68 y/o. Caucasian MBrain Metastasis from Melanoma

Shintaro Ono

Neurosurgery

HPI The patient is a 68 y.o. gentleman with h/o metastatic melanoma primarily on his left neck with spread to adjacent lymph nodes as well as potential metastases to liver and lung. On May 21, 2009, He presented to the BI and underwent routine follow up with brain MRI which showed a large intracranial hemorrhagic lesion in the right frontal lobe. This was new since his prior scan which was on Nov. 11, 2008.

Past Medical History- Metastic Melanoma to lung and liver - DM, HTN, and Af

Past Surgical History- Left lung lower lobectomy for metastasis (12/11/08) - Appendectomy 60 years ago

Medicatoin- lisinopril, aspirin, warfarin

Allergy NKDA

Family History - Non-contributory

Social History - Farmer with extensive sun exposure - Tobacco; a cigar / week (stopped in 2009) - EtOH; No, - illicit drugs; No

Case: 68 y/o. Caucasian M

Physical Examinations

VS: T: 98.5 BP: 146/79 HR: 103 R: 16 O2Sats: 96RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-->1.5, bilat EOMs intact, Neck: Supple. Lungs: CTA bilaterally. Cardiac: irregularly irregular. S1/S2.Abd: Soft, NT, BS+ Extrem: Warm and well-perfused.

Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: 3/3 objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors.

Case: 68 y/o. Caucasian M

Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Very slight left facial nerve droop, otherwise facial nerve intact and muscles intact, sensation intact to all fields VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations.

Motor: Normal bulk and tone bilaterally. Strength full power 5/5 throughout. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Coordination: normal on finger-nose-finger, heel to shin

Case: 68 y/o. Caucasian M

MRI

Nov. 11, 2008.May. 21, 2009.

Right frontal craniotomy was done on May 22, 2009.

4.5 x 3.7cm

4mm

Post-operative MRI

May. 21, 2009.May. 22, 2009.

He was discharged on May 26, 2009.

He is taking a course of whole brain radiation therapy.

•The most common intracranial tumors in adults (>50% in brain tumors).

•In patients with systemic metastasis, Brain Metastasis occurs 10 to 30 % in adults.

•The incidence of brain metastases is increasing due to improved imaging tools.

Lung — 16 to 20 %Renal cell cancer — 7 to 10 %

Melanoma — 7 % Breast cancer — 5 %

Colorectal cancer — 1 to 2 %

Brain Metastasis

•50% to 75% of malignant melanoma patient end up with brain metastasis.

•Melanoma is the third most common cause of brain metastases in US.

•The incidence of malignant melanoma is increasing at rate greater than any other human cancer.

Brain Metastasis from Melanoma

•Whole Brain Radio therapy WBRT after surgery reduce the rate of recurrence and possibly prolong survival.

[Wen, PY, Loeffler, JS. Management of brain metastases. Oncology (Huntingt) 1999; 13:941.][Skibber, JM, Soong, SJ, Austin, L, et al. Cranial irradiation after surgical excision of brain metastases in melanoma patients. Ann Surg Oncol 1996; 3:118.]

Treatment

•Chemotherapy Brain Metastases from melanoma are generally resistant to chemotherapy. But, fotemustine and temozolomide have a possibility of treatment.

[Jacquillat, C, Khayat, D, Banzet, P, et al. Final report of the French multicenter phase II study of the nitrosourea fotemustine in 153 evaluable patients with disseminated malignant melanoma including patients with cerebral metastases. Cancer 1990; 66:1873.] [Hwu, WJ, Lis, E, Menell, JH, et al. Temozolomide plus thalidomide in patients with brain metastases from melanoma. Cancer 2005; 103:2590. ]

• Craniotomy– Large, single/dominant, and accessible lesions – Patients with good performance status– Patients with herniation or a posterior fossa mass effect

• Stereotactic Radiosurgery (SRS)– Small(<3cm), multiple(=or<3), and deep lesions– Patients unlikely to tolerate general anesthesia.

There is no confirmed clear advantage of one treatment over the other. – No prospective randomized trials have been reported (M. L. Smith and J. Y. K. Lee 4 Neurosurg. Focus / Volume 22 / March, 2007)

Craniotomy vs SRS

• Resection, Craniotomy?

• SRS?

• Whole Brain Radiation Therapy (WBRT)?

• Chemotherapy?

• or Combination?

Treatment for the patient

What the reason for resection surgery and following WBRT?

The Patient•Good performance status (KPS 90 > 70)

•Large (>3cm), dominant Lesion

•Mass Effect

•Resectable

•The lesion cannot be well controlled with external radiation alone.

Reasons for Surgery

Reasons for Surgery

Mayo Clin Proc 2003; 78:1529.

•Case: 68 y/o. Caucasian M with Brain Metastasis from Melanoma

•The incidence of malignant melanoma is increasing at a rate greater than any other human cancer.

•Patient with brain metastasis from melanoma still has poor prognosis.

•New treatment and medical progression is needed for better prognosis.

Summary

Thank you!!

PatientAge; 68 y.o. (> 65 y.o.)Karnofsky Performance Score (KPS); 90Metastasis; Lung, Liver, Brain

Prognosis

Rating Definition100 percent No evidence of disease

90 percent Normal activity with minor signs of disease

80 percent Normal activity with effort; signs of disease

70 percent Cannot do normal activity but cares for self

60 percent Requires occasional assistance

50 percent Requires considerable assistance; frequent medical care

40 percent Disabled, requires special care

30 percent Severely disabled; hospitalization may be indicated

20 percent Very sick; hospitalization necessary for supportive treatment

10 percent Moribund

0 percent Death