- Metastatic Brain Tumor: 6 Things You Need to Know
- Diagnosis and Treatment Options for Brain Metastasis of Melanoma
- Understanding Jimmy Carter’s Surprise Cancer Turnaround: A Conversation with Jedd Wolchok
- The expanding role of stereotactic radiosurgery in the treatment of brain metastases
- WBRT or SRS?
- Chemotherapy, Systemic Therapy
- Radiation Necrosis
- Metastatic Brain Tumors
- What are the risk factors for metastatic brain tumor?
- The Radiation Team
- Clinical trials for new treatments
- Adjuvant radiotherapy and outcomes of presumed hemorrhagic melanoma brain metastases without malignant cells
Metastatic Brain Tumor: 6 Things You Need to Know
Linkedin Pinterest Brain, Nerves and Spine Brain Tumor Brain Tumor Treatment
When cancer that began somewhere else in the body spreads to the brain and causes a lesion or brain tumor, it's called brain metastasis.
At the Johns Hopkins Comprehensive Brain Tumor Center, we have experience diagnosing and treating thousands of patients.
We first confirm a brain tumor through an MRI scan or other imaging scans. We recommend surgery in situations where the diagnosis is unclear or to ease symptoms. Soon after, you'll meet with one or more doctors to discuss treatment options. The faster you start treatment, the better the chances of killing or controlling the disease.
Because brain metastases are different in each person, our treatment teams spend time determining what's best for each patient before moving forward with treatment.
The two main treatments for brain metastases are brain surgery and radiation.
While brain surgery can sound daunting, medical advancements in the field have come a long way in the past 50 years. Many patients not only get back to their lives within weeks of surgery, but some live for many years with a good quality of life after surgery.
Today, doctors use advanced tools to map your brain before surgery to plan your surgery precisely. This imaging acts as a sort of GPS, helping guide your surgeons to perform a more accurate and safer procedure.
In addition, during the surgery, image-guided therapy — using images from a specialized MRI scan, for example — gives doctors real-time pictures of your brain. This gives surgeons even more insight into how your brain works, which often leads to better results.
Every treatment comes with side effects. That's why Johns Hopkins doctors have a risk-benefit conversation with every patient about every treatment. We weigh the potential benefits of a specific treatment option against the possible risks and side effects.
Because radiation therapy has been so successful in treating brain metastases — and because many patients are living so long after treatment — studies are now looking at how to manage the long-term effects of the treatment.
There are two main types of radiation therapy:
- Whole-brain radiation targets the entire brain to hit any disease that hides from an MRI scan. It can cause hair loss, hearing loss, and memory and cognitive problems.
- Stereotactic radiosurgery directs a high dose of radiation targeted to the specific shape of the tumor, sparing surrounding healthy tissue from unnecessary radiation exposure. Stereotactic radiosurgery could cause radiation necrosis (dead tissue).
An expert medical team will guide you in finding the best treatment or combination of treatments for your disease and circumstances. You must talk about your individual case with a knowledgeable doctor.
At Johns Hopkins, medical specialists work closely together and with you to determine your best way forward, considering:
- The size, location and number of tumor(s)
- The pathology (structure and function) of the tumor
- Your overall health
- Your personal preferences and lifestyle
Diagnosis and Treatment Options for Brain Metastasis of Melanoma
Open access peer-reviewed chapter
By Khan K. Chaichana and Kaisorn L. Chaichana
Submitted: November 8th 2010Reviewed: April 26th 2011Published: October 5th 2011
Metastasis to the brain is a devastating and common consequence for patients with malignant melanoma. A significant number of patients with melanoma eventually develop brain metastasis at the time of death.
Patients are often symptomatic from their lesions and a large percentage of those with neurological deficits eventually die from the brain metastasis. Diagnosis does not typically occur until late in the disease course, which can preclude many treatment options.
