If You Are a Cancer Survivor, This Is a Must Read .


Getting through cancer treatment successfully is something to celebrate. To stay in good health, doctors say you need to watch for other symptoms, including vision changes, headaches and problems with balance.

What many cancer survivors don’t realize is that 25 percent of people who survive some common cancers go on to develop a brain tumor. These brain tumors don’t originate in the brain but are actually cancerous cells from the original tumor that travel to the brain through the bloodstream. When this happens, doctors call these tumors brain metastases.

“About one-third of patients with the most common cancers — lung, breast and kidney cancer and melanoma — are at risk of developing brain metastases,” says Cleveland Clinic neurosurgeon Gene Barnett, MD.

When this happens, the resulting growth needs early treatment. Dr. Barnett says early detection can help people get the right treatment at the right time to avoid serious complications. This is why you need to be vigilant and pay attention to your symptoms.

Watch for these 9 signs

If you’ve had cancer and experience these symptoms, be sure to tell your doctor:

  1. Vision changes (such as double vision or partial vision loss)
  2. Headaches (possibly with nausea)
  3. Numbness or tingling in part of the body
  4. Paralysis or difficulty moving any part of the body
  5. Inability to walk
  6. Difficulty with balance and an increased incidence of falls
  7. Difficulty speaking (including slurred words or incoherent speech)
  8. Problems with mental acuity (such as not being able to read or tell time)
  9. Seizure or convulsions

Metastatic brain tumors tend to develop gradually, although severe episodes can occur. No matter what, it’s important to tell your doctor immediately so he or she can evaluate you and treat you early as needed.

Treatable brain tumors

For years, doctors believed that brain metastases were uniformly fatal. Treatment could only to relieve symptoms. Today, they know that such tumors are treatable, thanks to technological and medical advances. The key is early detection.

To help in this fight, Cleveland Clinic teamed with the Northern Ohio American Cancer Society to establish the B-Aware Program. “Our goal is to educate at-risk cancer patients so that brain metastases are detected as early as possible, when they have the greatest number of treatment options,” says Dr. Barnett.

Many treatments available

We’ve come a long way from the days when the only treatment option available for brain metastases was whole brain radiation. This often failed to control the tumors. Today, aggressive and precisely delivered treatments produce better outcomes with fewer side effects.

Treatment options depend on the location, type and extent of the tumor, and include:

  • Radiosurgery. Radiosurgery directs highly focused beams of radiation at the tumor with extreme precision. This will not destroy the tumor, but may succeed in stopping tumor growth. Surgeons deliver this radiation so precisely that they can spare the surrounding brain tissue. Gamma Knife surgery is a common form of radiosurgery.
  • Minimal access surgery. This type of surgery allows doctors to remove the tumor in a faster, simpler way. Surgeons make a very small incision in the skull or hidden in a nearby structure. This reduces postoperative complications, minimizes pain and scarring, and shortens recovery time.
  • Localized radiotherapy, or radiation therapy. Radiotherapy exposes the cancerous cells to ionizing radiation that injures or destroys them. Doctors often use radiotherapy before or in addition to radiosurgery.
  • Medical therapies. Chemotherapy uses drugs to kill tumor cells that are dividing most rapidly. Many drugs used successfully for tumors in the body cannot penetrate into the brain. However, in certain cases, chemotherapy or other medical treatments may secure control of certain brain metastases.

“We want to help patients ‘be aware’ of all management options, so they don’t blindly agree to a proposed treatment which may not be in their best interest,” says Dr. Barnett. “They always have the right to seek a second opinion.”

Motor function after stereotactic radiosurgery for brain metastases in the region of the motor cortex.


Abstract

OBJECT

The authors sought to better define the clinical response of patients who underwent stereotactic radiosurgery (SRS) for brain metastases located in the region of the motor cortex.

METHODS

A retrospective analysis was performed in 2026 patients with brain metastasis who underwent SRS with the Gamma Knife between 2002 and 2012, and multiple factors that affect motor function before and after SRS were evaluated. Ninety-four patients with tumors ≥ 1.5 cm in diameter located in or adjacent to the motor strip were identified, including 2 patients with bilateral motor strip metastases.

RESULTS

Motor function improved after SRS in 30 (31%) of 96 cases, remained stable in 48 (50%), and worsened over time in 18 (19%) instances. Forty-seven patients had no motor weakness prior to radiosurgery; 10 (22%) developed new Grade 3/5–4/5 weakness. Thirty (68%) of 44 patients with ≥ 3/5 pre-SRS weakness improved, 6 (14%) remained stable, and 8 (18%) worsened. Three of 5 patients with < 3/5 pre-SRS motor function improved. Motor deficits prior to SRS did not correlate with a worse outcome; however, worse outcomes were associated with larger tumor volumes. The median tumor volume in patients whose function improved or remained stable was 5.3 cm3, but it was 9.2 cm3 in patients who worsened (p < 0.05). Tumor volumes > 9 cm3 were associated with a higher risk of worsening motor function. Adverse radiation effects occurred in 5 patients.

CONCLUSIONS

Most intact patients with brain metastases in or adjacent to motor cortex maintained neurological function after SRS, and most patients with symptomatic motor weakness remained stable or improved. Larger tumor volumes were associated with less satisfactory outcomes.

Source: http://thejns.org

 

A case-matched study of stereotactic radiosurgery for patients with multiple brain metastases: comparing treatment results for 1–4 vs ≥ 5 tumors.


