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Monday, February 20, 2006 · Last updated 7:22 p.m. PT
Doctors want to find spreading cancer
By LAURAN NEERGAARD
AP MEDICAL WRITER
WASHINGTON -- No one ever checked whether Leslie Bather's breast cancer was spreading to her brain, until the day tumors caused
three frightening seizures. MRI scans can help spot when cancer in another part of the body sends seedlings into the brain,
but few patients get routine checks.
Neurology specialists say it's time to change that: More patients are surviving initial tumors long enough for their brains
to be at risk, as treatments get better at battling cancer below the neck yet fail to protect the brain. And improved technology
is making it easier and safer to treat those new brain tumors, if they're caught early.
"If I were diagnosed with cancer tomorrow, the first thing I'd want is a brain scan," says Dr. Leonard Cerullo, director of
the Chicago Institute of Neurosurgery and Neuroresearch.
This type of brain cancer "is becoming a bigger and bigger clinical problem," adds Dr. Frank Lieberman, neuro-oncology chief
at the University of Pittsburgh Cancer Cancer.
Already, about 150,000 Americans a year are diagnosed with what is called a "metastatic brain tumor" - cancer that spread
into the brain from some other part of the body.
Any cancer can spread to the brain. But lung cancer is the leader; it will happen in up to 40 percent of lung cancer patients,
often very early in their disease.
Up to a third of breast cancer patients will experience a brain metastasis. Also common spreaders are melanoma and kidney
and colon cancer.
Not too many years ago, doctors mostly discovered metastatic brain cancer when its victims already were close to dying from
tumors riddling other parts of their bodies.
Now, breast specialists in particular are reporting an increasing number of women who beat back cancer elsewhere in the body,
only to have it flare in the brain. It seems to be a special concern among users of Herceptin, a powerful drug that targets
an aggressive type of breast cancer - everywhere except in the brain, because it's too large a molecule to penetrate the blood-brain
barrier, explains Lieberman.
But it's a more widespread concern. While the American Cancer Society doesn't yet have a count of the reported increase, it
notes that cancer patients overall are living longer, providing more time for microscopic tumor cells incubating in the brain
to take root.
Scientists are beginning to fight back:
-Studies are under way to see if an experimental drug called lapatinib, made by GlaxoSmithKline, can treat breast cancer that
spreads to the brain. Lapatinib targets the same aggressive breast cancer as Herceptin does but is thought to easily penetrate
the brain.
-Also under study is whether some commonly used cancer drugs could ever cross into the brain, especially if used in conjunction
with brain radiation.
-And neurology specialists are urging general oncologists to start checking patients, especially those with lung or breast
cancer, for spread to the brain well before symptoms appear.
There are no formal guidelines, but at Pittsburgh, MRI scans - not CT scans that Lieberman calls less sensitive in the brain
- are being incorporated shortly after original diagnosis. After that initial scan, Chicago's Cerullo advises including the
brain in any routine check for cancer spread. He says insurance generally pays.
High doses of whole-brain radiation once were the only treatment for metastatic brain cancer, and could cause such troubling
side effects as memory loss, Cerullo says.
Now, treatment is more sophisticated, especially for tumors caught early. Topping the list: radiosurgery, using focused beams
of radiation to zap just the cancerous cells and not surrounding healthy brain tissue.
Whole-brain radiation today comes in safer doses with fewer side effects, but when to use it is controversial. Some studies
suggest a preventive course could protect certain lung cancer patients, for example.
Lieberman and Cerullo advise patients to ask about a brain scan.
It's advice that Bather, the Chicago patient, echoes. She calls her 2004 seizures "definitely divine intervention" because
only then did she get a brain scan - even though tests that same week had found breast cancer spreading in her lungs and liver.
"You want to think you're OK," says Bather, 52, whose brain seems clear after treatment of more than 40 tumor sites, but she
still is battling cancer elsewhere. Instead, "what you don't know can hurt you."
---
EDITOR'S NOTE - Lauran Neergaard covers health and medical issues for The Associated Press in Washington.
