Neurosurgery 68 y/o. Caucasian M Brain Metastasis from

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68 y/o. Caucasian MBrain Metastasis from Melanoma
Neurosurgery

• Shintaro Ono

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Case 68 y/o. Caucasian M

• 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 AfPast Surgical
History- Left lung lower lobectomy for
metastasis (12/11/08) - Appendectomy 60 years
agoMedicatoin- 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
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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--gt1.5, 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.
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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
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MRI
4mm
4.5 x 3.7cm
Right frontal craniotomy was done on May 22, 2009.
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Post-operative MRI
He was discharged on May 26, 2009. He is taking a
course of whole brain radiation therapy.
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Brain Metastasis

• The most common intracranial tumors in adults
  (gt50 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
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Brain Metastasis from Melanoma

• 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.

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Treatment

• 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
  13941.Skibber, JM, Soong, SJ, Austin, L, et
  al. Cranial irradiation after surgical excision
  of brain metastases in melanoma patients. Ann
  Surg Oncol 1996 3118.

• 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 661873.
  Hwu, WJ, Lis, E, Menell, JH, et al.
  Temozolomide plus thalidomide in patients with
  brain metastases from melanoma. Cancer 2005
  1032590.

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Craniotomy vs SRS

• 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(lt3cm), multiple(orlt3), and deep lesions
• Patients unlikely to tolerate general anesthesia.

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Treatment for the patient

• Resection, Craniotomy?
• SRS?
• Whole Brain Radiation Therapy (WBRT)?
• Chemotherapy?
• or Combination?

What the reason for resection surgery and
following WBRT?
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Reasons for Surgery

• The Patient
• Good performance status (KPS 90 gt 70)
• Large (gt3cm), dominant Lesion
• Mass Effect
• Resectable
• The lesion cannot be well controlled with
  external radiation alone.

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Reasons for Surgery
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Summary

• 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.

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Thank you!!
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Prognosis
Patient Age 68 y.o. (gt 65 y.o.) Karnofsky
Performance Score (KPS) 90 Metastasis Lung,
Liver, Brain
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