Symptomatic management and imaging of brain metastases

The relationship of T2 hypointensity and diffusion restriction of brain metastases with the presence and amount of vasogenic edema in MRI

AIM

Brain metastases are seen in 15-40% of patients diagnosed with cancer. We aimed to search the relationship between the T2 hypointensity, diffusion-weighted imaging characteristics, and the presence and amount of vasogenic edema of brain metastasis in magnetic resonance imaging (MRI).

METHODS

A total of 292 patients with brain metastasis were included in the study. T2 signals of metastatic lesions, accompanying diffusion restriction and perilesional vasogenic edema findings, were investigated. In metastases accompanied by vasogenic edema, the largest dimension of the vasogenic edema-mass complex on T2-weighted sequences and the largest dimension of the mass in contrast-enhanced T1-weighted series were measured and the edema-mass ratio (EMR) was calculated by comparing these two values.

RESULTS

The frequency of vasogenic edema was statistically significantly higher in T2 hypointense metastases (89.1% vs 58.8%, χ2 = 18.949, p = <.001) and metastases accompanied by diffusion restriction(81% vs 61.5%, χ2 = 6.971, p = .008). EMR values were found to be statistically significantly higher in T2 hypointense metastases (EMR→ Z = -4.507, p = <.001) and metastases with diffusion restriction(EMR→ Z = -3.819, p = .001).

CONCLUSIONS

The frequency of vasogenic edema and EMR rates were higher in patients in T2 hypointense metastases and metastases accompanied by diffusion restriction in MRI.

Multidisciplinary Management of Brain Metastasis from Breast Cancer

The management of patients with breast cancer and brain metastases (BMs) is exquisitely multidisciplinary. Patients presenting with a symptomatic BM may be offered neurosurgical resection, followed by radiation. Stereotactic radiosurgery (SRS) is preferred over whole-brain radiotherapy (WBRT) in most patients presenting with a limited number of BMs, whereas WBRT with hippocampal-sparing and concomitant memantine is preferred for patients with multiple BMs. There is a growing role for systemic therapy, in some cases in lieu of local therapy, particularly in patients with HER2+ breast cancer.

Metastases in the Pineal Region: A Systematic Review of Clinical Features, Management Strategies, and Survival Outcomes

BACKGROUND

Pineal region metastases are rare but often cause severe neurologic deficits. Surgical resection and chemoradiotherapy can provide therapeutic benefit. We investigated the literature to analyze clinical characteristics, management strategies, and survival of adult patients with pineal region metastases.

METHODS

PubMed, Embase, Scopus, and Cochrane were searched following the PRISMA guidelines, including studies reporting clinical outcomes of patients with pineal region metastases. Clinical presentation, management, and survival were reviewed.

RESULTS

We included 31 studies comprising 47 patients. Lung cancer (29.8%) and carcinomas of unknown origin (14.9%) were the most frequent primary tumors. In 48.9% of patients, symptomatic pineal metastases preceded primary tumor diagnosis. Headache (67.4%) and confusion (46.5%) were the most common symptoms. Parinaud syndrome (46.5%) and hydrocephalus (87.2%) were noted. Biopsy (65.9%) was preferred over resection (34.1%), and shunting strategies used were endoscopic third ventriculostomy (43.9%) and ventriculoperitoneal (26.8%). Eleven patients (32.3%) received adjuvant chemotherapy and 32 (68%) received radiotherapy. Posttreatment improvement in symptoms (56.6%) and hydrocephalus (80.5%) were noted. In patients who received adjuvant chemotherapy/radiotherapy, significant improvement in posttreatment performance status occurred with both biopsy (P < 0.001) and resection (P = 0.007). No survival differences were reported between surgery and biopsy (P = 0.912) or between complete and partial resection (P = 0.220). Overall survival was neither influenced by surgical approach (P = 0.157) nor by shunting strategy (P = 0.822). Mean follow-up was 8 months and median overall survival 3 months. Only 2 cases (4.8%) of pineal metastasis showed recurrence.

CONCLUSIONS

Pineal region metastases carry significant morbidity. Biopsy or surgical resection, combined with adjuvant chemotherapy/radiotherapy and/or shunting, may significantly improve performance status.

Quality of Life and Role of Palliative and Supportive Care for Patients With Brain Metastases and Caregivers: A Review

Brain metastases (BM) are the most commonly diagnosed secondary brain lesions in adults, influencing these patients' symptoms and treatment courses. With improvements in oncologic treatments, patients with BM are now living longer with their advanced cancers, and issues pertaining to quality of life become more pressing. The American Society of Clinical Oncology has recommended early implementation of palliative care for cancer patients, though incorporation and implementation of palliative and other supportive services in the setting of true multidisciplinary care requires additional attention and research for patients with intracranial metastases. We review the physical, cognitive, and psychosocial challenges patients with BM and their caregivers face during their cancer course as well as the current published research on quality of life metrics relating to this patient population and the diverse roles specialty palliative care, rehabilitation services, and other healthcare providers play in a comprehensive multidisciplinary care model.