*****My brain cancer is GONE! I had a brain, MRI this week and three of the four lesions do not light up anymore and
the 4th one lights up a tiny bit but the report said that it is probably scar tissue formation. I was told the lesions would
never go away but that
they can be controlled. So basically, they are dead!" I know and she knows that this doesn't
mean they can't come back - but isn't it great? Just thought I'd share... (from a BCMETSTER)*****
My sister was first diagnosed with brain mets in May 2005.
She did not have typical symptoms so it was not caught until she had a
spread to her lymph nodes and her whole body was scanned.
She had developed significant short term memory loss (which despite
radiation treatments that eliminated most of the mets has not eased.)
The Drs believed the memory loss was stress related and it took them
some time to believe that it was mets related. More subtle things
included personality changes i.e. poor grooming habits, growing
irrationality.
She thankfully has not had any physical symptoms such as headaches
or seizures.
She now has leptomeningeal mets which were found via MRI but have not
caused her any symptoms as yet.
Carmen in Aurora, On, Canada
Headaches began to increase about 5 months ago. Finally told the oncologist. My vision (especially the left eye) has
grown worse since chemo in 97; however, I'm progressively losing vision in the left eye. Denial has kept me from the ophthalmologist.
I have drusen in both eyes. Mild double vision in the left eye, and slight shadows appearing in the right eye. My vertigo
has not been the best post-chemo, and most recently my balance stinks. I can be standing still and suddenly sway losing my
footing. Nausea is common, I've taken meclizine for years PRN. Haven't really told the onc. doc. about the dizziness and balance
problem growing more constant of late.
Had 1st MRI of the brain Feb. 02'. At first the radiologist thought I may have multiple sclerosis,(from Susan A.:if you view
both mets and ms lesions on films, they look a lot alike), vascular ischemia, et al. Saw a neurologist. Neurologist sent me
for 2nd brain MRI, after doing a piss-poor neurological evaluation (in my opinion). 2nd MRI shows Mild High Left-Greater-Than-Right
Increased T2 weighted signal within the pons. At this appt. the neuro doc tells me I have a brain lesion. He's running late,
and must go. I ask, "and what does this mean?", and his reply is he doesn't know. Says it doesn't mean brain mets necessarily.
Says to call him if I have any symptoms (!)... like what? He says, "You'll know". o.k., I think... Tells me I'll need a 3rd
MRI in June and to come see him again June 14th. I have the next MRI scheduled for May 24th. I'll hand-carry the films to
him 6/14.
My onc. doc is running bloodwork every 6 weeks. (This makes me nervous, but he tells me everything looks good.) I'm trusting
him (them). I don't know what questions to ask as far as the CA tests go. He told me what he ran, but I don't recall if it
was 15-3 or another type. What do I need to ask? and what are the markers about? My symptoms seem to be mildly increasing,
but then it could be all in my head (tee hee... ok... I've got to lighten up here a little or I'll go nuts!)
i just posted that my eye
doctor (after being pressed on it) told me that behind the eye
twitching, "caused
by stress, irregular sleep, lack of exersize, too
much caffeine" was actually an increase in adrenalin---i.e. all those
things can cause an increase in adrenalin--and i'm guessing some of our
treatments do as well. i think this
is helpful information in terms of
how to view and treat symptoms.
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getting brain MRIs every 3 months, and having had 4
brain mets diagnosed in the last year (when prior brain MRI
showed
nothing), is that these suckers can grow mighty quickly, and that above
2cm (which in my case developed
within 6 months, from no detectable
lesions), stereotactic radiation isn't considered a good option, and brain
surgery
(craniotomy) is indicated. BTDT...not fun. If your insurance
permits, I'd ask for a second opinion if I were in your
shoes - maybe at
Stanford? where they have CyberKnife (state of the art stereotactic
radiation equipment) available.
*********************
My sister was first diagnosed with brain mets in May
2005. She did not have typical symptoms so it was not caught
until she had a spread to her lymph nodes and her whole body was scanned.
