NECN Lung NSSG April 2012

Managing Solitary Brain Metastases from NSCLC

Dr Paula Mulvenna

Consultant Clinical Oncologist

Northern Centre for Cancer Care

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

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

NECN Lung NSSG April 2012

Incidence, a Local Issue: NCIN e-atlas

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

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

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

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

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

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

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

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

NECN Lung NSSG April 2012

Summary• Solitary metastasis

• Good PS (ECOG 0-1)

• No extra cranial metastatic disease

• Radically treatable primary