Brain metastases: An update on the multi-disciplinary approach of clinical management

IMPORTANCE

Brain metastasis (BM) is the most common malignant intracranial neoplasm in adults with over 100,000 new cases annually in the United States and outnumbering primary brain tumors 10:1.

OBSERVATIONS

The incidence of BM in adult cancer patients ranges from 10-40%, and is increasing with improved surveillance, effective systemic therapy, and an aging population. The overall prognosis of cancer patients is largely dependent on the presence or absence of brain metastasis, and therefore, a timely and accurate diagnosis is crucial for improving long-term outcomes, especially in the current era of significantly improved systemic therapy for many common cancers. BM should be suspected in any cancer patient who develops new neurological deficits or behavioral abnormalities. Gadolinium enhanced MRI is the preferred imaging technique and BM must be distinguished from other pathologies. Large, symptomatic lesion(s) in patients with good functional status are best treated with surgery and stereotactic radiosurgery (SRS). Due to neurocognitive side effects and improved overall survival of cancer patients, whole brain radiotherapy (WBRT) is reserved as salvage therapy for patients with multiple lesions or as palliation. Newer approaches including multi-lesion stereotactic surgery, targeted therapy, and immunotherapy are also being investigated to improve outcomes while preserving quality of life.

CONCLUSION

With the significant advancements in the systemic treatment for cancer patients, addressing BM effectively is critical for overall survival. In addition to patient's performance status, therapeutic approach should be based on the type of primary tumor and associated molecular profile as well as the size, number, and location of metastatic lesion(s).

Consensus recommendations for a standardized brain tumor imaging protocol for clinical trials in brain metastases

A recent meeting was held on March 22, 2019, among the FDA, clinical scientists, pharmaceutical and biotech companies, clinical trials cooperative groups, and patient advocacy groups to discuss challenges and potential solutions for increasing development of therapeutics for central nervous system metastases. A key issue identified at this meeting was the need for consistent tumor measurement for reliable tumor response assessment, including the first step of standardized image acquisition with an MRI protocol that could be implemented in multicenter studies aimed at testing new therapeutics. This document builds upon previous consensus recommendations for a standardized brain tumor imaging protocol (BTIP) in high-grade gliomas and defines a protocol for brain metastases (BTIP-BM) that addresses unique challenges associated with assessment of CNS metastases. The "minimum standard" recommended pulse sequences include: (i) parameter matched pre- and post-contrast inversion recovery (IR)-prepared, isotropic 3D T1-weighted gradient echo (IR-GRE); (ii) axial 2D T2-weighted turbo spin echo acquired after injection of gadolinium-based contrast agent and before post-contrast 3D T1-weighted images; (iii) axial 2D or 3D T2-weighted fluid attenuated inversion recovery; (iv) axial 2D, 3-directional diffusion-weighted images; and (v) post-contrast 2D T1-weighted spin echo images for increased lesion conspicuity. Recommended sequence parameters are provided for both 1.5T and 3T MR systems. An "ideal" protocol is also provided, which replaces IR-GRE with 3D TSE T1-weighted imaging pre- and post-gadolinium, and is best performed at 3T, for which dynamic susceptibility contrast perfusion is included. Recommended perfusion parameters are given.

The value of DTI: achieving high diagnostic performance for brain metastasis

BACKGROUND

The evaluation of brain metastases generally requires post-contrast MRI exam, but some patients have contraindication to contrast medium administration.

PURPOSE

To investigate the value of the MRI diffusion tensor imaging (DTI) for detection of metastatic brain tumor.

MATERIALS AND METHODS

We retrospectively analyzed the MRI data from 23 patients (13 males and 10 females) with brain metastases. The MRI protocol consisted in T1WI, T2WI, post-contrast 3DT1WI and DTI images (b = 1000) sequences. The brain metastatic lesions were counted in each of these sequences. We compared the advantages and limitations of different sequences in the brain metastases detection. The number of metastatic lesions identified on the contrast-enhanced 3DT1WI image is used as the reference. FA values were measured in the intratumoral, adjacent peritumoral and distant peritumoral edema area (PTEA) of brain metastasis, and the differences were statistically analyzed.

RESULTS

DTI can detect more brain metastatic lesions rather than T1WI and T2WI. The number of brain metastases on DTI is similar to post-contrast 3D T1WI. There is no statistical difference in the FA value change between the adjacent and distant PTEA.

CONCLUSION

The DTI original image can be used as an alternative examination for patients with contraindications to contrast-enhanced MRI. It has high sensitivity to intratumoral hemorrhage, which has advantage to detect brain metastatic lesions as compared with T1WI or T2WI images.

