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Recognising and managing a

patient with brain metastasis


Palliative Medicine Lecture Series
Dr Chay Wen Yee

Brain metastases
Signs and Symptoms
Neurological deficits
Seizures
Giddiness/Headache
Confusion, drowsiness
Change in Mentation
Gradual onset vs stroke sudden

Brain metastases
Differential Diagnosis
Intracranial events
Sepsis
Metabolic
Drugs (e.g. morphine)

Brain Metastases & Raised ICP

Mayo Clin Proc (2006) 81:835-848

Mdm CMK
32 chinese female
Previously diagnosed with L breast Ca (T1b N1 M0 ) after
she self palpated breast lump
- WEAC done 2006
- histo 10 mm , 1/10 LN positive , SBR Grade 3 , extensive
LVSI , margins -ve
- ER /PR -ve Her2Neu -ve ie triple negative
- s/p AC #4 then RT
Currently admitted from clinic May 2010 for
headache last 3 months
Any further history you would like to take?

Mdm CMK
32 chinese female
Previously diagnosed with L breast Ca (T1b N1 M0 ) after she self palpated
breast lump
- WEAC done 2006
- histo 10 mm , 1/10 LN positive , SBR Grade 3 , extensive LVSI , margins ve
- ER /PR -ve Her2Neu -ve ie triple negative
- s/p AC #4 then RT

Currently admitted from clinic May 2010 for


headache last 3 months a/w vomitting
- headache worse on straining during BO
- otherwise no visual disturbances / diplopia
- no focal neurological signs
- no fits

Patient alert
Afebrile
VS stable
H S1S2
L clear
A soft NT no HPM
moving all 4 limbs
no sensory deficit
Left dysmetria

Further investigations you would like to


perform?

Further investigations you would like


to perform:

Hypocount
Baseline CLC
CT
MRI
If plan for op preop bloods
Septic workup if infection is a differential

CT brain: Left cerebellar rim enhancing lesions compatible


with metastases. There is some mass effect on to the 4th
ventricle and the left quadrigeminal cistern is effaced.
- MRI brain : A solitary lobulated rim enhancing cystic lesion
in the left cerebellar hemisphere represents a cerebral
metastasis. Associated perilesional oedema is seen with
some mass effect on the 4th ventricle but no
hydrocephalus is identified. Some old blood product within
this cerebellar metastasis is also noted
CT T/A/P : Metastatic deposits to the right lung upper lobe
and right hilar nodal station and the left iliac bone are
noted.

CT Brain

MRI brain

- patient started on IV dexamethasone and


referred to NES and TRD
CT T/A/P : Metastatic deposits to the right
lung upper lobe and right hilar nodal station
and the left iliac bone are noted.
- S/B Neurosurgery : offered surgery
- S/B Radiation Oncology with plan is to offer
RT to patient after surgery

Case 2
Metastatic colon Ca dx August 2009.
OGD: normal; colonoscope 12/8/09: sigmoid Ca (malignant
stricture); CEA 12/08/09: 28.1
- underwent left hemicolectomy on 24/8/09.
Histo: Moderately differentiated adenocarcinoma reaching
pericolonic fat ( pT3). 16 benign lymph nodes.
- Post-operatively Xelox #2, underwent liver resection ( left
hemihepatectomy and segment VI resection 3/12/2009) then Xelox
x 6 cycles
Histo: Metastatic adenocarcinoma.
- noted lung nodules Sep 2010 s/p #4 Xeliri
-PD at anastomotic site, s/p extended AR in April 2011 subsequently
declined further chemo

Currently admitted for


1) Left sided weakness x1/52
-unable to raise arm or leg
-a/w numbness
-acute in onset, no preceding fall or head injury
2) Drowsiness x 1 day
-no fever, chills or rigors
-no URTI or abdo pain
-no headache, visual distubance

MRI Brain

Brain metastases
Management
IV Steroids - reduces oedema & provides symptomatic relief
Consider iv Mannitol effective within min; last several
hours
Whole brain RT (whether or not op done)
Refer Neurosurgery for decompression/ VP shunt if:
Solitary brain met
Large brain metastasis
Posterior fossa lesion
Hydrocephalus

Then patients son starts to press the call bell


urgently as patient appears to be jerking.

