NECN Lung NSSG April 2012 Managing Solitary Brain Metastases from NSCLC Dr Paula Mulvenna Consultant...
-
Upload
grace-peters -
Category
Documents
-
view
215 -
download
0
Transcript of NECN Lung NSSG April 2012 Managing Solitary Brain Metastases from NSCLC Dr Paula Mulvenna Consultant...
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