Predicting Local Failure after Stereotactic Radiation Therapy in Brain Metastasis using Quantitative CT and Machine Learning

Despite recent advances in cancer treatment, the prognosis of patients diagnosed with brain metastasis is still poor. The median survival is limited to months even for patients undergoing treatment. Radiation therapy is a main component of treatment for brain metastasis. However, radiotherapy cannot control local progression in up to 20% of the metastatic brain tumours. An early prediction of radiotherapy outcome for individual patients could facilitate therapy adjustments to improve its efficacy. This study investigated the potential of quantitative CT biomarkers in conjunction with machine learning methods to predict local failure after radiotherapy in brain metastasis. Volumetric CT images were acquired for radiation treatment planning from 120 patients undergoing stereotactic radiotherapy. Quantitative features characterizing the morphology and texture were extracted from different regions of each lesion. A feature reduction/selection framework was adapted to define a quantitative CT biomarker of radiotherapy outcome. Different machine learning methods were applied and evaluated to predict the local failure outcome at pre-treatment. The optimum biomarker consisting of two features in conjunction with an AdaBoost with decision tree could predict the local failure outcome with 71% accuracy on an independent test set (20 patients, 31 lesions). This study is a step forward towards prediction of radiotherapy outcome in brain metastasis using quantitative imaging and machine learning.

Ulcerated breast cancer with single brain metastasis: A combined surgical approach. Clinical presentation at one year follow up - A case report

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Solitary brain metastasis of breast cancer in a patient with neurological symptoms as first presentation is a rare complication.

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Simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction is unusual event.

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Successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up.

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Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

Introduction

Breast cancer is the most common malignancy in woman. Approximately 5–10% of breast cancer occurs as de novo stage IV and some studies have shown that from 10% to 30% of those patients presents Brain Metastasis.

Presentation of case

In this study, we report a case of solitary brain metastasis of breast cancer in a 63-year-old Italian Caucasian woman with neurological symptoms as first clinical presentation. After the correct diagnosis and multidisciplinary meeting it was decided to simultaneously perform a metastasectomy surgery plus right mastectomy, right axillary dissection and immediate breast reconstruction. In our clinical practice we report a successful combined surgical approach in a stage IV de novo breast cancer patient with single site brain metastasis at one year follow-up.

Discussion

Metastasectomy plus mastectomy provided neurological control of acute complication of metastatic disease and complete breast cancer local control. One-time operation could be the best option when diagnosis of breast cancer is made thanks to the onset of oncological emergency like intracranial hypertension due to single brain metastasis.

Conclusion

Combined surgical approach offers the opportunity to treat two different oncological urgencies, reducing the unnecessary repeated surgical and anesthesiologic trauma.

Clinical characteristics of CNS metastases from primary gynecologic cancers

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Most common symptoms for patients with CNS metastases are headaches and ataxia.

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Multiple foci are more common than solitary lesions on initial brain imaging.

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The frontal lobe is most likely to be involved.

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GTN is diagnosed at a younger age when compared to other gynecologic cancers.

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More aggressive histologic subtypes confer an increased risk of CNS metastasis.

The development of brain and central nervous system (CNS) metastases from primary gynecologic cancers is an extremely uncommon but deadly process. Through this retrospective case series of patients treated at a single institution from 2004 to 2018, we aim to explore potential clinical patterns of this phenomenon with respect to primary tumor type, histology, and symptomatology.

A total of 42 patients were identified with CNS metastases, with 24 patients having endometrial cancer, 9 patients with ovarian cancer, 5 patients with cervical cancer, and 4 patients with gestational trophoblastic neoplasia (GTN). The two most common presenting complaints were headache and ataxia. Most patients (67%) presented with more than one lesion on imaging and the frontal lobe was most likely to be involved. The median age of diagnosis for both primary cancer and CNS metastasis were significantly younger in the GTN group when compared to other cancers. Meningeal involvement was more prevalent in patients with cervical cancer. Over 83% of endometrial cancer patients in this cohort had type II histologies, a significantly higher percentage than that in the general population.

While the rarity of CNS metastases in primary gynecologic malignancies precludes routine screening, patients diagnosed with more aggressive histologic subtypes of endometrial and uterine cancers may benefit from a lowered threshold of brain imaging in the context of new onset neurological symptoms.

Late-onset Metastasis of Intracranial Papillary Thyroid Carcinoma

BACKGROUND

Papillary thyroid carcinoma is the most common subtype of thyroid cancers, accounting for >90% of all thyroid carcinomas. Despite a favorable long-term survival rate of 94.4%, people with distant metastases show worse outcome. Cerebral metastases are slightly uncommon and stand for only 1%-3% of all metastases.

CASE DESCRIPTION

We present a 56-year-old male patient complaining of serious headaches for >20 days. He underwent thyroidectomy surgery 13 years ago due to papillary thyroid carcinoma and was reported "tumor free" on his follow-ups without any complaints. On his cranial magnetic resonance imaging scan a right temporal mass lesion was detected. During surgery, the tumor was removed and reported as papillary thyroid carcinoma metastasis.

