Chirurgie des métastases cérébrales Dr Mark Dexter Head, Department of Neurosurgery The Westmead Hospitals
The Westmead patient population
THE INCONVENIENT TRUTHS Cerebral metastases occur in 10 16 % of patients with metastatic breast disease. 72 % of patients have multiple brain metastases. Overall median survival following diagnosis of cerebral metastases in breast cancer 5.6-6.6 months. With improved chemotherapy number of cerebral metastases is likely to increase.
SOURCES OF CEREBRAL METASTASES IN ADULTS LUNG 46 % BREAST 10 % SKIN / MELANOMA 4 % COLON 3 % LIVER / PANCREAS 2 % PROSTATE 2 % LYMPHOMA 1 % RENAL 1 %
FREQUENCY OF BRAIN METS IN ADULTS AT AUTOPSY SKIN / MELANOMA 48 % LUNG 32 % BREAST 21% THYROID 17% SARCOMA 15% RENAL 11% LEUKAEMIA 8 % COLON 6 % OTHER 19 %
Neuro-oncology oncology multi-disciplinary Oncology Database Allied Health team Nursing Intensive Care Neurology / Epilepsy Neurooncology strategy Anaesthetics Neurosurgery Radiotherapy Imaging Pathology
MDT circa 1990
Potential Roles for Neurosurgery in Cancer Patients Establish histological diagnosis Cytological reductions prior to chemotherapy or radiotherapy Symptomatic improvement/control Rarely curative resection Part of a multi-disciplinary team.
What has changed in Neurosurgery? With improvements in chemotherapy and radiation therapy, both the impact and incidence of CNS involvement is increasing. Altered patient expectations. Quality of life. Cosmesis and reconstructions. Minimally invasive surgery. Stereotactic radiosurgery.
Case One 41 year old male with 7 days of headache, nausea, vomiting and intermittent confusion. No significant medical history. Previous smoker. CT imaging of the brain -multiple lesions. CT imaging of the chest, abdomen and pelvis showed no abnormality.
Case One
Case One Stereotactic right parietal keyhole craniotomy. Discharged home on second post operative day. Histology shows metastatic small cell lung cancer. Palliative whole brain radiotherapy. Systemic chemotherapy. Died after 7 months.
Demographic changes in Intracranial Metastatic Disease Most common brain tumour seen by neurosurgeons. 25% of patients will develop cerebral metastatic disease. Increasing incidence of cerebral metastases due to: Increasing survival of cancer patients Enhanced ability to detect metastatic disease. Presence of blood-brain barrier.
Clinical Presentation Raised intracranial pressure Focal signs: 80% in cerebrum 16% in cerebellum 3% in brain stem Seizures: 15% -25% of patients
Investigation and Imaging MRI Systemic staging: CT scan of the chest, abdomen and pelvis PET-FDG If a patient has a single supratentorial lesion and a history of treated malignancy then in 93%, the lesion will be metastatic. If there is no history of malignancy and a normal chest x-ray: 7% metastatic 87% primary malignancy 6% non-neoplastic
Research and Advances in Neuroimaging and Diagnosis
3 T MRI and Brain Tumours
Neurosurgical Procedures for Intracranial Metastatic Disease Biopsy for histological diagnosis. Craniotomy to remove 1 or more symptomatic lesions. Placement of an intraventricular reservoir.
Neurosurgical Procedures for Intracranial Metastatic Disease Primary role of surgery is treatment of single brain metastases in patients with controlled or controllable systemic cancer. Major factors affecting survival: Extent of systematic disease Condition (ECOG status) prior to surgery Histological diagnosis is important: 11% of patients with lesions on MR imaging, with a history of cancer treated in preceding 5 years, do not have metastases.
Advances in Surgical Techniques Image guided surgery Minimally invasive surgery Cortical mapping Awake craniotomy Cosmesis and reconstruction
CNS Metastatic Disease Collaboration between neurosurgery, radiation oncology, medical oncology and the respiratory medicine teams. Goal of therapy is to maintain acceptable quality of life and extend survival.
CASE 2 61 F PRESENTS WITH HEADACHE AND RIGHT HEMIPARESIS. 13 MONTHS POST-MASTECTOMY SOLITARY BRAIN LESION ON CT & MRI. NO EXTRACRANIAL DISEASE