Additionally, rapid progression of the disease state and worsening health status magnifies the difficulties of treatment. Currently, contrast-enhanced computer tomography (CT) and magnetic resonance imaging (MRI) remain the main diagnostic modalities. Confirmation is usually achieved with surgical biopsy or resection.
After diagnosis, treatment options are somewhat limited – surgical management, radiation therapy, and chemotherapy are most commonly used either alone or in combination.
This chapter provides a description of the common presenting symptoms, diagnostic modalities, and treatment options for patients with metastatic melanoma to the brain.
This chapter will also discuss emerging technologies which may have notable impacts on the future of disease management.
Ultimately, prompt diagnosis and treatment for patients with brain metastases may have important implications for the duration and quality of life of these patients.
In general, patients with intracranial metastases significantly outnumber those with primary brain tumors. However, there are a small number of population-based epidemiological studies that address the true incidence of intracranial metastases, and studies devoted primarily to intracranial melanoma metastases are even less common .
Along with the limitations inherent to most surveys, such as sampling size and variability, there are several other limiting factors. This includes inadequate reporting, difficulty attaining ante-mortem diagnosis, and greater emphasis cancer databases place on the incidence of primary tumors rather than metastasis .
As a result, it is quite ly that current population-based epidemiological studies underestimate the true incidence of cancer metastasizing to the brain . A significant amount of the reported data now originates from clinical, neurosurgical, and autopsy series which are subject to their own limitations as well.
However, as methods of diagnosis and treatment continue to improve, a more accurate picture can be portrayed.
Malignant melanoma is one of the most common systemic cancers to metastasize to the central nervous system (CNS). Following lung and breast carcinoma, melanoma historically has the third highest incidence of metastasis to the brain .
One recent study has indicated it may now surpass that of breast carcinoma, most ly a result of increasing rates over time . Of cases with metastasis to the brain, melanoma is the primary tumor for about 5 to 21 percent of these patients .
CNS involvement or deficits are the first manifestation of melanoma in 9 to 12 percent of patients . For those that carry a diagnosis of melanoma, between 12 to 60 percent can expect to develop metastases to the brain [6, 7].
However, because it only accounts for 5% of metastatic cancers , the total number of cases or individuals is often erroneous . Although melanoma is a less common cancer, it has the highest propensity for metastasis to the brain [1, 9].
An estimated 49 to 73 percent of patients who die from melanoma will have developed brain metastases by the time of death and are found on autopsy [10, 11]. It is responsible for the deaths in an estimated 20 to 55 percent of affected patients, and contributes to death in up to 95 percent of all cases [11-13]. Thus, the impact and consequences of metastatic melanoma are quite detrimental in medicine.
Anyone with a diagnosis of melanoma is at risk for developing CNS metastases. Previous studies have tried to elucidate these factors that increase the risk of CNS metastases. Among the demographic aspects intrinsic to patient demographics, only male gender was found to show greater predominance in patients with brain metastases .
Of the characteristics of the primary lesion, melanomas appearing wide, thick, or ulcerated or with acral lentiginous or nodular histological findings were more frequently found in patients who developed brain metastases. Also, primary lesions arising from the mucosal surfaces, skin of the head and neck, or skin of the trunk were more frequently found in this group [14, 15].
Patients with involvement of the lymph nodes or visceral organs, especially the lungs or multiple visceral organs, showed an increased lihood of metastasizing to the brain [14, 16]. These factors are also associated with shortened overall survival time survival times [14, 16].
Interestingly, with the exception of primary lesions of the head and neck region, these factors did not affect survival after a diagnosis of a brain metastasis .
Other factors that were evaluated, such as the patient’s race, pigmentation of the primary tumor, and pregnancy at the time of melanoma diagnosis, were not significantly correlated with the development of brain metastases. The average age of presentation of patients with brain metastases is 48 to 53 years old, which is similar to that of patients with extracranial metastases[14, 17].
Metastases to the brain requires a complex series of steps, each mediated by a combination of intricate molecular mechanisms that are not completely understood. Each of these steps typically involves overcoming various physiological barriers including the blood-brain barrier .