CONCLUSION

A case in which a patient with papillary thyroid carcinoma developed brain metastasis after such a long time was not reported in the literature before.

Classifying brain metastases by their primary site of origin using a radiomics approach based on texture analysis: a feasibility study

OBJECTIVE

To examine the capability of MRI texture analysis to differentiate the primary site of origin of brain metastases following a radiomics approach.

METHODS

Sixty-seven untreated brain metastases (BM) were found in 3D T1-weighted MRI of 38 patients with cancer: 27 from lung cancer, 23 from melanoma and 17 from breast cancer. These lesions were segmented in 2D and 3D to compare the discriminative power of 2D and 3D texture features. The images were quantized using different number of gray-levels to test the influence of quantization. Forty-three rotation-invariant texture features were examined. Feature selection and random forest classification were implemented within a nested cross-validation structure. Classification was evaluated with the area under receiver operating characteristic curve (AUC) considering two strategies: multiclass and one-versus-one.

RESULTS

In the multiclass approach, 3D texture features were more discriminative than 2D features. The best results were achieved for images quantized with 32 gray-levels (AUC = 0.873 ± 0.064) using the top four features provided by the feature selection method based on the p-value. In the one-versus-one approach, high accuracy was obtained when differentiating lung cancer BM from breast cancer BM (four features, AUC = 0.963 ± 0.054) and melanoma BM (eight features, AUC = 0.936 ± 0.070) using the optimal dataset (3D features, 32 gray-levels). Classification of breast cancer and melanoma BM was unsatisfactory (AUC = 0.607 ± 0.180).

CONCLUSION

Volumetric MRI texture features can be useful to differentiate brain metastases from different primary cancers after quantizing the images with the proper number of gray-levels.

KEY POINTS

• Texture analysis is a promising source of biomarkers for classifying brain neoplasms. • MRI texture features of brain metastases could help identifying the primary cancer. • Volumetric texture features are more discriminative than traditional 2D texture features.

Brain metastases epidemiology in a Tunisian population: trends and outcome

AIM

We reported anatomo-clinical features of brain metastases (BMs) collected in a Tunisian medical oncology department.

PATIENTS & METHODS

We retrospectively identified all cases of BM within a cohort of 7055 patients, treated for a histologically confirmed nonhematological cancer between 2000 and 2016. Data about age, sex and primary tumor were collected.

RESULTS

Incidence was 1.9% and mean age was 54 years with a 1.24 sex ratio. BMs were symptomatic in 73.7% of cases after a median time of 16 months. A total of 73.4% patients receiving local therapy, 88% by whole brain radiation therapy and 21.6% had a metastasectomy. Lung and breast cancers were the primary in 80% of the BM.

CONCLUSION

BM showed trends of young with underestimated incidence.

Brain tumor delineation enhanced by moxifloxacin-based two-photon/CARS combined microscopy

Delineating brain tumor margin is critical for maximizing tumor removal while sparing adjacent normal tissue for better clinical outcome. We describe the use of moxifloxacin-based two-photon (TP)/coherent anti-Stokes Raman scattering (CARS) combined microscopy for differentiating normal mouse brain tissue from metastatic brain tumor tissue based on histoarchitectural and biochemical differences. Moxifloxacin, an FDA-approved compound, was used to label cells in the brain, and moxifloxacin-based two-photon microscopy (TPM) revealed tumor lesions with significantly high cellular density and invading edges in a metastatic brain tumor model. Besides, label-free CARS microscopy showed diminishing of lipid signal due to the destruction of myelin at the tumor site compared to a normal brain tissue site resulting in a complementary contrast for tumor detection. This study demonstrates that moxifloxacin-based TP/CARS combined microscopy might be advantageous for tumor margin identification in the brain that has been a long-standing challenge in the operating room.

The evolving clinical management of cerebral metastases

Concepts in the management of brain metastases are evolving. Until recently, brain metastases have been considered as a homogenous condition, managed with whole brain radiotherapy, surgical resection for large lesions and stereotactic radiosurgery for smaller lesions. Increasingly, specific systemic medical therapies are being used to treat brain metastases based on the primary site of disease. This disease specific management is causing a change in perspective about brain metastases and has led to improved survival for patients with primary disease subtypes amenable to tailored medical therapies. We review the recent literature to present evidence for the use of subtype specific medical therapies, advances in surgical resection techniques and stereotactic radiosurgery as the primary treatment modalities. The decline in use of whole brain radiotherapy as first line treatment is also discussed. Based on the recent literature, we propose a new management algorithm to reflect the progress in available options for tailoring disease specific treatments and support the change in paradigm to consider brain metastases as separate disease states based on the primary site of cancer rather than as a homogenous entity.

