Cerebral Metastases In Patients Research Articles

Brain metastases

Cerebral metastases in patients with metastatic lung cancer are found in more than 30% of patients at baseline and manifest themselves in two out of three patients during disease evolution. For a long time, the cerebral manifestation of the disease was classified as prognostically unfavorable and hence such patients were regularly excluded from therapy studies. In the context of targeted molecular therapy strategies and established immuno-oncological systemic therapies, the blood-brain barrier no longer represents an insurmountable barrier. However, the treatment of brain metastases requires decision making in a multidisciplinary team within dedicated lung cancer and/or oncology centers. The differentiated treatment decision is based on the number, size and location of the brain metastases, neurology and general condition, comorbidities, potential life expectancy and the patient's wishes, but also tumor biology including molecular targets, extra-cranial tumor burden and availability of a CNS-effective therapy. Systemic therapies as well as neurosurgical and radiotherapeutic concepts are now often combined for optimized and prognosis-improving therapeutic strategies.

Surgical treatment of patients with cerebral metastases in the motor area

Introduction. The surgical stage takes an important place in the complex treatment of patients with cerebral metastases of malignant tumors. In general, all efforts during surgical intervention should be aimed at restoring a good functional status, since severe neurological symptoms can deprive patients of the opportunity to continue complex treatment, which will negatively affect overall survival. The most pronounced neurological symptoms are observed in patients with metastases in the motor area. In this article, we tried to substantiate the need for surgery of cerebral metastases in patients with severe motor deficits, evaluate the results of surgical treatment and also to develop optimal surgical removal techniques.The study object – to assess the effectiveness of surgical removal of metastases in the motor cortex by evaluating the dynamics of motor function recovery and regression of paroxysmal symptoms.Materials and methods. An analysis of the surgical treatment of 18 patients with metastases in the motor area was carried out. Tumor localization was verified using magnetic resonance imaging, before surgery, neuronavigation system Brainlab during surgery. Мagnetic resonance tractography made it possible to assess the localization and degree of compression of the fibers of the cortico-spinal tract. Functional monitoring was not performed during the operation. The operations were performed using a ZEISS OPMI PENTERO 800 microscope.Results. Recovery of motor function after surgery was noted in 17 (94.5 %) cases. It was complete or partial. With metastases of a solid, solid-necrotic, solid-cystic structure, regression of pyramidal symptoms developed gradually, starting from 4 days after surgery. As a rule, rehabilitation therapy (therapeutic exercise, massage, electromyostimulation) is carried out on patients from 3 days after surgery, which accelerated the recovery process. The maximum effect developed on the 15th day after the operation. Faster recovery of motor function was observed in patients with large cystic metastases who underwent surgery in the volume of Ommaya reservoir implantation. They began to recover motor function a few hours after awakening. Regression of paroxysmal symptoms was noted in all cases. Although the patients continued to take anticonvulsants. The observation period was 6 months.Сonclusion. Surgical removal of cerebral metastases in the motor area allows achieving complete or partial regression of neurological symptoms. At the same time, the recovery period is short – from several hours to 14 days. It becomes possible to cancel glucocorticoids 7–10 days after the operation. Conditions are being created for the continuation of complex treatment of patients previously considered incurable.

A preliminary PET radiomics study of brain metastases using a fully automatic segmentation method

BackgroundPositron Emission Tomography (PET) is increasingly utilized in radiomics studies for treatment evaluation purposes. Nevertheless, lesion volume identification in PET images is a critical and still challenging step in the process of radiomics, due to the low spatial resolution and high noise level of PET images. Currently, the biological target volume (BTV) is manually contoured by nuclear physicians, with a time expensive and operator-dependent procedure.This study aims to obtain BTVs from cerebral metastases in patients who underwent L-[11C]methionine (11C-MET) PET, using a fully automatic procedure and to use these BTVs to extract radiomics features to stratify between patients who respond to treatment or not. For these purposes, 31 brain metastases, for predictive evaluation, and 25 ones, for follow-up evaluation after treatment, were delineated using the proposed method. Successively, 11C-MET PET studies and related volumetric segmentations were used to extract 108 features to investigate the potential application of radiomics analysis in patients with brain metastases. A novel statistical system has been implemented for feature reduction and selection, while discriminant analysis was used as a method for feature classification.ResultsFor predictive evaluation, 3 features (asphericity, low-intensity run emphasis, and complexity) were able to discriminate between responder and non-responder patients, after feature reduction and selection. Best performance in patient discrimination was obtained using the combination of the three selected features (sensitivity 81.23%, specificity 73.97%, and accuracy 78.27%) compared to the use of all features. Secondly, for follow-up evaluation, 8 features (SUVmean, SULpeak, SUVmin, SULpeak prod-surface-area, SUVmean prod-sphericity, surface mean SUV 3, SULpeak prod-sphericity, and second angular moment) were selected with optimal performance in discriminant analysis classification (sensitivity 86.28%, specificity 87.75%, and accuracy 86.57%) outperforming the use of all features.ConclusionsThe proposed system is able i) to extract 108 features for each automatically segmented lesion and ii) to select a sub-panel of 11C-MET PET features (3 and 8 in the case of predictive and follow-up evaluation), with valuable association with patient outcome. We believe that our model can be useful to improve treatment response and prognosis evaluation, potentially allowing the personalization of cancer treatment plans.

