History
Approximately 60% of patients with brain metastases have subacute symptoms. Symptoms are usually related to the location of the tumor. About 85% of the lesions are in the cerebrum, 15% are in the cerebellum, and 5% are in the brainstem. Morning headache with nausea and vomiting together with papilledema are suggestive of intracranial hypertension. Features such as headache, nuchal rigidity and photophobia indicate meninges involvement. The timing of the onset of these symptoms is subacute rather than acute.
Acute onset of symptoms suggests vascular or electrical etiology such as bleeding or seizure. Dementia and cognitive deficits of a gradual onset most likely indicate a demyelination problem, radiation necrosis. Paraneoplastic syndromes include limbic encephalopathy and cerebellar degeneration. The latter is commonly associated with ovarian cancer. Progressive weight loss and general fatigue can be ominous and highly suggestive of recurrent systemic cancer. Similarly, neurologic problems such as polyneuropathy or myopathy can be sinister.
Headache (42%) and seizure (21%) are the 2 most common presenting symptoms.
New onset of seizures in a patient older than 35 years is highly suggestive of primary or metastatic disease.
In addition, 35% of patients have cognitive dysfunction, and 30% have motor dysfunction.
About 10% of patients present with hemorrhage. Metastases commonly derive from choriocarcinoma, melanoma, bronchogenic carcinoma, thyroid carcinoma, and renal carcinoma bleeding; most of these hemorrhages are intramural.
Physical
Findings on the neurologic examination depend on the location of the metastatic lesions. Focal findings are common. Findings consistent with generalized CNS dysfunction also can occur secondary to the cumulative effects of multiple CNS lesions, edema associated with large single or multiple CNS lesions, and/or adverse effects of medications.
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Management of recurrent metastasis.
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Multiple brain metastasis in a patient with known non-small cell lung adenocarcinoma. There was also systemic disease in the liver.
Tables
Primary Tumor Site |
Percentage (%) |
Lung |
21 |
Breast |
9 |
Melanoma |
40 |
Lymphoma, mainly non-Hodgkin |
1 |
GI tract |
3 |
Genitourinary tract |
11 |
Osteosarcoma |
10 |
Head and neck |
6 |
Group |
Karnofsky Performance Status |
Systemic Disease |
Median Survival, mo |
Age 65 y or younger |
70 or higher |
Controlled primary disease; no extracranial metastases |
7.1 overall; 13.5 for single metastasis, 6 for multiple metastases |
Age 65 y or older |
70 or higher |
Uncontrolled systemic disease; extracranial metastasis |
4.2 overall; 8.1 for single metastasis, 4.1 for multiple metastases |
Any age |
Any |
Any |
2.3 |