Brain Metastases: Surgical Treatment and Overall Survival

BACKGROUND

Brain metastases occur in 10%-40% of patients with cancer and are more common than primary brain tumors (30%-40%); their incidence is growing because of improvements in control of systemic disease, better radiologic detection, and prolonged survival. Modern treatment of brain metastases has dramatically changed the expected prognosis. Traditionally, the prognosis has been considered very poor, and patients were referred to palliative treatment because of their terminal stage; however, new prognostic indexes have been proposed to evaluate these patients. The aim of our study was to determine the long-term effect of surgery on overall survival (OS) in patients with brain metastases from dissimilar primary tumors and to identify prognostic variables associated with prolonged survival.

METHODS

We retrospectively reviewed a consecutive series of patients who underwent surgery between January 2010 and October 2014 for cerebral metastases from lung, kidney, breast, and gastrointestinal cancers and melanoma. Variables included age; sex; histology; location of lesions; and specific treatments patients had undergone including chemotherapy, radiotherapy, and surgery, individually or combined.

RESULTS

No patients deteriorated after surgery. At discharge, 19 patients (26.76%) had an unchanged postoperative neurologic examination, whereas 52 patients (73.23%) showed improvement (χ² = 34.84, P < 0.0001). Expected OS, considering all tumor subtypes, was 372.24 months; the patients in our series had an OS of 787 months, more than twice the expected OS; specifically, average expected survival of each patient was 5.24 months, whereas actual survival was 11.08 months (P = 0.000008).

CONCLUSIONS

Surgery is a safe and effective procedure for cerebral metastases and should not be considered an aggressive treatment in such disease. In our series, 55% of patients had a survival >6 months and a significant improvement in terms of actual versus expected survival. Surgical resection should be considered the primary option for patients with brain metastases.

Brain metastases: an overview

So far brain metastases represent a critical stage of a disease course and the frequency is increasing over the years. The treatment of brain metastases should be individualized for each patient: in case of single brain metastasis, surgery or radiosurgery should be considered as first options of treatment; in case of multiple lesions, whole-brain radiotherapy is the standard of care in association with systemic therapy or surgery/radiosurgery. Chemotherapy should be considered when surgery or radiation therapy are not possible. In the last decades, TKIs or monoclonal antibodies have shown increase in overall response rate and overall survival in Phase II-III trials. The aim of this paper is to make an overview of the current approaches in management of patients with brain metastases.

The role of magnetic resonance imaging in the management of brain metastases: diagnosis to prognosis

This article reviews the different MRI techniques available for the diagnosis, treatment and monitoring of brain metastases with a focus on applying advanced MR techniques to practical clinical problems. Topics include conventional MRI sequences and contrast agents, functional MR imaging, diffusion weighted MR, MR spectroscopy and perfusion MR. The role of radiographic biomarkers is discussed as well as future directions such as molecular imaging and MR guided high frequency ultrasound.

Brain metastases

Brain metastases are the most frequent neurological complication of cancer and the most common brain tumour type. Lung and breast cancers, and melanoma are responsible for up to three-quarters of metastatic brain lesions. Most patients exhibit either headache, seizures, focal deficits, cognitive or gait disorders, which severely impair the quality of life. Brain metastases are best demonstrated by MRI, which is sensitive but non-specific. The main differential diagnosis includes primary tumours, abscesses, vascular and inflammatory lesions. Overall prognosis is poor and depends on age, extent and activity of the systemic disease, number of brain metastases and performance status. In about half of the patients, especially those with widespread and uncontrolled systemic malignancy, death is heavily related to extra-neural lesions, and treatment of cerebral disease doesn't significantly improve survival. In such patients the aim is to improve or stabilize the neurological deficit and maintain quality of life. Corticosteroids and whole-brain radiotherapy usually fulfill this purpose. By contrast, patients with limited number of brain metastases, good performance status and controlled or limited systemic disease, may benefit from aggressive treatment as both quality of life and survival are primarily related to treatment of brain lesions. Several efficacious therapeutic options including surgery, radiotherapy and chemotherapy are available for these patients.

Stereotactic radiosurgery boost to the resection cavity for cerebral metastases: Report of overall survival, complications, and corticosteroid protocol

Background:

This report focuses on the overall survival and complications associated with treatment of cerebral metastases with surgical resection followed by stereotactic radiosurgery (SRS). Management and complications of corticosteroid therapy are underreported in the literature but represent an important source of morbidity for patients.

Methods:

Fifty-nine consecutive patients underwent surgical resection of a cerebral metastasis followed by SRS to the cavity. Patient charts were reviewed retrospectively to ascertain overall survival, local control, surgical complications, SRS complications, and corticosteroid complications.

Results:

Our mean follow-up was 14.4 months (median 12.0 months, range 0.9-62.9 months). Median overall survival in this series was 15.25 months and local control was 98.3%. There was a statistically significant survival benefit conferred by Radiation Therapy Oncology Group recursive partitioning analysis Classes 1 and 2. The surgical complication rate was 6.8% while the SRS complication rate was 2.4%. Corticosteroid complications are reported and dependence at 1 month was 20.3%, at 3 months 6.8%, at 6 months 1.7%, and at 12 months no patients remained on corticosteroid therapy.

