Palliative Care: Brain Metastases
Background
What is the most common intracranial tumor?
Brain mets is the most common intracranial tumor.
What is the annual incidence of brain mets in the U.S.?
170,000 cases/yr of brain mets in the U.S.
What cancers are associated with hemorrhagic brain mets?
Hemorrhagic brain mets is associated with melanoma, renal cell carcinoma, and choriocarcinoma.
What does the term solitary brain met connote?
A solitary brain met is only 1 brain lesion.
What cancers are most likely to metastasize to the brain?
Cancers associated with brain mets: lung (40%–50%), breast (15%), melanoma (10%), and unknown −primary (5%–10%)
What is more common type of brain met: single or multiple?
Most pts have multiple brain mets rather than a single lesion.
How do pts with brain mets present?
Presentation of pts with brain mets: Sx of ↑ ICP (HA, n/v), weakness, change in sensation, mental status changes, and seizure
Where do most brain mets occur?
Most brain mets arise in the gray/white matter −junction due to narrowing of blood vessels. (Delattre J et al., Arch Neurol 1988)
Are most brain mets infra- or supratentorial?
The majority of brain mets are supratentorial.
What is the distribution of brain mets within the brain?
The distribution of brain mets correlates with relative weight and blood flow:
Cerebral hemispheres: 80%
Cerebellum: 15%
Brain stem: 5%
(Delattre J et al., Arch Neurol 1988)
If a pt presents with brain mets without a prior Dx of cancer, what is the most likely source?
Pts presenting with brain mets without a prior Dx of cancer most often have a lung primary.
What is the overall median time from initial cancer Dx to development of brain mets?
The median overall time from initial cancer Dx to development of brain mets is 1 yr.
Do most pts with brain mets die from their CNS Dz?
No. ~30%–50% of pts with brain mets die from their CNS Dz.
Workup/Staging
Describe the workup of a brain met.
Brain met workup: H&P focus on characterization of any neurologic Sx, evaluation for infectious causes (fever, CBC), careful neurologic exam, MRI brain +/− gadolinium, assessment for status of extracranial Dz, determination of Karnofsky performance status (KPS), and neurosurgery consult
What imaging test is 1st line in evaluating brain mets?
MRI is 1st line in the evaluation of brain mets.
What is the DDx for a new lesion in the brain?
Brain lesion DDx: mets, infection/abscess, hemorrhage, primary brain tumor, infarct, tumefactive demyelinating lesion, and RT necrosis
What imaging features are suggestive of brain mets?
Imaging features suggestive of brain mets include lesions at gray/white matter junction, multiple lesions, ring-−enhancing lesions, and significant vasogenic edema
What is triple-dose gadolinium, and why is it used?
Triple-dose gadolinium: 0.3 mmol/kg. It is used to increase the sensitivity of MRI.
Treatment/Prognosis
The RTOG recursive partitioning analysis (RPA) divides brain mets pts into how many prognostic classes?
The RTOG RPA divides brain mets pts into 3 −prognostic classes.
What prognostic factors are included in the RPA for brain mets?
Prognostic factors included in the RPA for brain mets include KPS, control of the primary, age <65 yrs, and the presence of mets outside the CNS. (Gaspar L et al., IJROBP 1997)
What pts are included in class I according to the RTOG for brain mets?
Brain met RPA class I: KPS ≥70, age <65 yrs, −primary controlled, and no extracranial mets
What pts are included in class II according to the RTOG for brain mets?
Brain mets RPA class II: KPS ≥70 with 1 of the following—primary uncontrolled, age >65 yrs, or extracranial mets
What pts are included in class III according to the RTOG for brain mets?
Brain mets RPA class III: KPS <70
What is the MS time for RTOG RPA classes I, II, and III?
MS according to the RTOG brain met RPA:
Class I: 7.2 mos
Class II: 4.2 mos
Class III: 2.3 mos
What is the Sperduto Index?
The Sperduto Index is a graded prognostic assessment based on age, KPS, # of brain mets, and the presence or absence of extracranial mets developed from an analysis of 1,960 pts in the RTOG database. Criteria is based on a point system:
0 points: age >60 yrs, KPS <70, >3 brain mets, presence of extracranial mets
0.5 points: age 50–59 yrs, KPS 70–80, 2 CNS mets
1 point: age <50 yrs, KPS 90–100, 1 CNS met, no extracranial mets
The sum of points predicts MS in mos:
0–1 point: 2.6 mos
1.5–2.5 points: 3.8 mos
3 points: 6.9 mos
3.5–4 points: 11 mos
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