A 54-year-old male smoker presents with a five-day history of expressive dysphasia and a 24-hour history of confusion and headache. He has no other neurological symptoms or signs and is otherwise fit and well. A brain computed tomography (CT) scan shows multiple ring-enhancing lesions in both cerebral hemispheres surrounded by marked oedema. The oedema is causing 11 mm of midline shift. Appearances are consistent with multiple brain metastases (Figure 33.1).
What is the immediate management of this patient?
What investigations does the patient need?
What is the definitive management of this patient?
Brain CT scan with contrast showing multiple enhancing brain metastases with surrounding vasogenic oedema and effacement of the ventricle.
Brain metastases affect 20%–40% of patients with malignancy during the course of their illness and cause significant morbidity even with treatment. A suggested management pathway is illustrated in Figure 33.2. The most common primary tumours sites are lung (44%), breast (15%), renal (7%) and melanoma (7%). Presenting symptoms include headache (49%), focal weakness (30%), gait ataxia (21%) and seizures (18%).
Management of suspected brain metastases
Prognosis following a diagnosis of brain metastases is poor, with a median survival of 1-2 months. With treatment, prognosis may be improved but patients must be carefully selected to prevent unnecessary toxicity in the last few weeks of life. Various prognostic indices can be used to help guide appropriate management, as a patient with a solitary brain metastasis is likely to have differing outcomes and management than someone with multiple metastases.1 Recursive partitioning analysis (RPA), a study which combined data from three North American trials, can be used to predict patients likely to benefit from therapy.2 The RPA score categorizes patients into three groups based on the Karnofsky performance scale, primary tumour status, age and the presence of extracranial disease (Table 33.1).
Table 33.1Prognostic groups for outcome after palliative radiotherapy of brain metastases by recursive partitioning analysis (see also ref.2). |Favorite Table|Download (.pdf) Table 33.1 Prognostic groups for outcome after palliative radiotherapy of brain metastases by recursive partitioning analysis (see also ref.2).
|Class ||Prognostic factors ||Median survival, months |
|I ||KPS >70% ||7.1 |
| ||Age <65 years || |
| ||Controlled primary site || |
| ||No extracranial metastases || |
|II ||KPS < 70 ||2.3 |
|III ||All others ||4.2 |
Other factors, such as primary site of disease and number of metastases, are important as they may also dictate prognosis.3 Patients with breast cancer primaries and those patients with fewer metastases do better. Treatment for brain metastases is predominantly with corticosteroids and whole-brain radiotherapy. Patients ...