Conclusions:

Overall survival and local control with this treatment paradigm compare well to the other published literature. Complications associated with this patient population are low. A corticosteroid tapering protocol is proposed and demonstrated lower rates of steroid-related complications and dependence than previously reported.

Risk of seizure and its clinical implication in the patients with cerebral metastasis from lung cancer

BACKGROUND

The prevalence, risk factors, and clinical implication of seizure development were investigated in patients with metastatic brain tumors.

METHODS

Medical records and radiological findings were analyzed retrospectively in 258 patients with brain metastasis from lung cancer who underwent Gamma Knife radiosurgery (GKS) between January 2008 and December 2009.

RESULTS

During the follow-up period 32 patients (12.4 %) experienced seizure episodes. Coexistence of leptomeningeal seeding was a significant risk factor related to development of seizure (p < 0.001). Prophylactic use of anticonvulsants was not correlated with reduction of seizure incidence (p = 0.818). Continued use of anticonvulsants was necessary in nine of the 258 patients (3.5 %) because of recurrent seizures. Imaging studies performed immediately after seizure attacks in the patients with known metastatic brain lesions revealed tumor progression or complications related to treatment in 35 of 42 episodes of seizure (77.8 %).

CONCLUSIONS

Patients with metastatic lesions have a substantial risk of developing seizure. Seizure in known metastatic brain tumor patients are usually related to disease progression or complications of treatment. Follow-up imaging should be considered for each seizure episode and adequate multimodal treatment needs to be added to antiepileptic medication.

Imaging of brain metastases

Imaging plays a key role in the diagnosis of central nervous system (CNS) metastasis. Imaging is used to detect metastases in patients with known malignancies and new neurological signs or symptoms, as well as to screen for CNS involvement in patients with known cancer. Computed tomography (CT) and magnetic resonance imaging (MRI) are the key imaging modalities used in the diagnosis of brain metastases. In difficult cases, such as newly diagnosed solitary enhancing brain lesions in patients without known malignancy, advanced imaging techniques including proton magnetic resonance spectroscopy (MRS), contrast enhanced magnetic resonance perfusion (MRP), diffusion weighted imaging (DWI), and diffusion tensor imaging (DTI) may aid in arriving at the correct diagnosis. This image-rich review discusses the imaging evaluation of patients with suspected intracranial involvement and malignancy, describes typical imaging findings of parenchymal brain metastasis on CT and MRI, and provides clues to specific histological diagnoses such as the presence of hemorrhage. Additionally, the role of advanced imaging techniques is reviewed, specifically in the context of differentiating metastasis from high-grade glioma and other solitary enhancing brain lesions. Extra-axial CNS involvement by metastases, including pachymeningeal and leptomeningeal metastases is also briefly reviewed.

Predicting compliance and survival in palliative whole-brain radiotherapy for brain metastases

OBJECTIVE

Brain radiotherapy is the main treatment for patients with brain metastases but its goal is just symptom control. Our aim was to study if different performance tools, used in geriatric practice, could improve patient selection for decision-making in the palliative brain radiotherapy setting.

PATIENTS AND METHODS

Data from 61 consecutive patients were analysed. In addition to Karnofsky Performance Status (KPS) their physical activity was assessed by means of the activity of daily living (ADL) and instrumental ADL (IADL) scales. A neurocognitive evaluation was performed with the Pfeiffer Short Portable Mental Status Questionnaire (SPMSQ) and with the Mini-Mental Status Exam (MMSE). Radiotherapy compliance and short survival were the endpoints of the study.

RESULTS

High rates of cognitive impairment were found by both neurocognitive tools (Pfeiffer: 19.7% of patients; MMSE: 30%). Dependence was also highly prevalent, either measured by the ADL (50.8%) or by the IADL (43.3%). Nearly one third (27.9%) of patients died soon after radiotherapy evaluation. Longer survival was related to female, younger than 60 years, breast cancer primary tumour, steroid response, RPA class, and higher performance and neurocognitive score tools. A premature death was associated with neurocognitive tools, IADL and longer interval from brain metastatic diagnosis to radiotherapy. Twenty-three percent of patients were not able to finish the WBRT course due to clinical deterioration. The only variable related to compliance was a low MMSE score.

CONCLUSIONS

Results suggest that the geriatric tools analysed could offer information on brain palliative radiotherapy complementary to that offered by the more usual tools. It will be interesting to study if our data could be extrapolated to the general palliative oncological field.

Comparison of C-11 methionine and C-11 choline for PET imaging of brain metastases: a prospective pilot study

PURPOSE

The aim of the study was the comparison of C-11 methionine (MET) and C-11 choline (CHO) in the positron emission tomography (PET) imaging of brain metastases in correlation to the histopathology findings in stereotactic biopsy.