Risk factors for in-brain local progression in elderly patients after resection of cerebral metastases

Intracranial metastases are the most frequent brain tumor with recurrence rates after treatment of around 40–60%. Age is still considered a determinant of treatment and prognosis in this pathology. Recent studies analyzing the impact of metastasectomy in elderly patients focused on reporting perioperative mortality and morbidity rates but not on the evaluation of oncological outcome parameters. Aim of this study is to determine risk factors for in-brain local recurrence after brain surgery in this sub-population. From October 2009 until September 2016 all patients aged 65 years and above with histopathologically confirmed metastasis after surgical resection were retrospectively studied. Clinical, radiological and perioperative information was collected and statistically analysed. Follow-up consisted of clinical and radiological assessment every 3-months following surgery. 78 patients were included, of these 50% were female (39 patients). Median age was 71 years (66–83). Early postoperative-MRI verified a complete surgical resection in 41 patients (52.6%) and showed a tumor-remnant in 15 patients (19.2%). In 22 patients the MRI result was inconclusive (28.2%). None of the patients experienced severe complications due to surgery. The median postoperative NIHSS was adequate 1 ± 1.4 (0–6), nonetheless, insignificantly improved in comparison to the preoperative NIHSS (p = 0.16). A total of 20 patients (25.6%) presented local recurrence. The only statistically significant factor for development of local in-brain recurrence after resection of cerebral metastases in patients above 65 years of age was a tumor-remnant in the early postoperative MRI (p = 0.00005). Median overall survival was 13 months. Local in-brain recurrence after surgical resection of a cerebral metastasis in patients above 65 years of age was 25.6%. In our analysis, tumor-remnant in early postoperative MRI is the only risk factor for local in-brain recurrence. Oncological parameters in the present cohort do not seem to differ from recent phase III studies with non-geriatric patients. Nevertheless, controlled studies on the impact of metastasectomy in elderly patients delivering high quality reliable data are required.

Predicting Survival After Whole-brain Irradiation for Cerebral Metastases in Patients with Cancer of the Bladder.

This study aimed to create a predictive tool for estimating the remaining lifespan of patients after whole-brain irradiation (WBI) for cerebral metastases from bladder cancer. In 34 of these patients clinical parameters were analyzed for survival including age at start of WBI, gender, Karnofsky score, number of cerebral metastases and involvement of extra-cranial sites of metastasis. Involvement of extra-cranial sites (14%) and Karnofsky score (9%) showed the greatest difference regarding 6-month survival and were considered for the tool. Points were assigned based on the following: no involvement of extra-cranial sites=1 point, involvement of extra-cranial sites=0 points, Karnofsky score ≥70=1 point, Karnofsky score ≤60=0 points. Patients' scores were 0, 1 or 2 points with 6-month survival rates of 13%, 27% and 50%, respectively. Based on two clinical parameters, a tool was developed that may help estimate the lifespan of patients irradiated for cerebral metastases from bladder cancer.

Cerebral Metastases in Patients with Left Atrial Myxoma

We describe two cases of cardiac myxomas with cerebral metastases and review the literature on this subject. doi: 10.1111/jocs.12727 (J Card Surg 2016;31:289-293).

Relating neurological symptoms to cerebral metastases at the time of initial staging scan

Aims Cerebral metastases represent a significant obstacle in the treatment of patients with systemic malignancies, occurring in 10-30% of patients with cancer. Brain imaging in neuro-asymptomatic patients is advised for some malignancies but not for others. Our aim was to examine the incidence of cerebral metastases in patients with a new diagnosis of the primary malignancies that commonly spread to the brain, and relate this with the patients’ neurological symptoms, if any.