Similar to other systemic cancers, as the primary melanoma matures, the process of angiogenesis increases the vascular supply to sustain the metabolic needs of the cancer cells and allows the tumor to grow.
It progressively invades the surrounding host tissue and eventually spread hematogenously by invading local venules or lymph channels, which drain into the venous circulation .
Because venous circulation returns to the right side of the heart, the first capillary beds the circulating tumor cells encounter are typically found in the lungs. These tumor cells are generally larger than the capillary vessels and may arrest in these pulmonary capillary beds.
As a result, patients typically have lung metastases earlier in the time course of melanoma. They may often be identified at the time intracranial metastases are diagnosed. Between about 27 to 68 percent of affected patients may have concurrent lung metastases, which further shortens the survival time [14, 18, 19].
In order to reach arterial circulation and thus the cerebral vasculature, these melanoma cells must reach the left side of the heart either by: (1) metastasizing to the lung and invading the pulmonary venous circulation, (2) traversing the lung capillary bed to the pulmonary venous circulation, or (3) crossing through a patent foramen ovale thus bypassing the pulmonary circulation .
When tumor cells reach the left side of the heart and systemic circulation, the most important factors involved in promoting intracranial metastasis are the blood supply and greater preference for brain tissue .
The cerebral vasculature receives approximately 15 to 20 percent of the cardiac output in the resting state, which increases the lihood that circulating tumor cells will reach the brai n.
It would be expected to receive a proportional amount as well, however the distribution of metastases blood flow, or the mechanical hypothesis, does not account for the high propensity of melanoma to metastasize to the brain compared to other cancers .
Instead, the seed and soil hypothesis ly contributes to the metastasis and plays an important role in explaining this phenomenon.
This hypothesis postulates that certain genetic alterations in the tumor cells (the seed) influences them to show preference for the brain and find its microenvironment a more favorable place (the soil) to support their growth . These alterations may include increased expression of adhesion molecules that show preferential adhesion to brain endothelial cells [21, 22] and increased production of degradative enzymes enabling tumor cells to penetrate the endothelium and the basement membrane . Locally produced growth factors in the brain may also stimulate growth of the metastatic cells .
When tumor cells reach the cerebral vasculature, they may arrest in the capillary beds due to their greater size. In order to form metastases, they must extravasate across the microvasculature of the blood-brain barrier into the brain parenchyma .
The blood-brain barrier is a continuous, non-fenestrated endothelium composed of tight junctions and protects against the invasion of microorganisms and also the interaction of most drugs, including chemotherapeutic drugs .
However, it provides little protection against the invasion of metastatic cells into the brain parenchyma and may even be altered to a leakier barrier in primary tumors and metastases . The cells adhere to and penetrate the basement membrane and astrocytic foot processes, eventually reaching the parenchyma.
In the end, only about 0.1 percent of the initial circulating tumor cells survive the protective mechanisms of the body to form distant metastases . Additionally, metastasis typically occurs relatively late in the disease course for most patients with malignant melanoma.
This may be explained by CNS involvement occurring as a result of a late metastatic event from another distant metastatic site, such as the lungs .
It may also be possible that metastasis is actually an early event in the disease course, but relatively slow metastatic growth results in delayed neurological effects and delayed detection .
The histopathology of intracranial metastases mimics that of the primary melanoma. Melanoma can metastasize to virtually any portion of the intracranial cavity.
The most common site is the parenchyma, but involvement of any anatomic structure in the CNS can occur, including the dura, leptomeninges, choroid plexus, pituitary, and pineal glands.
As with other systemic cancers that metastasize to the brain, the distribution reflects the size and volume of the region and its vasculature.