Abstract

OBJECT

Although stereotactic radiosurgery (SRS) alone for patients with 4–5 or more tumors is not a standard treatment, a trend for patients with 5 or more tumors to undergo SRS alone is already apparent. The authors’ aim in the present study was to reappraise whether SRS results for ≥ 5 tumors differ from those for 1–4 tumors.

METHODS

This institutional review board–approved retrospective cohort study used the authors’ database of prospectively accumulated data that included 2553 consecutive patients who underwent SRS, not in combination with concurrent whole-brain radiotherapy, for brain metastases (METs) between 1998 and 2011. These 2553 patients were divided into 2 groups: 1553 with tumor numbers of 1–4 (Group A) and 1000 with ≥ 5 tumors (Group B). Because there was considerable bias in pre-SRS clinical factors between Groups A and B, a case-matched study was conducted. Ultimately, 1096 patients (548 each in Groups A and B) were selected. The standard Kaplan-Meier method was used to determine post-SRS survival and the post-SRS neurological death–free survival times. Competing risk analysis was applied to estimate cumulative incidences of local recurrence, repeat SRS for new lesions, neurological deterioration, and SRS-induced complications.

RESULTS

The post-SRS median survival time was significantly longer in the 548 Group A patients (7.9 months, 95% CI 7.0–8.9 months) than in the 548 Group B patients (7.0 months 95% [CI 6.2–7.8 months], HR 1.176 [95% CI 1.039–1.331], p = 0.01). However, incidences of neurological death were very similar: 10.6% in Group A and 8.2% in Group B (p = 0.21). There was no significant difference between the groups in neurological death–free survival intervals (HR 0.945, 95% CI 0.636–1.394, p = 0.77). Furthermore, competing risk analyses showed that there were no significant differences between the groups in cumulative incidences of local recurrence (HR 0.577, 95% CI 0.312–1.069, p = 0.08), repeat SRS (HR 1.133, 95% CI 0.910–1.409, p = 0.26), neurological deterioration (HR 1.868, 95% CI 0.608–1.240, p = 0.44), and major SRS-related complications (HR 1.105, 95% CI 0.490–2.496, p = 0.81).

In the authors’ cohort, age ≤ 65 years, female sex, a Karnofsky Performance Scale score ≥ 80%, cumulative tumor volume ≤ 10 cm3, controlled primary cancer, no extracerebral METs, and neurologically asymptomatic status were significant factors favoring longer survival equally in both groups.

CONCLUSIONS

This retrospective study suggests that increased tumor number is an unfavorable factor for longer survival. However, the post-SRS median survival time difference, 0.9 months, between the two groups is not clinically meaningful. Furthermore, patients with 5 or more METs have noninferior results compared to patients with 1–4 tumors, in terms of neurological death, local recurrence, repeat SRS, maintenance of good neurological state, and SRS-related complications. A randomized controlled trial should be conducted to test this hypothesis.

Source: JNS

 

Systemic Treatment for Brain Metastases from HER2-Positive Breast Cancer.


Two thirds of patients achieved a partial response; half experienced grade 3 or 4 adverse effects.

As new targeted agents have improved outcomes in HER2-positive breast cancer, studies have suggested that survivors might have a longer time to be at risk for developing brain metastases. Radiation therapy is the mainstay for treatment of breast-cancer brain metastases, but it causes adverse effects, and whole-brain radiotherapy (WBRT) impairs cognitive function. Alternatively, systemic therapy seems to have relatively little penetration into the central nervous system (CNS), and evidence of it producing a CNS antitumor effect is lacking. However, recent studies have shown that the oral tyrosine kinase inhibitor lapatinib — administered as monotherapy or in combination with capecitabine — might be an effective treatment. To determine whether this approach could delay radiation therapy, French investigators conducted an industry-funded, single-arm, open-label, phase II (LANDSCAPE) trial of lapatinib and capecitabine involving 44 evaluable patients with HER2-positive breast cancer who had not received whole brain radiotherapy (WBRT).

Treatment was administered in 21-day cycles: patients received oral lapatinib (1250 mg) daily and oral capecitabine (2 gm/m2) on days 1 to 14. Clinical assessments of toxicity and neurological effects were conducted every 3 weeks. Patients underwent computed tomography and magnetic resonance imaging studies to detect CNS lesions every 6 weeks. More than 90% of patients had received prior trastuzumab, 57% had neurological signs and symptoms at enrollment, and 84% had extra-CNS sites of disease, most commonly in bone, liver, and lung. The primary end point of the study was the rate of objective CNS response, defined as a 50% volumetric reduction in CNS lesions without progression of symptoms, extra-CNS disease, or use of steroids.

At median follow-up of 21.2 months, 66% of patients achieved objective CNS responses, all of which were partial responses. Patients were equally likely to attain CNS response whether previously treated with trastuzumab or not. Median time to CNS progression was 5.5 months, and median time to radiotherapy was 8.3 months. The majority of patients (78%) had CNS as the first site of disease progression. Nearly 50% of patients had at least one grade 3 or 4 adverse event, most commonly diarrhea or hand-foot syndrome.

Comment: Brain metastases remain a significant therapeutic challenge, and patients who have a relatively long survival after WBRT might experience some of the well-described cognitive and functional deficits. The LANDSCAPE trial offers patients with HER2-positive brain metastases the potential to delay radiation therapy. However, the combination of lapatinib and capecitabine has the potential to produce substantial adverse effects, which can also negatively affect quality of life.

Source: Journal Watch Oncology and Hematology