Elsevier

Mayo Clinic Proceedings

Volume 69, Issue 11, November 1994, Pages 1062-1068
Mayo Clinic Proceedings

Brain Metastatic Lesions

https://doi.org/10.1016/S0025-6196(12)61374-3Get rights and content

Objective

To describe current concepts in the diagnosis and treatment of brain metastases.

Results

More than 25% of all autopsy-proven brain metastases have a pulmonary source. Most brain metastases manifest with a combination of focal and generalized symptoms and signs. Typically, patients have subacute, progressive symptoms. In most situations, a computed tomographic scan of the head provides sufficient neuroimaging and allows one to monitor the effects of therapy. Magnetic resonance imaging has become increasingly useful in the diagnosis and management of brain metastases. It can detect computed tomographic occult metastases, identify associated leptomeningeal disease, and reveal early therapeutic complications.

Conclusion

Treatment options for patients with brain metastases include corticosteroids, whole-brain radiation therapy (WBRT), surgical intervention, stereotactic radiosurgical techniques, and chemotherapy. Corticosteroids produce prompt improvement in most patients; however, prolonged use is associated with considerable risks. For most patients, WBRT is the preferred treatment. Nonetheless, it has associated nonneurologic and neurologic complications, some of which are serious. In patients with a single metastasis, surgical removal should be considered. Recent studies have suggested that resection of a single metastatic lesion followed by radiation therapy offers better survival than does radiation therapy alone. The subsequent administration of WBRT after radiosurgical treatment has become standard practice. The role of chemotherapy is uncertain.

Section snippets

EPIDEMIOLOGIC FEATURES

A 1972 Mayo Clinic study demonstrated the annual incidence of brain metastases to be 11.1 per 100,000 population, an approximation of the incidence of primary brain tumors.5 A study published about a decade later found similar results; incidence figures for primary and secondary brain tumors were almost identical.6 In 1978, Posner and Chernik2 published a study of 2,375 patients with cancer who underwent autopsy at Memorial Sloan-Kettering Cancer Center. Of those patients, 15% had brain and

BIOLOGIC PROCESSES

More than 25% of all autopsy-proven brain metastases have a pulmonary source; those from breast cancer are second most common, and those from cutaneous melanoma are third.2 Thus, malignant melanoma, which represents only 1% of all cancers, has the highest propensity of all systemic malignant tumors to metastasize to the brain. In an autopsy study, almost 40% of patients with melanoma harbored brain metastases.8 Furthermore, striking differences in incidence of metastasis also occur among

PATHOLOGIC INVOLVEMENT

Brain metastasis tends to occur at the gray-white matter junction of the brain, characteristic of an embolic event.9 Metastases are multiple in approximately 50% of patients and typically are well demarcated and solid.10 Occasionally, they may be cystic, necrotic, and hemorrhagic. Brain metastases are characterized by severe peritumoral edema, which often contributes to neurologic symptoms.13 The distribution of brain metastases roughly parallels brain weight and cerebral blood flow.14

CLINICAL FINDINGS

Most brain metastases manifest with a combination of focal and generalized symptoms and signs. Since the development of modern neuroimaging with computed tomography (CT) and magnetic resonance imaging (MRI), the initial findings of brain metastases have changed. Cairncross and Posner3 reviewed the initial symptoms and signs in a large group of patients with brain tumors before and after the availability of CT. In the post-CT era, headaches were less frequent and mental change was more common

TREATMENT

Several factors affect the optimal management of a patient with brain metastases, including the patient's neurologic, functional, and overall performance status; the extent of the primary tumor and other sites of systemic disease; the number and site of brain metastases; and the radiosensitivity or chemosensitivity (or both) of the patient's disease.3 Therapeutic options might include (1) no treatment in moribund patients with widespread disease, (2) emergency treatment such as relief of

CONCLUSION

Recent literature has confirmed independent prognostic variables in patients with brain metastases. In a “good-risk” population, surgical intervention followed by radiation therapy is superior to only irradiation for patients with solitary metastases. Stereotactic radiosurgical treatment is feasible in the same select patient population, but questions about the extent of delayed toxicity, tumor response, and effect on quality of life and longevity remain to be answered. For patients with

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