Thus, a significant majority are supratentorial, the most common location being the cerebral hemispheres along the vascular distribution of the border zones (water-shed areas) between the anterior and middle cerebral arteries as well as the middle and posterior cerebral arteries [6, 14]. In total, the parietal lobe is involved in about 26 to 45%, frontal love in 21 to 36%, temporal lobe in 19%, occipital lobe in 11%, cerebellum in 7%, and cerebellum in
Understanding Jimmy Carter’s Surprise Cancer Turnaround: A Conversation with Jedd Wolchok
Update: The immunotherapy drug that helped President Carter beat back cancer is yielding even more encouraging results.
Data released on May 18, 2016 in advance of the annual meeting of the American Society of Clinical Oncology indicate that 40% of patients who received pembrolizumab (Keytruda®) as part of a large clinical trial are still alive three years later — a huge improvement over just a few years ago when average survival time for patients with metastatic melanoma was measured in months.
This week, former President Jimmy Carter announced that he is “cancer free” after receiving treatment for metastatic melanoma — a type of skin cancer that often spreads, or metastasizes, to other parts of the body. Mr. Carter’s cancer was discovered in his liver and spread to his brain.
In addition to surgery and radiation, Mr. Carter received a new immunotherapy drug called pembrolizumab (Keytruda®), which releases a brake on the immune system, empowering it to mount a stronger attack against cancer. The particular braking molecule targeted by this drug is called PD-1.
To get a better sense of what Mr. Carter’s surprise announcement means — especially for patients in a similar situation — we spoke with Jedd Wolchok, Chief of the Melanoma Service at Memorial Sloan Kettering.
That’s a great question. My colleagues and I were just discussing this. I think it’s probably a contribution from all of the above. I don’t think it’s possible to ascribe the very favorable result to just one intervention. As time goes on, if he continues to have durable control of his disease, then I think we can be confident that immunotherapy played an important role.
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There is that possibility. The hope is that when you kill a tumor with a tool radiation therapy, you release cell debris that can trigger an immune response — similar to a kind of vaccination. Then, by blocking an immune checkpoint — in this case PD-1 — you allow that immune response to really take off.
Mr. Carter's case is a great example of how far the field has come in a relatively short period.
We’ve certainly seen isolated examples of this phenomenon, called the abscopal response, with other immunotherapy drugs. I wrote a paper about this a couple of years ago with my MSK colleague Michael Postow.
We’re now about to open a study using a combination of two immunotherapy drugs, ipilimumab and nivolumab, along with radiation for patients with melanoma.
A lot of folks are really interested in this, and you can build a strong rationale for why it makes sense to use them together. But it has to be tested.
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We have a lot of issues yet to settle here. We know that the same medicines that can have a favorable effect on disease outside of the brain can have a favorable effect in the brain. There was a clinical trial that I participated in and published in Lancet Oncology about two years ago that looked at ipilimumab treatment in melanoma patients with brain metastases.
Learn more about melanoma screening and diagnosis.
The challenge with brain metastases is that sometimes patients require corticosteroid treatments [which can suppress the immune system] to control swelling and symptoms. In the trial I referred to, the benefit of ipilimumab was seen only in the patients who were able to come off corticosteroids. So that’s an important consideration.
That’s why it’s good to do exactly what Mr. Carter’s physicians did, which was to control the brain metastases to the best of their ability — in this case with stereotactic radiosurgery — get him off the steroids as quickly as possible, and then initiate the immunotherapy.
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It’s becoming more and more common. Mr. Carter’s case is a great example of how far the field has come in a relatively short period.
If you turn back the clock ten years or so, people with melanoma and brain metastases had life expectancies that were measured in weeks and months.
Now, there are patients in my practice who have had brain metastases and have been alive for years. And of course we hope the same is true for Mr. Carter.
I find it very inspiring that he’s been able to continue the important work that he’s engaged in without any side effects from treatment.
It’s also inspirational to patients, who can see that a devastating diagnosis doesn’t necessarily mean that you’re going to die immediately, or that the treatment is going to incapacitate you. Here’s a 90-year-old person not just living but fully active and engaged in activities that are making the world better for the rest of us.
