March 2017

53yo with intermittent speech problems

History 
•53yo M who was diagnosed with renal cell carcinoma s/p nephrectomy 10 years ago. He recently developed issues with headaches and intermittent confusion and difficulty speaking.
•PMH is otherwise unremarkable
 
Examination
•Vital signs normal
•Neurologically intact except for mild word finding difficulty
 
Further information
 

Initial Imaging

Followup Imaging

 
1. What tests would you order prior to intervention?
2. The patient underwent surgical resection and the pathology was consistent with metastatic renal cell carcinoma. What cancer types most frequently metastasize to the brain?
3. He subsequently underwent stereotactic radiosurgery for small enhancement around the surgical resection cavity. What dose would you prescribe?
4. The patient presents increasing headaches and N/V w/ imaging revealing increased enhancement & edema. He is treated w/ steroids for 4 weeks & cannot be weaned off. What treatment is LEAST likely to result in improvement in brain edema and his symptoms?
5. Which of the following describes you?
6. I practice in one of the following locations.
7. Comments
  • Questions seem to be leading. Question 4 is confusing at best.

  • I hope to improve my knowledge. Best Regards, Tomasz Skaba

  • Prognosis is poor in spite of all available treatment modalities.

  • I would have advised CT/PET Scan of the body before getting CT Scan of a particular part

Case Explanation: Explanation of Answers

1. The patient has a history of renal cell carcinoma therefore re-staging his cancer by obtaining a CT of his chest/abd/pelvis would be prudent prior to treating his brain lesion. The presence of wide-spread metastatic disease would potentially change your treatment plan. The diagnosis of multiple myeloma, infection and demyelinating disease are less likely.
2.  The most common types of cancer to result in brain metastasis are lung cancer, breast cancer, and melanoma. Colon, prostate and renal cell have a much lower incidence of brain metastases.
3. SRS doses for brain metastasis are usually 20Gy for a single isocenter (smaller lesions) and 17.5Gy for multiple isocenters (larger lesions).
4. Radiation necrosis can be treated with hyperbaric oxygen treatment, surgical resection or MRI guided laser ablation (laser interstitial thermotherapy). Continuing steroids for more than 4 weeks is unlikely to result in resolution of the lesion and edema. 

References:

•Stelzer et al. Epidemiology and prognosis of brain metastasis. Surg Neurol Int 2013.
•Rahman et al. Radiographic response of brain metastasis after LINAC radiosurgery. Stereotact Funct Neurosurg 2012.
•Shaw et al. Single dose radiosurgical treatment of recurrent previously irradiated primary brain tumors and metastases: Final report of RTOG protocol 90-05. Int J Radiat Oncol Biol Phys 2000.
•Torres-Reveron et al. Stereotactic laser induced thermotherapy (LITT): a novel treatment for brain lesions regrowing after radiosurgery. J Neurooncol 2013.

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