Tanat Vaniyapong MD Neurosurgery Unit Faculty of Medicine Chiang Mai University 8 January 2016 Introduction 1030 of breast cancer brain metastasis incidence longer survival new imaging modalities ID: 912655
Download Presentation The PPT/PDF document "Surgery for Metastatic Brain Tumor from ..." is the property of its rightful owner. Permission is granted to download and print the materials on this web site for personal, non-commercial use only, and to display it on your personal computer provided you do not modify the materials and that you retain all copyright notices contained in the materials. By downloading content from our website, you accept the terms of this agreement.
Slide1
Surgery forMetastatic Brain Tumor from Breast Cancer
Tanat Vaniyapong, MDNeurosurgery Unit, Faculty of Medicine, Chiang Mai University
8 January 2016
Slide2Introduction10-30% of breast cancer brain metastasis
incidence (longer survival / new imaging modalities)
Slide3Risk factors for brain metastasisYounger age (<50
yr)> 2 metastatic sitesHigh tumor gradeTumor size > 2 cmHER2 positive
Triple-negative breast cancer(Weil, 2005;
Heitz
, 2009)
Slide4Prognosis1-year overall survival: 20%
Median survivalUntreated: 4 weekWBRT: 4-6 moSingle lesion with surgery and RT: 16
mo
Slide5Prognostic factorsHER2 positive (worst in triple negative)
KPS > 70Size of primary cancerInterval from Dx brain metastasesNumber of metastasisAgeER statusExtracranial
metastases
Slide6Prognostic factors
Andres, 2011, Cancer. April 15; 117(8): 1602–1611
Slide7PrognosisRecursive partitioning analysis (RPA)
KPSPrimary tumor statusExtracranial metastasisAgeGraded prognostic assessment (GPA) indexKPSNumber of CNS metastasisExtracranial metastasis
Age
The Radiation Therapy Oncology
Group (RTOG)
Slide8PrognosisRecursive partitioning analysis (RPA)
KPSPrimary tumor statusExtracranial metastasisAgeBreast cancer – specific – GPA indexKPSNumber of CNS metastasis
Extracranial metastasisAgeHER2 and ER/PR status
The Radiation Therapy Oncology
Group (RTOG)
Slide9PrognosisGil-Gil, 2014
(A) GPA index(B) Median survival
0
0.5
1
Age
>60
50-59
<50
KPS
<70
70-80
90-100
No
. CNS metastases
>3
2-3
1
Extracranial
metas
Present
-
None
GPA
0-1
1.5-22.5-33.5-4OS in months (All tumors)3.15.49.616.7S in months (Breast cancer)3.47.715.125.3
Slide10Treatment of Brain Metastasis
Focal treatmentSurgical resection (Sx)Stereotactic Radiosurgery (SRS)Regional treatmentWhole brain Radiation (WBRT)
Slide11Treatment of Brain Metastasis
Treatment optionsSx+WBRT vs WBRTSx+WBRT vs Sx
Sx+WBRT vs SRS + WBRT
SRS
vs
SRS
+WBRT
Slide12Ranasinghe
, 2007: modified from Fife, 2004
Slide13WBRTVS Surgery + WBRT
Slide14WBRT VS SURGERY+WBRT
3 RCT – single brain metastasis
Patchell 1990 (48pt)
Median survival :
Sx+WBRT
VS
WBRT alone
(40 wk VS 15 wk)
Sx
group had longer functional independence
(38 wk VS 8 wk)
Vecht
1993 (63 pt)
Median survival
Sx+WBRT
VS WBRT :
10 mo VS
6
mo (p 0.04)
Mintz
1996
(84 pt)
Median survival
Sx+WBRT VS WBRT:5.6 VS 6.3 yr
No difference in cause of death and quality of life
Slide15Hart MG, Cochrane Review, 2004
Slide16Hart MG, Cochrane Review, 2004
Slide17Slide18WBRT VS SURGERY+WBRT
Surgery + WBRT may improve FIS but not overall survival. Surgery + WBRT may
reduce the proportion of deaths due to neurological cause esp. in a highly selected group of patients.
Operating
on
metastases
does
not
confer
significantly
more
adverse
effects.