Pembrolizumab is one of two PD-1-blocking drugs approved by the FDA for the treatment of advanced melanoma, the other being nivolumab (Opdivo®). The five-year survival rate for patients treated with nivolumab is 34%, as reported last month at the annual meeting of the American Association for Cancer Research. Check back here on the MSK blog for more updates on progress in immunotherapy.
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The expanding role of stereotactic radiosurgery in the treatment of brain metastases
Stereotactic radiosurgery (SRS), introduced in 1951 by Swedish neurosurgeon, Lars Leksell, MD, continues to advance the treatment of brain metastases. Historically, SRS has been performed in a single session using the Leksell Gamma Knife (Elekta, Stockholm, Sweden), developed by Dr. Leksell in 1968.
1 However, as linear accelerator technology progressed with sophisticated beam-shaping technology, advanced treatment planning systems and image-guidance tools, new linac-based SRS solutions entered the market, including the CyberKnife (Accuray, Sunnyvale, California), Novalis Radiosurgery (Brainlab, Munich, Germany) and the Edge (Varian Medical Systems, Palo Alto, California).
“SRS has revolutionized the management of brain metastases, and more or less replaced whole-brain radiation therapy (WBRT) for patients who have limited disease,” says Gene H.
Barnett, MD, MBA, a neurosurgeon and director of Cleveland Clinic’s Brain Tumor and Neuro-Oncology Center, Cleveland, Ohio. Dr.
Barnett is also vice chairman of the Department of Neurological Surgery, and director of the Cleveland Clinic Health System Gamma Knife Center.
“Now that we can treat the individual spots that we see in the brain, we can spare exposing much of [a patient’s] normal brain tissue to radiation,” adds Lawrence Richard Kleinberg, MD, associate professor of Radiation Oncology and Molecular Radiation Sciences at Johns Hopkins Medicine, Baltimore, Maryland. Dr. Kleinberg uses the Cyberknife system (Figure 1).
In general, two types of SRS systems are available: a dedicated, frame-based system such as the Gamma Knife, and linac-based systems such as the CyberKnife, Novalis and Edge. The Gamma Knife involves a high-dose, single-fraction treatment while the linac-based solutions typically involve multiple fractions at lower doses.
“More recently, there has been enthusiasm for multisession treatments,” says Samuel T. Chao, MD, a radiation oncologist at the Cleveland Clinic and associate professor at the Cleveland Clinic Lerner College of Medicine at Case Western Reserve University, Cleveland, Ohio.
In particular, a study by Minniti et al concluded that multifraction SRS at a dose of 27 Gy in 3 daily fractions for brain metastases > 2 cm was associated with better local control and reduced risk of radiation necrosis compared to a single-fraction SRS treatment.2 “We know that in brain metastases much greater than 2 to 2.
5 cm, local control would decrease and toxicity would increase if we use a single fraction,” says Scott G. Soltys, MD, radiation oncologist and assistant professor, Stanford University Cancer Center, Stanford, California.
“The normal control rate in brain metastases < 2 cm is 85% to 90%, but that drops to 60% to 70% with larger-sized metastases.”
The Minniti study also found that the most significant difference in local control was for lesions > 3 cm, with single-fraction SRS treatment having a local control of 54% at 1 year vs. 73% with multifraction SRS.2 Dr.
Barnett and colleagues have been using single-fraction SRS on patients with larger-sized brain metastases who traditionally would not have achieved the desired local control with a staged treatment.
In these cases, the patient would return in a month for another treatment to achieve the necessary therapeutic dose, thus reducing the need for surgery, he says.
While surgery has an important role in treating brain metastases, the focus has shifted to the timing of SRS in conjunction with surgery to further maximize control, adds Dr. Chao. The recurrence rate is 50% with surgery alone compared to > 70 % with surgery followed by SRS, he says.
WBRT or SRS?
