Brain Metastases

From Anvita Health Wiki

Contents 1 Etiology 2 Epidemiology 3 Pathology 4 Genetics 5 Clinical-manifestations 6 Laboratory 7 Radiology 8 Complications 9 Differential-diagnosis 10 Management 11 More General Terms 12 Internet Database 13 References

Etiology

• lung cancer (most common)

• ~37% metastasize to brain
• accounts for ~50% of metastatic brain tumors

• breast cancer

• ~23% metastasize to brain
• account for ~15-20% of metastatic brain tumors

• melanoma

• ~40% metastasize to brain
• accounts for ~10% of metastatic brain tumors

• adenocarcinoma of the colon/rectum

• ~11% metastasize to brain
• accounts for ~5% of metastatic brain tumors

• renal cell carcinoma: ~19% metastasize to brain
• lymphoma & leukemia tend to involve leptomeninges more than brain parenchyma (see carcinomatous meningitis)
• adenocarcinoma of the esophagus
• cervical carcinoma: ~9% metastasize to brain
• prostate carcinoma: ~2% metastasize to brain
• unknown primary 10%

• Single metastasis more common:

• breast carcinoma
• renal cell carcinoma
• colon carcinoma

• Multiple metastases more common:

• melanoma
• lung carcinoma

Epidemiology

• most common form of brain tumor, accounting for > 50% of brain tumors in adults
• occurs in ~10-30% of adults with cancer; ~6-10% of children with cancer
• ~98,000 -170,000 new cases per year

Pathology

• distribution:

• ~80% cerebral hemispheres
• ~15% cerebellum
• ~5% brainstem

• GI & pelvic tumors have predilection to metastasize to posterior fossa
• metastases tend to be located at the gray-white junction where blood vessels decrease in diameter
• leptomeningeal metastases common with lymphoma/ leukemia but may occur with any cancer metastasizing to the brain

Genetics

• defects in EPHB2 may be associated with prostate cancer metastasis to the brain

Clinical-manifestations

• headache
• mental status changes
• focal neurologic deficit
• seizures
• leptomeningeal metastasis

• headache or spine pain
• cranial nerve pain or spinal radicular pain
• mental status changes

Laboratory

• lumbar puncture with CSF analysis

• indications: suspected leptomeningeal metastasis but negative MRI
• elevated CSF protein
• diminished CSF glucose
• positive CSF cytology

Radiology

• magnetic resonance imaging ( MRI)
• computed tomography ( CT) if MRI is unavailable
• communicating hydrocephalus may be apparent with leptomeningeal metastasis

Complications

• 
  
• disease interaction(s) of cancer with Alzheimer's disease

Differential-diagnosis

• primary brain tumor
• abscess
• progressive multifocal leukoencephalopathy
• demyelination
• cerebral infarct/bleed
• radiation necrosis

Management

• radiotherapy & surgery for single brain metastasis

• surgical excision

• good performance status
• minimal or no evidence of extracranial disease
• accessible lesion that can be completely excised

• postoperative whole brain radiotherapy

• radiotherapy for multiple brain metastases

• whole brain radiation

• 3,000 cGy in 10 fractions or 2,000 cGy in 5 fractions
• optimal use of radiosurgery undefined

• chemotherapy followed by radiation therapy

• indication: leptomeningeal metastasis
• methotrexate & cytarabine

• glucocorticoids as initial adjunctive therapy for parenchymal & leptomeningeal metastasis
• supportive care

More General Terms

• metastasis

Internet Database

OMIM: 03688

References

1. Saunders Manual of Medical Practice, Rakel (ed), WB Saunders, Philadelphia, 1996, pg 1068-70
2. Medical Knowledge Self Assessment Program (MKSAP) 14, American College of Physicians, Philadelphia 2006
3. National Guideline Clearinghouse
   - Management of single brain metastases: a clinical practice guideline. (Program in Evidence-based Care) ngc-guideline: [1]
   - Pre-irradiation evaluation and management of brain metastases. (American College of Radiology) ngc-guideline: [2]
   - Single brain metastasis. (American College of Radiology) ngc-guideline: [3]
   - Follow-up and retreatment of brain metastases. (American College of Radiology) ngc-guideline: [4]
   - Multiple brain metastases. (American College of Radiology) ngc-guideline: [5]
   - Brain metastases. European Federation of Neurological Societies ngc-guideline: [6]
   - The role of chemotherapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [7]
   - The role of emerging and investigational therapies for metastatic brain tumors: a systematic review and evidence- based clinical practice guideline of selected topics. Congress of Neurological Surgeons ngc-guideline: [8]
   - The role of prophylactic anticonvulsants in the management of brain metastases: a systematic review and evidence-based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [9]
   - The role of retreatment in the management of recurrent/ progressive brain metastases: a systematic review and evidence-based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [10]
   - The role of stereotactic radiosurgery in the management of patients with newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [11]
   - The role of steroids in the management of brain metastases: a systematic review and evidence-based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [12]
   - The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence- based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [13]
   - The role of whole brain radiation therapy in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline. Congress of Neurological Surgeons ngc-guideline: [14]

brain metastases