METHODS

In all, 8 patients underwent MET and CHO PET and magnetic resonance imaging, in 7 of these, the metastases were previously treated by radiation therapy. Histopathologic diagnosis was made for each patient by frame-based stereotactic serial biopsy. Standardized uptake values of tumor uptake and lesion-to-normal brain tissue ratios (LNRs) of the lesions were determined. LNRs for each tracer were compared with the histopathology findings and follow-up.

RESULTS

In 6 patients, biopsy revealed viable metastases, 1 patient suffered from tumor recurrence in follow-up and 1 patient was tumor free in biopsy and follow-up. In the last mentioned patient, LNR was the lowest determined in all patients for CHO, but not for MET. Mean standardized uptake values of the lesions were in median 1.8 for MET and 1.1 for CHO, median LNRs were 1.5 for MET and 6.6 for CHO. LNRs for CHO were significant higher than those for MET (P = 0.007).

CONCLUSIONS

In the direct comparison to the well-established amino acid tracer MET, CHO seems to be promising for the imaging of brain metastases because of significantly higher LNRs in tumor tissue compared with MET without evidence for a lower specificity of CHO uptake.

[Management of brain metastases from non-small cell lung carcinoma]

INTRODUCTION

In France, approximately 30,000 new patients per year develop brain metastases (BM), most of them resulting from a lung cancer.

STATE OF THE ART

Surgery and radiosurgery of all the BM must be considered when possible. In other cases, whole brain radiotherapy remains the standard of care.

PERSPECTIVES

The role of chemotherapy, poorly investigated so far, should be revisited.

CONCLUSION

This review focused on BM secondary to a non-small cell lung carcinoma.

Increases in the number of brain metastases detected at frame-fixed, thin-slice MRI for gamma knife surgery planning

For gamma knife planning, 2.4-mm-slice MRIs are taken under rigid frame fixation, so tiny tumors become visible. This study evaluated differences in the numbers of brain metastases between conventional contrast-enhanced MRI (6 ± 1 mm slice thickness) taken before patient referral and contrast-enhanced MRI for gamma knife planning. The numbers of metastases on the 2 images were counted by at least 2 oncologists. For gamma knife planning, spoiled gradient-recalled echo images were obtained after 0.1 mmol/kg gadolinium administration using a 1.5-T system. Images from 1045 patients with an interval between the 2 MRI studies of 6 weeks or less were analyzed. Increases in the number of metastases were found in 33.7% of the 1045 patients, whereas the number was identical in 62.3%. In 4.0%, the number decreased, indicating overdiagnosis at conventional MRI. These proportions did not differ significantly by the interval before gamma knife. An increase from single to multiple metastases was found in 16.0%. Meningeal dissemination was newly diagnosed in 2.3%. On planning images, the proportions of patients with 1, 2, 3, and 4 or more lesions were 37.6%, 19.3%, 9.3%, and 33.8%, respectively. In cases of colorectal cancer and hepatoma, the proportions of patients with a single metastasis (32 of 61 [52%] and 5 of 6 [83%], respectively) were higher than that of patients with other malignancies. In about one-third of the patients, an increased number of metastases were found on the thin-slice images. This should be kept in mind when deciding the treatment strategy for brain metastases.

Detection of brain metastases from small cell lung cancer: consequences of changing imaging techniques (CT versus MRI)

BACKGROUND

The aims of this study were to show 1) the effect of changing from computed tomography (CT) to magnetic resonance imaging (MRI) on the prevalence of detected brain metastases (BM) in patients with newly diagnosed small cell lung cancer (SCLC); 2) the difference in survival between patients with single and multiple BM; and 3) the effect of the change in patient labeling on eligibility for prophylactic brain irradiation.

METHODS

From 1980 to 2004, 481 consecutive patients with SCLC were enrolled. Brain imaging was routinely performed after diagnosis of SCLC. At the start of 1991, MRI replaced CT in almost all patients. All patients were regularly examined by a neurologist.

RESULTS

The prevalence of detected BM was 10% in the CT era and 24% in the MRI era. In the CT era, all detected BM were symptomatic, whereas in the MRI era, 11% were asymptomatic. In both periods, patients labeled as single BM survived longer than those labeled as multiple BM. For patients labeled as single BM or multiple BM, survival was longer in the MRI era than in the CT era. The proportion of patients who were eligible for prophylactic cranial irradiation was lower in the MRI era.

CONCLUSIONS

The estimated prevalence of BM increases when MRI is used instead of CT. Patients with a detected single BM survive longer than patients with multiple BM. The apparently increased survival in the MRI era can be attributed to the "Will Rogers phenomenon". The use of MRI makes fewer patients eligible for prophylactic cranial irradiation.