In addition to offering better control with larger-sized metastases, SRS is being used more often for cases with multiple brain metastases. More studies report that the total intracranial tumor volume correlates with survival rather than the number of tumors. 3-5
Ideal WBRT candidates include patients with leptomeningeal disease in which the tumor cells spread to the membranes surrounding the spinal cord and brain, and those with multiple radiosensitive lesions, says Dr. Barnett.
Modern linacs capable of volumetric-modulated arc therapy (VMAT)/intensity-modulated radiation therapy (IMRT) or tomotherapy can help avoid the hippocampi, which may lessen the risk of cognitive side effects, adds Dr. Soltys.
Brown et al studied the effects on cognitive function in patients with 1 to 3 metastases who either received treatment using SRS alone or SRS in conjunction with WBRT.
In the 213 randomized participants, the study found less cognitive deterioration at 3 months with SRS alone compared to when SRS was used with WBRT.
6 this study and others, the American Society for Radiation Oncology (ASTRO) issued recommendations in 2014, which were updated in 2016, that oncologists should not routinely add adjuvant WBRT to SRS in patients with limited brain metastases, with good performance status and brain metastases from solid tumors.
The Yamamoto study was the first clinical trial to prospectively omit WBRT in patients with up to 10 brain metastases.
7 “When comparing 2 to 4 or 5 to 10 brain metastases, Yamamoto et al found there was no detriment to survival when using SRS rather than WBRT,” says Dr. Chao.
Now, he and Cleveland Clinic colleagues still consider SRS for patients with up to 8 or even more brain metastases, and consider delivering hypofractionated or multiple session SRS treatments more frequently.
“The Yamamoto study provides prospective data to justify SRS alone for up to 10 brain metastases,” says Dr. Soltys. “Whether this principle can be extended to > 10 metastases is unknown.”
Clinicians also need to consider patients with poor prognosis who may be best served with palliative or supportive care, he says.
The Quality of Life after Treatment for Brain Metastases (QUARTZ) trial compared WBRT to optimal supportive care (OSC) and found no difference in overall survival between the two groups, and a small difference in quality of life for the OSC group.
The author suggested that in this patient group—nonsmall cell lung cancer with brain metastases unsuitable for resection or stereotactic radiation therapy—WBRT “provides little additional clinical significant benefit.”8
Chemotherapy, Systemic Therapy
With SRS, patients also can continue chemotherapy during treatments. Dr. Kleinberg explains that a combined toxicity occurs when using WBRT and chemotherapy. Blood circulates through the brain and, after WBRT, blood counts and immune cells both drop; chemotherapy has the same effect.
“We have learned that SRS … can be done in the midst of chemotherapy depending on the type [of systemic drug] the patient is receiving,” Dr. Kleinberg says. “We try to use SRS in the weeks the patient does not receive chemotherapy treatments, and it has been very safe.”
Although not commercially available, systemic therapies involving targeted agents and immunotherapy are also being investigated for their therapeutic role with SRS.
“Now with a better understanding of biomarkers and genetics, we need to think about the variety of ways we can manage a patient with brain metastases—how we can utilize that systemic therapy to improve the ability to control disease in the brain,” says Dr. Chao.
Despite advances in SRS, an unfortunate and serious side effect remains: radiation necrosis, which can resemble tumor recurrence on MR imaging, says Dr. Kleinberg. “Beyond necrosis, a patient can also get edema after radiation exposure,” he adds, “and we have no means to differentiate necrosis from swelling and tumor re-growth.”
Kleinberg says that some investigations of MR spectroscopy and MR protein transfer, as well as other potential imaging techniques involving fluorothymidine F 18 (FLT) PET, may help distinguish these conditions in the future. In addition to continued development of sequences and tracers, a blood biomarker could help distinguish between necrosis, swelling, and tumor regrowth, says Dr. Soltys.
- Chen JCT, Girvigian, MR. Stereotactic radiosurgery: instrumentation and theoretical aspects—part 1. Perm J. 2005;9(4)23-26.