FC8 Efficiency of total body 18F PET/CT in the detection of cerebral metastases in patients with advanced melanoma

Objective Melanoma has a strong tendency for metastasis within the brain. There are no validated recommendations for the surveillance of the brain in patients undergoing treatment for advanced melanoma. We investigated the value of including the brain in the field of view (FOV) of total body FDG-PET/CT scans in patients with advanced melanoma who clinically were not suspected to have brain involvement. Materials and method Melanoma patients who were examined between 01-04-2008 and 30-11-2009, by total body FDG-PET/CT (including the entire brain in the FOV) and subsequent MRI within three months of the FDG-PET/CT were identified in our institutional data base. The CT portion of the FDG-PET/CT-scan was acquired in the venous phase after IV-contrast administration. MRI of the brain included gadolinium enhanced T1, T2 and FLAIR sequences. Results A total of 49 examinations were identified in 34 patients [17 M, 17 F; mean age, 52.7 y (range 26–80 y)]. The average time interval between FDG-PET/CT and MRI was 15.8 days. Seventy-three lesions suggesting the presence of brain metastases were identified by FDG-PET/CT (36 were only identified on CT, 34 were identified on both FDG-PET and CT; 26 were hypometabolic and 8 hypermetabolic; 3 lesions were identified only on FDG-PET/CT as focal hypermetabolic areas). One hundred thirty-three lesions were identified by subsequent MRI. When compared to MRI, FDG-PET/CT had a sensitivity of 55% for detecting individual lesions; no true negative lesions were present. When considering the results per examination, 22/49 FDG-PET/CT examinations were considered positive for the presence of CNS involvement and all of these cases were confirmed by MRI. MRI demonstrated brain metastases in 23 patients. In 18 patients suspicious lesions were identified both on FDG-PET/CT, as well as on contrast enhanced CT, whereas in 4 cases lesions were only detected on CT. The sensitivity, specificity, and accuracy of FDG-PET/CT scans compared to the MRI was 96%, 100%, and 98% respectively. Conclusion Including the brain in the FOV for follow-up of advanced melanoma with FDG-PET/CT is useful to detect brain metastases at an early stage. This could potentially lead to more efficient treatment and prevention of CNS metastasis related morbidity. We therefore recommend the inclusion of the brain in the FOV in patients undergoing FDG-PET/CT during follow-up for advanced melanoma. MRI remains the method of choice for further evaluation of the brain when metastases are identified on FDG-PET/CT or in case of a negative FDG-PET/CT with suspicious clinical findings.

Evaluating novel radiation techniques for the treatment of cerebral metastases

Evaluating novel radiation techniques for the treatment of cerebral metastases

Metástasis neurológicas secundarias a tumor testicular germinal

Neurological metastases secondary to urological tumors account for 12% overall. The ones derived from germ cells testicular tumors are exceptional in the age of cisplatin. We report one case of mixed germ cell tumor in a 49-year-old male patient treated with systemic chemotherapy during 18 months before presenting with severe central and peripheral neurological symptoms leading to death due to massive cerebral hemorrhage. We describe three types of presentation of cerebral metastases in patients with testicular cancer. Type I present synchronically with the primary tumor. Type 2 are diagnosed after a period of remission after conventional cytostatic treatment. Type 3 metastases are diagnosed during the course of the disease and its treatment. Except unique metastases classified in groups 1 and 2, which are susceptible of surgery or radiosurgery, in which in response may be expected; the rest of lesions secondary to germ cell tumors have an ominous prognosis and outcomes, with short survivals.

Ovarian cancer presenting as chest wall subcutaneous nodule: A case report and a literature review

