NECN Lung NSSG April 2012 Managing Solitary Brain Metastases from NSCLC Dr Paula Mulvenna Consultant...
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Transcript of NECN Lung NSSG April 2012 Managing Solitary Brain Metastases from NSCLC Dr Paula Mulvenna Consultant...
![Page 1: NECN Lung NSSG April 2012 Managing Solitary Brain Metastases from NSCLC Dr Paula Mulvenna Consultant Clinical Oncologist Northern Centre for Cancer Care.](https://reader036.fdocuments.net/reader036/viewer/2022062421/56649e255503460f94b1390e/html5/thumbnails/1.jpg)
NECN Lung NSSG April 2012
Managing Solitary Brain Metastases from NSCLC
Dr Paula Mulvenna
Consultant Clinical Oncologist
Northern Centre for Cancer Care
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NECN Lung NSSG April 2012
This Talk:• Prevalence of solitary brain metastases• Case histories
• Investigation – mandatory modalities• Patients suitable for aggressive (radical)
management
• Pathway• Summary
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NECN Lung NSSG April 2012
Incidence – a Global issue• 2002:
– 10.2 million new cancers worldwide
– 1.35 million lung cancers
• 2020– 15 million new cases
cancer– 2 million lung
• 50% of these will develop intracranial metastatic disease
• Parkin et al CA Cancer J Clin 2005
• Patients with brain metastases from lung cancer:– USA: ~85,000 patients per
annum– UK: ~40,000 patients per
annum
• 35% have solitary metastasis • 65% multiple metastases• Median survival < 6m
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NECN Lung NSSG April 2012
Incidence, a Local Issue: NCIN e-atlas
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NECN Lung NSSG April 2012
Stage
442%
2A0%
3A14%
3B32%
nk4%
2B1%
1B3%
1A4%
Crude Incidence, a Local Issue:NSCLC Referrals (to PMM) since 2001- 2008 (n=1810)
• Treatment Intent:– Palliative – 83%– Radical – 17%
• 10% presented with brain metastases
• 24% of those with stage III disease have then developed brain metastases (after combined modality treatment up front)
• i.e. in my day to day practice:
• 215 patients with NSCLC + Brain metastases between 2001-8– 1 per fortnight
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NECN Lung NSSG April 2012
Case History 1• 67 year old female – • non-smoker
• Cough Feb 2010• RUL adenocarcinoma• T2 N1M0
• Staging – aiming for radical surgical approach… until CT head…..
March 2010
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NECN Lung NSSG April 2012
Case History 1 cont’d• Chemotherapy (JG)• Radiological Almost CR• PS 0/1 (KPS 90)
• ?Role for radical management of intra and extra cranial Disease
• PET (renal CT) • MRI brain
Sept 2010Radical RT to RUL remnant Oct 2010
Gamma Knife SRS to brain met Nov 2010
Intra-thoracic Local recurrence March 2012 – brain clear
Further systemic treatment
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NECN Lung NSSG April 2012
Case History 2• 57 year old male• Feb 2011: Post chest
pain + haemoptysis• Life long smoker (50 pack
year)• Alcohol xs; Lives alone
• RUL squamous cell cancer 2010
• T3N2M0 (CT head clear)• PS 1 (but other tobacco
related co morbidities)
• Gem Carbo chemo
• Good PR
• Radical RT – • Good PR Aug 2011
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NECN Lung NSSG April 2012
Case History 2 cont’d
• Feb 2012 – unsteady, falls ++
• MRI brain – 5x4 cm right cerebellar cystic mass
• Extra cranial disease - active
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NECN Lung NSSG April 2012
Micro-Surgical resectionor Stereotactic Radiosurgery (SRS)?• For solitary metastasis – comparable outcomes
– Kalkanis et al J. Neuro Oncology 2010; 96(1): 33-43
• Surgical series: superficial, larger, midline shift– Best results if complete en bloc resection– Where possible, avoid piecemeal resection
Do less well if >9.5cm or if removed piecemeal
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NECN Lung NSSG April 2012
Micro-Surgical resectionor Stereotactic Radiosurgery (SRS)?
•SRS
•smaller (<3cm)
•Deep seated
•Less mid line shift
•Both (Sx or SRS) provide comparable local control and overall survival (ms >10m)
•Addition of WBRT – further intra cranial control; no further benefit seen in OS
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NECN Lung NSSG April 2012
Pathway• Patient Presents with possible solitary metastasis
from confirmed NSCLC– PS 0/1 (KPS 90 – 100)– MRI Head– Full Staging of extra-cranial Disease - PET-CT
• Lung MDT• Neuro-Oncology MDT (central)• Decision re microsurgical resection or SRS
• De novo presentation - ?surgery for thoracic component / non-surgical oncological radical approach
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NECN Lung NSSG April 2012
Summary• Solitary metastasis
• Good PS (ECOG 0-1)
• No extra cranial metastatic disease
• Radically treatable primary