Current therapeutic options for breast cancer central nervous system metastases

OPINION STATEMENT

Breast cancer metastases to the central nervous system (CNS) has devastating consequences for the individual. As treatment options for metastatic breast cancer expand and as quality of life and overall survival improve, researchers are targeting potential treatments for this sanctuary site. Attention is now being focused on defining the phenotype of breast cancer that has a propensity to metastasize to the CNS. Specific therapies that penetrate the blood brain barrier as well as adjuvant therapies that decrease recurrence in the CNS are currently being investigated. We will review current approaches to the diagnosis, evaluation, and treatment of CNS metastases in breast cancer patients.

Brain metastasis from non-seminomatous germ cell tumor of the testis

Brain metastasis occurs rarely in patients with testicular cancer in the modern era where cisplatin-based chemotherapy regimens are used. The occurrence of brain metastasis can be synchronous or metachronous (with or without concurrent systemic disease). Long-term survival can be achieved in some patients. The vast majority of testicular cancer cases with brain metastasis reported in the literature involve nonseminomatous germ cell tumor and this subtype will be the focus of this review. This article reviews the literature of the diagnosis and management of brain metastasis from nonseminomatous germ cell tumor of the testis.

Improving lesion detection and visualization: implications for neurosurgical planning and follow-up

Contrast-enhanced magnetic resonance (MR) imaging is considered the most sensitive method for detecting tumors in the central nervous system (CNS). The primary objective is to improve lesion detection, delineation, and characterization (benign or malignant) in order to more accurately define the location, extent, and type of disease and the appropriate treatment option for improved patient outcome (surgical intervention, radiation therapy or cytotoxic chemotherapy). This article reviews the various types of tumor occurring in the brain and the specific role of contrast-enhanced MR imaging for the evaluation of these tumors. Emphasis is placed on the value of contrast-enhanced MR imaging in the evaluation of primary intra-axial brain lesions and how high relaxivity contrast agents such as MultiHance (Bracco Imaging, Milan, Italy) might improve detection, treatment planning, and follow-up.

Evaluation of intraaxial enhancing brain tumors on magnetic resonance imaging: intraindividual crossover comparison of gadobenate dimeglumine and gadopentetate dimeglumine for visualization and assessment, and implications for surgical intervention

Object

The goal in this article was to compare 0.1 mmol/kg doses of gadobenate dimeglumine (Gd-BOPTA) and gadopentetate dimeglumine, also known as gadolinium diethylenetriamine pentaacetic acid (Gd-DTPA), for enhanced magnetic resonance (MR) imaging of intraaxial brain tumors.

Methods

Eighty-four patients with either intraaxial glioma (47 patients) or metastasis (37 patients) underwent two MR imaging examinations at 1.5 tesla, one with Gd-BOPTA as the contrast agent and the other with Gd-DTPA. The interval between fully randomized contrast medium administrations was 2 to 7 days. The T1-weighted spin echo and T2-weighted fast spin echo images were acquired before administration of contrast agents and T1-weighted spin echo images were obtained after the agents were administered. Acquisition parameters and postinjection acquisition times were identical for the two examinations in each patient. Three experienced readers working in a fully blinded fashion independently evaluated all images for degree and quality of available information (lesion contrast enhancement, lesion border delineation, definition of disease extent, visualization of the lesion's internal structures, global diagnostic preference) and quantitative enhancement (that is, the extent of lesion enhancement after contrast agent administration compared with that seen before its administration [hereafter referred to as percent enhancement], lesion/brain ratio, and contrast/noise ratio). Differences were tested with the Wilcoxon signed-rank test. Reader agreement was assessed using kappa statistics.

Significantly better diagnostic information/imaging performance (p < 0.0001, all readers) was obtained with Gd-BOPTA for all visualization end points. Global preference for images obtained with Gd-BOPTA was expressed for 42 (50%), 52 (61.9%), and 56 (66.7%) of 84 patients (readers 1, 2, and 3, respectively) compared with images obtained with Gd-DTPA contrast in four (4.8%), six (7.1%), and three (3.6%) of 84 patients. Similar differences were noted for all other visualization end points. Significantly greater quantitative contrast enhancement (p < 0.04) was noted after administration of Gd-BOPTA. Reader agreement was good (κ > 0.4).

Conclusions

Lesion visualization, delineation, definition, and contrast enhancement are significantly better after administration of 0.1 mmol/kg Gd-BOPTA, potentially allowing better surgical planning and follow up and improved disease management.

Update in the treatment of brain metastases from lung cancer

Brain metastases from lung cancer represent a prevalent and challenging clinical dilemma. The brain is an extremely common site of failure for non-small-cell lung cancer and small-cell lung cancer, often as a solitary site of disease. Despite steady research developments during recent years, survival rates remain poor. Some research suggests that the outcomes and characteristics of brain metastases that result from lung cancer primary sites are perhaps different than those from other primary sites. Clinical treatment strategies should therefore be adjusted accordingly. This article reviews the clinical characteristics, prognostic factors, and treatment strategies of brain metastases from lung cancer with a particular emphasis on recent research developments in the field.