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Case history

image A 54-year-old male smoker presented with a 5 day history of expressive dysphasia and a 24 h history of confusion and headache. He had no other neurological symptoms or signs and was otherwise fit and well.

A brain CT scan showed multiple ring-enhancing lesions in both cerebral hemispheres surrounded by marked oedema. The oedema was causing 11 mm of midline shift. Appearance was consistent with multiple brain metastases.

What is the immediate management of this patient?

What investigations does the patient need?

When does surgery play a role?

What other treatment modalities might be considered for patients with brain metastases?

What is the immediate management of this patient?

Brain metastases affect 20–40% of patients with malignancy during the course of their illness and cause significant morbidity even with treatment. The most common primary tumour sites are lung, breast, renal and melanoma. Presenting symptoms include headache, focal weakness, gait ataxia and seizures.

Prognosis following a diagnosis of brain metastases is poor if untreated. With treatment, prognosis may be improved but patients must be carefully selected to avoid unnecessary toxicity in the last few weeks of life. Various prognostic indices may be used to help guide appropriate management, as a patient with a solitary brain metastasis is likely to have different outcomes and management from those of someone with multiple metastases.1 Recursive partitioning analysis (RPA), a statistical analysis study combining data from three North American radiotherapy trials, has been used to predict patients likely to benefit from therapy.2 The RPA score categorises patients in three groups based on Karnofsky performance status, primary tumour status, age and presence of extracranial disease (Table 26.1).

Table 26.1Prognostic groups for outcome after palliative treatment of brain metastases by RPA (adapted from Gaspar et al.2).

Other factors such as the primary site of disease and the number of metastases may also influence the prognosis.3 Patients with primary breast cancer and those with fewer metastases have better outcomes. Traditionally, treatment for patients with multiple brain metastases was predominantly corticosteroids, with either whole brain radiotherapy (WBRT) or symptomatic care alone. This approach is changing. The availability of systemic treatment with targeted drugs, such as immunotherapy or biological agents, and stereotactic radiosurgery (SRS) for multiple small-volume metastases is providing improved outcomes with less cognitive morbidity compared with WBRT. Patients with solitary or oligometastatic disease should be considered ...

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