 7.1 to 10.5 months II KPS = 70 = 3.5 to 4.2 months III KPS < 70 = 2.0 to 2.3 monthsKarnofsky Score (KPS) 70 = Cares for self; unable to carry on normalactivity or do active workKPS 60 = Requires occasional assistance, but is able to care for mostpersonal needs
  47. 47. Survival by Treatment (WB whole brain, Ssurgery, RS radiosurgery) and Performance Score (RTOG)RTOG WB S RS I 7.1 mos 14.8 mos 16.1 mos II 4.2 mos 9.9 mos 10.3 mos III 2.3 mos 6.0 mos 8.9 mos
  48. 48. Brain Metastases Robert Miller