- Minniti G, Scaringi C, Paolini S, et al. Single-fraction versus multifraction (3 x 9 Gy) stereotactic radiosurgery for large (>2 cm) brain metastases: a comparative analysis of local control and risk of radiation-induced brain necrosis. Int J Radiat Oncol Biol Phys. 2016;95(4):1142-1148.
- Bhatnagar AK, Flickinger JC, Kondziolka D, et al. Stereotactic radiosurgery for four or more intracranial metastases. Int J Radiat Oncol Biol Phys. 2006;64:898-903.
- Likhacheva A, Pinnix CC, Parikh NR, et al. Predictors of survival in contemporary practice after initial radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys. 2013;85:656-661.
- Baschnagel AM, Meyer KD, Chen PY, et al. Tumor volume as a predictor of survival and local control in patients with brain metastases treated with gamma knife surgery. J Neurosurg. 2013;119:1139-1144.
- Brown PD, Jaeckle K, Ballman KV, et al. Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases a randomized clinical trial. JAMA. 2016;316(4):401-409.
- Yamamoto M, Serizawa T, Shuto T, et al. Stereotactic radiosurgery for patients with multiple brain metastases (JLGK0901): a multi-institutional prospective observational study. Lancet Oncol. 2014;15(4):387-95.
- Mulvenna P, Nankivell M, Barton R, et al. Dexamethasone and supportive care with or without whole brain radiotherapy in treating patients with non-small cell lung cancer with brain metastases unsuitable for resection or stereotactic radiotherapy (QUARTZ): results from a phase 3, non-inferiority, randomised trial. Lancet. 2016;388:2004-14.
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Metastatic Brain Tumors
Linkedin Pinterest Cancer Brain Tumor Brain Tumor Treatment What You Need to Know
- Metastatic brain tumors (also called secondary brain tumors) are caused by cancer cells spreading (metastasizing) to the brain from a different part of the body.
- The cancer cells break away from the primary tumor and travel to the brain, usually through the bloodstream, then commonly go to the part of the brain called the cerebral hemispheres or to the cerebellum. Cancer can also spread to the spine (metastatic spine tumors).
- Metastatic brain tumors are five times more common than primary brain tumors (those that originate in the brain).
- Metastatic brain tumors can grow rapidly, crowding or destroying nearby brain tissue. Sometimes a patient may have multiple metastatic tumors in several different areas of the brain.
The most common types of cancer that cause metastatic brain tumors are cancers of the lung, breast, skin (melanoma), colon, kidney and thyroid gland.
Some metastatic brain tumors appear many years after the primary cancer. Others metastasize so quickly that they are identified before the primary cancer.
In other cases, the body is able to destroy the primary cancer but not the metastatic brain tumor. When this occurs, the primary cancer can be unknown.
If you or someone you love has a metastatic brain tumor, you’ll want these basics for what lies ahead.
Common signs and symptoms
- Weakness in the arms or legs
- Loss of balance
- Memory loss
- Speech disturbance
- Behavior and personality changes
- Blurred vision/vision disturbance
- Hearing loss
What are the risk factors for metastatic brain tumor?
About one third of patients with another type of cancer will develop one or more metastatic brain tumors. The risk for metastatic brain tumors begins to increase after age 45 and is highest in those over 65.
Johns Hopkins neurosurgeon Michael Lim, M.D., says every brain tumor — and every patient — is unique. Find out more about his approach to treating brain tumors.
Metastatic brain and spine tumors are not usually diagnosed until symptoms appear. Here are some ways doctors may diagnose a metastatic brain tumor:
- Physical exam: After gathering information about your symptoms and personal and family health history, the doctor proceeds with a physical exam and vision and reflex tests.
- Neurological exam
- Computed tomography (CT or CAT scan)
- Magnetic resonance imaging (MRI)
- Diffusion tensor imaging (DTI): This scan allows the surgeon and treating team to visualize the circuitry (or wiring) of the brain to guide the surgery. These images can then be loaded into navigation systems that are used in the operating room to serve as a kind of GPS and map for the surgeon.