Management of fits
Ensure respiratory and circulatory status ( and supportive
therapy eg mechanical ventilation given as needed)
Blood sugar level ensure fits not due to hypoglycemia
Benzodiazepines eg diazepam 0.1 0.3 mg/kg ( stat dose
either IV or rectal suppository) for rapid control
Phenytoin ( given up to 20mg/kg)
Increased risk of hypotension and cardiac arrthymias with faster
infusion rates
Cardiac monitoring required

IV midazolam infusion/ use of barbiturates if status


epilepticus
More details on fit management coming up from Pall med
lecture by Dr D Watkinson later

Thank you and any questions?

Pericardial Tamponade

Pericardial Tamponade
Signs and Symptoms
Breathlessness, chest pain, orthopnoea, lethargy
Becks Triad tamponade
Raised JVP
Muffled heart sounds
Hypotension

Pulsus Paradoxus

Pericardial Tamponade
Diagnosis
CXR:

GLOBULAR heart with distinct heart

borders
ECG small voltages
Small bilateral pleural effusions

*ACC/AHA definition for low QRS voltage is amplitude


<5mm in standard limb leads or <10mm in precordial
leads

Pericardial Tamponade
Confirmatory Diagnosis
2DE separation of pericardial layers can be detected
when fluid exceeds 1535 ml; early diastolic collapse of
RV wall (tamponade)
CT Chest

Acute pericardial tamponade with diastolic collapse of the


RV wall

Pericardial Tamponade
Management
IV Drip to maintain intravascular volume
Avoid diuretics
Refer to CVM and CTS
Pericardial window
In the meantime - pericardiocentesis

Superior Vena Cava Obstruction

Superior Vena Cava Syndrome

Superior Vena Cava Obstruction


>90% caused by malignant tumors
85% by lung cancer (small cell lung cancer, squamous-

cell lung cancer)


Malignant lymphomas
<2% thymoma or germ cell tumors
Other metastatic tumors

Non-malignant
Long-term central venous catheters, thrombosis

Superior Vena Cava Obstruction


Symptoms
SOB 63%
Facial swelling 50%

Cough 24%
Arm swelling 18%
Chest pain 15%
Dysphagia 9%

Signs
Neck veins distended

66%

Venous distension of

chest wall 54%

Facial oedema 46%

Stridor from laryngeal

oedema

Cyanosis 20%
Facial plethora 19%

Symptoms may be aggravated


by bending forward, stooping
or lying down

Oedema of arms 14%


Papilloedema

Superior Vena Cava Obstruction


Investigations
CXR- superior mediastinal widening and pleural

effusion most common

CT Chest

Superior Vena Cava Obstruction


Rarely causes life threatening situation
Except with sudden obstruction leading to brain edema

>50% symptomatic before cancer diagnosis made

Superior Vena Cava Obstruction


Management: Relieve symptoms + treat underlying

cause

ABCs of resuscitation
Oxygen
Nurse at 45
Diuretics (iv lasix 40mg) if SBP >100mmHg
IV dexamethasone 8mg tds (withhold in patients

without histological diagnosis as may precipitate tumor


lysis syndrome in eg. lymphoma)
IV in lower limbs

Superior Vena Cava Obstruction


If goal is palliative or when urgent treatment of

venous obstruction is required:

Radiation therapy to lesion is primary treatment


Endovascular stenting and angioplasty +/-

thrombolysis
Surgery (rare)

Superior Vena Cava Obstruction


50% of malignant causes due to small cell lung ca,

lymphoma, germ cell tumours- all are chemosensitive tumors and potentially curable chemo
will be primary treatment

If 1st presentation and no diagnosis esp in young

pts where lymphoma likely intubate if necesssary


to protect airway and obtain biopsy

Superior Vena Cava Obstruction


Chemotherapy

- malignant lymphoma
- small cell lung carcinoma

- chemo-nave non-small cell lung carcinoma


Significant response: 1-2 wks
Radiotherapy

- recurrent non small cell lung ca


- chemo-insensitive tumour

Significant response: 2 wks

Nursing care
Assessment of worsening neurological,
pulmonary and cardiac function
Elevation of HOB, oxygen and allaying anxiety
Decrease exertion
Fluid balance