Background. Distant metastasis from primary epithelial ovarian carcinoma is commonly found as nodal and intraperitoneal spread, spread via haematogenous routes or transcoelomic spread. [Rose PG, Piver MS, Tsukada Y, Latus. Metastatic patterns in histologic variants of ovarian cancer. An autopsy study. Cancer 1989;64(7):1508–13; McLaughlin JE, Diebold MD, Rigaud C. Blood borne metastases from an immature teratoma of the ovary in a 36 yr old woman. Histopathology 1989;15(5):546–50] Ovarian cancer presents in different ways, but common presentations include abdominal pain, distention or ascites due to metastatic involvement of peritoneal cavity. Most tumour present at advanced stage and distant metastases to common and uncommon sites are found in patients who have undergone treatment for primary ovarian cancer. [LeRoux PD, Berger MS, Elliott JP, Tamimi HK. Cerebral metastases from ovarian carcinoma. Cancer 1991;67(8):2194–9; Hardy JR, Harvey VJ. Cerebral metastases in patients with ovarian cancer treated with chemotherapy. Gynaecol Oncol 1989;33(3):296–300; Mayer RJ, Berkowitz RS, Griffiths CT. Central nervous system involvement by ovarian carcinoma: a complication of prolonged survival with metastatic disease. Cancer 1978;41(20):776–83] Subcutaneous metastatic nodules from primary ovarian cancer are rarely found in advanced disease [Dapulat J, Hacker NF, Nieberg RK, Berek JS, Rose TP, Sagar S. Distant metastases in epithelial ovarian carcinoma. Cancer 1987;60(7):1561–66]. We describe a case of asymptomatic ovarian carcinoma presenting as a chest wall nodule. Case. An unusual case of primary ovarian carcinoma presenting as asymptomatic chest wall subcutaneous nodules that subsequently were diagnosed as metastatic lesions. Conclusion. An unusual case of ovarian carcinoma where the patient was totally asymptomatic and referred with two tiny subcutaneous nodules. Therefore, lumps of recent onset, although asymptomatic, should either have fine needle aspiration cytology or excision biopsy.

The value of performing head CT in screening for cerebral metastases in patients with potentially resectable non-small cell lung cancer: experience from a UK cardiothoracic centre

AIM: To evaluate the whether screening for cerebral metastases in neurologically intact patients with potentially resectable non-small cell lung cancer patients is both worthwhile and cost-effective. METHODS: We prospectively performed computed tomography (CT) of the head in 105 consecutive patients with potentially resectable lung cancer over an 18-month period. None of these patients had neurological symptoms or signs. RESULTS: Five patients (4.8%) with cerebral metastases were identified using CT. At our institution the financial saving of avoiding five thoracotomies was £45,000, whilst the cost of performing 105 head CTs was £16,000. This represented a substantial saving for the healthcare provider and preserved the quality of life in five patients. CONCLUSIONS: We conclude that screening for cerebral metastases in neurologically intact patients with potentially resectable non small cell lung cancer patients is both worthwhile and cost effective.

Cerebral metastasis from a primary adenocarcinoma of the fallopian tube

BackgroundPrimary adenocarcinoma of the fallopian tube is a rare disease, and cerebral metastasis from this tumor is an extremely rare event. CaseA 61-year-old female, who had been thought to be in a disease-free state after the initial treatment for stage IIIc fallopian tube adenocarcinoma, presented with severe headache, dizziness, nausea, and vomiting. Brain CT and MRI revealed solitary metastatic lesion in the cerebrum, which was the only site of recurrence. It was removed surgically, followed by platinum-based combination chemotherapy, and a clinical remission was achieved for 36 months. ConclusionAttention should be paid to the possibility of cerebral metastasis in patients who develop neurogenic signs and symptoms. Prolonged survival could be achieved with aggressive treatment containing surgical debulking and adjuvant chemotherapy for solitary cerebral metastasis.

Incidence of cerebral metastases in patients treated with trastuzumab for metastatic breast cancer.

Trastuzumab is an effective treatment for patients with metastatic breast cancer (MBC) that overexpresses HER-2. A high incidence of brain metastases (BM) has been noted in patients receiving trastuzumab. A retrospective chart review was conducted of 100 patients commencing trastuzumab for metastatic breast cancer from July 1999 to December 2002, at the Christie Hospital. Seven patients were excluded; five patients developed central nervous system metastases prior to starting trastuzumab, and inadequate data were available for two. Out of the remaining 93 patients, 23 (25%) have developed BM to date. In all, 46 patients have died, and of these 18 (39%) have been diagnosed with BM prior to death. Of the 23 patients developing BM, 18 (78%) were hormone receptor negative and 18 (78%) had visceral disease. Univariate analysis showed a significant association between the development of cerebral disease and both hormone receptor status and the presence of visceral disease. In conclusion, a high proportion of patients with MBC treated with trastuzumab develop symptomatic cerebral metastases. HER-2-positive breast cancer may have a predilection for the brain, or trastuzumab therapy may change the disease pattern by prolonging survival. New strategies to address this problem require investigation in this group of patients.

Cytoplasmic expression of nm23 predicts the potential for cerebral metastasis in patients with primary cutaneous melanoma

The authors wish to apologise for writing the name of the final author of this paper incorrectly. The correct way to write his name is C. Soon Lee.