It is important to know that metastatic brain tumors are often treatable and can be well controlled.
Optimal treatment for metastatic brain or spine tumors is tailored to each patient. The neurosurgeon determines the most appropriate treatment approach, considering these factors:
- The type of primary cancer the patient has, response to treatment and current status
- The location and number of metastatic tumors within the brain or spine
- The patient’s general health and preferences regarding potential treatment options
- The patient's current symptoms
Surgery provides fast relief of “mass effect” — pressure inside the skull resulting from a growing tumor and swelling of the brain. Patients can experience improvement within hours of surgery if mass effect is what is causing their symptoms.
The goal of surgery is to minimize the amount of space the tumor takes up by debulking, removing as much of the tumor as possible while maintaining the patient’s neurological function.
In general, doctors recommend surgery when:
- There is a clear correlation of neurologic deficits with the tumor’s location
- The patient’s primary cancer is treatable and under control
- A patient has one or two metastatic brain tumors, or a few tumors that are close to each other that can be safely removed
The most common type of surgery to remove metastatic brain tumors is called a craniotomy, which can be performed through a variety of approaches, including the keyhole craniotomy.
The surgeon may choose a microsurgery procedure, and use newer tools — such as image-guided surgery and minimally invasive endoscopy — to ensure the best chance for a good outcome.
Radiation therapy is the treatment of tumors using X-rays and other forms of radiation (light energy) to destroy cancer cells or prevent a tumor from growing. It is also called radiotherapy.
These painless treatments involve passing beams of radiation through the body, which can treat cancers in areas of the brain that are difficult to reach through surgery. Procedures may include any one or combination of the following:
These procedures may also be performed after surgery to prevent tumors from growing near the site of the tumor removal and into other brain tissue.
Choosing radiation therapy is complex and often involves a team approach. Some patients receive a form of radiation therapy called stereotactic radiosurgery instead of surgery. Other patients will receive whole-brain radiation or a combination of both therapies, depending on what the treatment team determines is best.
The Radiation Team
Treatment planning for radiation therapy includes mapping to pinpoint the exact location of the tumor using X-rays or other images.
A radiation oncologist uses these images to create a three-dimensional picture of the patient’s brain. For some types of radiation therapy, a custom-fitted mask is created to increase the precision of the treatment. Fiducials — small markers temporarily attached to the scalp — may also be used.
A radiation oncologist then designs the patient’s treatment, determining the most appropriate radiation dose (the level of radiation energy to be used) and delivery method.
A dosimetrist or medical physicist (professionals who specialize in using radiation therapy equipment and calculating and measuring radiation) will calculate the dose, the angle of the treatment beam and the amount of time for each beam. After they work with the radiation oncologist to review the calculations, the treatments can be scheduled.
Because traditional chemotherapy cannot cross the blood-brain barrier, a new treatment called targeted therapy is used as the primary type of chemotherapy for treating metastatic brain tumors.
These drugs identify and attack cancer cells (the target) with minimal harm to normal cells while preventing the growth and spread of cancer cells. Targeted therapy can be administered after surgery or in conjunction with radiation therapy to destroy remaining cancer cells.
Targeted therapies used to treat metastatic brain tumors include:
- Trastuzumab for breast cancer that has metastasized to the brain
- Erlotinib for the most common type of lung cancer (non-small cell lung cancer) that has metastasized to the brain
Cancer immunotherapy is a fast-growing field of research that seeks to develop drugs, vaccines and other therapies that trigger the immune system’s natural abilities to fight cancer.
Clinical trials for new treatments
Researchers are always finding new ways to treat metastatic brain tumors. These new methods are tested in clinical trials. Talk with your healthcare provider to find out if there are any clinical trials you should consider.
Dr. Malcolm Brock is researching how metastatic cancers spread. Using this knowledge, he hopes to treat cancer by making other organs less hospitable to the disease.
Adjuvant radiotherapy and outcomes of presumed hemorrhagic melanoma brain metastases without malignant cells
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