Brain, metastases

Discuss the different treatment options for melanoma with brain metastasis. 

Brain metastasis is common in melanoma, and treatment options for brain metastasis include surgery, radiation, and chemotherapy. The choice of therapy depends on the number of metastatic lesions, accessibility of the lesions for surgery, the presence of neurologic symptoms, and the status of extracranial disease. 

Brain metastasis is the most common neurologic complication seen in patients with cancer. Approximately 170,000 patients develop brain metastases in the United States each year.20 Many malignancies are frequently associated with brain metastases (Table 96-7). While melanoma is the tumor type most likely to metastasize to the brain, brain metastases owing to lung and breast cancers are seen more often because they are among the most common cancers. In addition, brain metastasis may be diagnosed at the same time as the primary malignancy in around 20% of cases.22 Around 80% of brain metastases occur in the cerebral hemispheres, 15% in the cerebellum, and 5% in the brain stem. 

Improta G, Zupa A, Fillmore H et al (2001) Protein pathway activation mapping of brain metastasis from lung and breast cancers reveals organ type specific drug target activation. J Proteome Res 10 3089-3097... 

Kawai A, Nagasaka Y, Muraki M, et al. 1997. Brain metastasis in malignant pleural mesothelioma. 

Brain lesion analysis is also an active area of research. DTI metrics have been found to help differentiate between tumor types and promises to provide a sensitive method for abnormal tissue characterization. Fractional anisotropy has already been found to correlate with the cell density of brain tumors (Beppu et al., 2003 Beppu et al., 2005). The ability of FA to correlate with cell density likely accounts for the sensitivity of FA to tissue typing in brain lesions. Fractional anisotropy has been found to differentiate between low grade and anaplastic astrocytomas, to help differentiate between brain metastasis and high grade gliomas, and there is evidence that FA may help to detect tumor infiltration not visible by conventional MRI (Holmes et al., 2004 Tsuchiya et al., 2005 Goebell et al., 2006). Other DTI metrics have been utilized in brain lesion analysis and the early findings point to the breadth of future possibilities. 

Kruger, A., Sanchez-Sweatman, O. H., Martin, D. C., Fata, J. E., Ho, A. T., Orr, E. W., Ruther, U. and Khokha, R. (1998). Host TIMP-1 overexpression confers resistance to experimental brain metastasis of a fibrosarcoma cell line. Oncogene 16, 2419-2423. 

Schackert, G. and Fidler, I. J. (1988a) Development of in vivo models for studies of brain metastasis. Int. J. Cancer 41, 589-594. 

Tsuchiya K, Fujikawa A, Nakajima M, Honya K (2005) Differentiation between solitary brain metastasis and high-grade glioma by diffusion tensor imaging. Br J Radiol 78 533-537. 

Polyzoidis, K.S., Miliaras, G. and Pavlidis, N. (2005) Brain metastasis of unknown primary a diagnostic and therapeutic dilemma. Cancer Treat. Rev., 31, 247-55. 

Nodes Enlarged hard nodes Metastatic disease (brain metastasis as cause of neurologic deficit, may need contrast CT scan) or marantic endocarditis... 

Galicich JH, Sundaresan N, Thaler HT. Surgical treatment of single brain metastasis. Evaluation of results by computerized tomography scanning. J Neurosurg 1980 53 63—67. 

Conversely, a retrospective study of 40 patient records (diagnosis unspecified) indicated that dexamethasone reduced serum phenytoin levels the serum phenytoin levels of 6 patients receiving fixed doses of phenytoin were halved by dexamethasone. Another report describes a patient with brain metastases who required over 8 mg/kg of phenytoin (6(X) mg) to achieve therapeutic phenytoin levels in the presence of dexamethasone 16 mg. When the dexamethasone was increased to 28 mg daily he experienced seizures, and an increase in his phenytoin dose from 600 mg to 1 g only resulted in an increase in his levels from 13.9 to 16.4 micrograms/mL. Another patient, also with a brain metastasis, needed a large dose of phenytoin (greater than 10 mg/kg) while taking dexamethasone. He had an almost fourfold rise in serum phenytoin levels when dexamethasone was stopped."... 

Pancreaticoblastoma, or infantile adenocarcinoma, is a rare tumor in children (Monte marano et al. 2000 Roebuck et al. 2001). It usually presents in the fourth year of life with males being more affected than females. This tumor conunonly arises from the head or tail of the gland, and has been associated with Beckwith-Wiedemann syndrome. Microscopic analysis will show proliferation of poor differentiated squamous cells surrounded by a fibrous capsule. Although it has a better prognosis than the adult adenocarcinoma, metastases can occur and are commonly present at the time of the initial exam or diagnosis. Common sites for metastases include the liver and lymph nodes. Lung and brain metastasis are rarely seen. Usually, vanillylmandelic acids (VMA) are not elevated but the alpha-fetoprotein is. 

Hu C, Chang EL, Hassenbusch SJ 3rd, Allen PK, Woo SY, Ma-hajan A, et al (2006) Nonsmall cell lung cancer presenting with synchronous solitary brain metastasis. Cancer 106 1998-2004... 

Fig. 5.12a, b. A 71-year-old male patient with bronchogenic carcinoma invading the mediastinum and brain metastasis. Superior vena cava obstruction syndrome was treated by placement of a Wallstent endoprosthesis in the superior vena cava. At 3 weeks after endoluminal treatment, obstruction symptoms recurred, a Phlebography obtained by a femoral approach and catheterization of the stent lumen showed stent obstruction, and extensive filling of mediastinal veins, b After balloon dilatation at the junction of the stent with the internal jugular vein, a residual stenosis (arrow), due to insufficient stent covering of mediastinal tumor extent was evident... 

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