Hart MG, Cochrane Review, 2004
Slide19SurgeryVSSurgery + WBRT
Slide20Sx+WBRT VS Sx alone
1 RCTPatchell 1998Recurrence and neurological death were less likely in pt treated with Sx+WBRTNo significant in median survival
Slide21Slide22Slide23Selection for Resection
Age, Functional status and Extracranial diseaseRecursive Partitioning Analysis (RPA) for Prognostic Factors from Radiation Therapy Oncology Group (RTOG) dataAgePerformance StatusPrimary Disease
Extracranial Metastasis
Gasper 1997,Agboola 1998
Slide24Selection for Resection
Age, Functional status and Extracranial diseaseRPA Class I: Age ≤ 65
KPS > 70controlled primary diseaseno
extracranial
metastasis
RPA Class III
: KPS < 70
RPA Class
II
: others
Median Survival (14.8, 9.9, 6.0 mo for Class I,II,III)
Gasper 1997,Agboola 1998
Slide25Selection for Resection
Age, Functional status and Extracranial diseaseRPA Class I patients are good candidates for craniotomy and resectionRPA Class III patients – not likely to realize benefit from surgeryRPA Class II patients – carefelly selected by survival and operative risks
Agboola 1998
Slide26Selection for Resection
Single and multiple brain metastasesMultiple metastasis is no longer an barrier to craniotomyBindal 1993 56 pt with multiple brain metastases and found that survival was similar to a matched control group of pt with single metastases
Patients ≥ 4 tumors are usually poor prognosis and usually not treated surgically
Wronski 1997
No difference in overall outcome bet surgically treated pt with single or multiple metastases
Slide27Selection for Resection
Nontraditional indicationsSignificant mass effect symptom relief or improve QoL4 or more lesions : one is large and creating life or limb threateningSmall single lesion with extensive edema and/or refractory seizure
Extracranial suspected primary but difficult to Bx
Slide28Selection for Resection
Nontraditional indicationsSymptomatic small tumor that have edema or necrosis and less likely to respond to RTRecurrent metastases – may provide additional information (radionecrosis/edema)
Slide29Selection for Resection
Recurrent MetastasesAdvantage of surgeryMay improve survival and quality of lifeConfirm histopathologyLocal chemotherapeutic adjuncts (BCNU wafer)
Slide30Importance of preoperative evaluation
Patient Age and Functional StatusDisease free survivalLonger survival in longer disease-free interval
Leptomeningeal DiseaseLeptomeningeal carcinomatosis
associated with poor prognosis
Surgery has no significant benefit
Mainstay treatment is RT and
intrathecal
or systemic chemotherapy
Slide31Selection for Resection
Factors favorable for tumor resection Age < 65KPS > 70Control of extracranial disease
Single tumorSize < 3 cmSurgical accessibility
Good tumor localization
Absences of
leptomeningeal
involvement
Undiagnosed primary site of cancer
Long disease-free survival
Local symptomatic mass effect
Slide32Sterotactic Biopsy
Suitable forDeeply seated lesion, near eloquent brain Small lesion Medically unable to tolerate GA
Suspected radio/chemosensitive tumor
Complications
Low (<1%) – most common = hemorrhage
Slide33Sterotactic Biopsy
AdvantageLess invasiveAccuracy/PrecisionLocal anesthesiaLocationFew complication
DisadvantageExtent of removal – survival ?Device/technic
Slide34Sterotactic Surgery
Framed
sterotactic
biopsy
Slide35Sterotactic Surgery
Frameless stereotactic biopsyNeuronavigation system
Slide36Mr. H, 60 yr, CA lung
Slide37P.M. 54 y , CA lung s/p resection
Slide38Slide39P.. 36 yr
Slide40Mr.DK. 40 yr , CA stomach
Slide41P.S. 40 yr , Advanced CA lung
Slide42K, 52
yr
Slide43Summary
Surgery + WBRT > SurgerySurgery + WBRT > WBRTGood candidatesSingle lesionAge < 60Good KPSControlled primary
Slide44Summary
Surgery decision is individualized forPoor KPS, advanced primary, multiple metastasisBiopsy/sterotactic Bx – selected case
Slide45Guideline for brain metastasis in northern breast cancer patients
Symptom suspected brain metastasisCT or MRI brain as initial investigation
Confirmed brain metastasis
- Start dexamethasone IV
- Other supportive medication
Single lesion
Multiple lesions
Consult Neurosurgeon
Consult Radiation Oncologist
Appropriate for tumor resection
Inappropriate for tumor resection
Remove tumor
followed by PORT
Breast
cancer patients
Slide46The End