High incidence of cerebral metastases in patients with metastatic breast cancer treated with trastuzumab

High incidence of cerebral metastases in patients with metastatic breast cancer treated with trastuzumab

Unusual Metastatic Features in a Patient with Concomitant Malignant Orbital Melanoma and Prostate Carcinoma

A 73-year-old man with a history of malignant orbital melanoma and prostate carcinoma was admitted for progressive visual disturbance. Brain magnetic resonance imaging showed a suprasellar enhancing nodular lesion with major impingement on the anterior optical ways and sellar invasion. The extensive imaging work-up could not demonstrate with certainty its origin. Surprisingly, the transphenoidal biopsy of this patient revealed a prostate cancer metastasis outlining the importance of a histopathological diagnosis of cerebral metastases in patients with multiple malignancies when there is a doubt about the nature of the lesion.

Importance of MR technique for stereotactic radiosurgery.

We investigated how frequently the imaging procedure we use immediately prior to radiosurgery--triple-dose gadolinium-enhanced MR performed with the patient immobilized in a nonrelocatable head frame and 1-mm-thick MPRAGE (magnetization-prepared rapid gradient echo) images (SRS3xGado)-identifies previously unrecognized cerebral metastases in patients initially imaged by conventional MR with single-dose gadolinium (1xGado). Between July 1998 and July 2000, the diagnoses established for 47 patients who underwent radio-surgical procedures for treatment of cerebral metastases at The Gamma Knife Center of New York University were based initially on the 1xGado protocol. In July 1998, we began using SRS3xGado as our routine imaging protocol in preparation for targeting lesions for radio-surgery, using triple-dose gadolinium and acquisition of contiguous 1-mm Tl-weighted axial images. Because our SRS3xGado scans sometimes unexpectedly revealed additional metastases, we sought to learn how frequently the initial 1xGado scans would underestimate the number of metastases. We therefore reviewed the number of brain metastases identified on the SRS3xGado studies and compared the results to the number found by the 1xGado protocol, which had initially identified the brain metastases. Additional metastases, ranging from 1 to 23 lesions per patient, were identified on the SRS3xGado scan in 23 of 47 patients (49%). In 57% of the 23 patients, only one additional lesion was identified. The mean time interval between the 1xGado and the SRS3xGado scans was 20.6 days (range, 4-83 days), and the number of additional lesions detected and the time interval between two scans were negatively correlated (-0.11). The number of lesions detected on the SRS3xGado was associated only with the number of lesions on the 1xGado and not with any other patient or tumor pretreatment characteristics such as age, gender, largest tumor volume on the 1xGado, or number of days between the 1xGado and the SRS3xGado or prior surgery. The identification of additional lesions with SRS3xGado MR may have implications for patients who are treated with stereotactic radiosurgery alone (without whole-brain irradiation) with single-dose gadolinium imaging, in that unidentified lesions may go untreated. As a result of these findings we continue to use and advocate SRS3xGado scans for radiosurgery.

Listerienmeningitis bei metastasiertem Mammakarzinom - ein Fallbericht

The risk of cerebral metastasis in patients with breast cancer is associated with the duration of the disease and the number of chemotherapy regimens received. Infectious diseases of the central nervous system can cause similar symptoms as cerebral metastases and should be included in the differential diagnosis of patients with central nervous symptoms. We describe a 58-year-old woman with metastatic breast cancer who was referred for evaluation for cerebral metastases or carcinomatous meningitis. Breast cancer had been diagnosed 8 years previously and treated with surgery and antiestrogens. Recurrence 3 years later was treated with a number of chemotherapy regimens, most recently docetaxel and vinorelbine, Lumbar puncture showed meningitis due to Listeria. Despite prompt treatment with penicillin and aminoglycosides the patient died of complications of meningitis.

Cerebral metastasis in patients with uterine cervical cancer.

We report on eight patients who developed brain metastases following uterine cervical cancer. The mean interval between diagnosis of the primary cancer and diagnosis of the brain metastasis was 28.4 months (range: 6.1-61.8 months). Nausea and vomiting due to increased intracranial pressure were the most frequent symptoms. Surgical excision of the brain lesions, followed by postoperative radiotherapy, was performed in three patients. The other five patients received only cranial radiotherapy. When the metastatic brain lesions were detected, other distant metastatic lesions were confirmed at the same time in five patients. The median survival time after diagnosis of the brain metastases was only 3.0 months.