She had developed significant short term memory
loss
(which despite radiation treatments that eliminated
most of the mets has not eased.) The Drs believed the
memory
loss was stress related and it took them some
time to believe that it was mets related. More subtle
things included
personality changes i.e. poor
grooming habits, growing irrationality.
She thankfully has not had any physical symptoms
such
as headaches or seizures.
Carmen
From: Midge
I had severe pain in the base of my skull, my neck and head on one side, which increased over the
months, but my onc felt that since I had responded to other chemo so well and the research seemed to support only doing these
brain MRI's when some symptoms present themselves. The onc seemed to feel it was a waste of time, until I insisted, because
I was suffering so much. Sure enough, I had brain mets, even though I SO hoped I didn't, and had 4 tumors, 2 2cm. and 2 1cm,
and
considerable edema/swelling of the brain. So why
didn't they think my symptoms were reflective of
possible brain
mets? I still don't understand, and it
took me several months to convince them to please do
the MRI. we have to be as
assertive as possible about things when our gut tells us to. And what can it hurt for them to do a routine check, if our insurance
doesn't hassle us about it?Like I said, they also need to ?examine what would constitute the symptoms that would set them
on the trail, since mine didn't start to effect my vision until the actual day I had the MRI. The intense pain
WAS the
symptomology!
My 2.9x3.6cm cerebellum bcmets brain tumor was
dx'd by MRI in March 2005, about 10 months
after my previous,
"clear" brain MRI -
equilibrium problems, which I tried to ignore at first. Continuously & increasingly, I could
not
sustain my balance with my weight on one leg (and I awoke & found myself staggering to the
bathroom, balancing
myself by putting a hand on
a wall- as though I were drunk!
-Sandy
It really depends on the location. Mine, left parietal
lobe, affects mainly my right arm and leg (clumsiness, numbness,
focal seizures). I've also at times had dizziness, nausea, confusion and light sensitivity. -Menya
the most frequent symptoms of brain tumors: Headaches
that tend to be worse in the
morning and ease during
the day
Seizures (convulsions)
Nausea or vomiting
Weakness or loss of feeling in the arms or legs
Stumbling or lack of coordination in walking
Abnormal
eye movements or changes in vision
Drowsiness
Changes in personality or memory
Changes in speech.
My family doctor diagnosed congestion. I finally knew I had to get a 2nd opinion. Believe me, this felt very different
from anything I'd ever felt in almos 70 years of life. For me it was morning headaches, nausea, and loss of balance. All depends
on where the tumor is.-Marilyn
My wife had seizures in early June and discovered a
single lesion on the front of her brain. They removed
it
surgically and she had 23 days of whole brain
radiation. She did fairly well with it, but noticed
after she was done
she was having a little trouble
hearing. The ear, nose, throat specialist put in ear
tubes in both ears to let fluid
drain. The theory was
that her estuachian tubes were plugged from the
radiation and fluid was accumulating from breakdown
of
tissue. Her hearing acuity still comes and goes
some. The tubes evidently get plugged some too. She
has been a little
confused at times, but that may be
due to the surgery also.
-Dean
Short term memory problems but they were attributed to stress. She subsequently found a lump on her neck ?> lymph
node which was biopsied and determined to be malignant. had numerous brain mets but no other mets in her body.
-Carmen
I have always been nearly asymptomatic. With increased
dizziness and peripheral vision lights in left eye on
a
few occasions. That was all of my 'symptoms'.
-pattyz
I went to my (ex) family doctor and told him I
thought I had a brain tumor or something very serious.
He shined
a light up my nose and declared it was
congestion. Well, I wanted to believe him, so I took
Clariton D and returned
in 3 days, this time reeling
like a drunk. He said that was caused by clogged
estuchean tubes and to continue the Claritin
and come
back in 3 weeks. After 2 weeks of staggering around
the house, my husband insisted I get a second
opionion.
That doc sent me for a CT scan immediately,
and I was put in the hospital the same day. Anytime
you're not satisfied,
get a 2nd opinion. My husband
called to cancel my appt. with the old doc and told
him that I was in the hospital getting
brain surgery,
and that "apparently his pills didn't work". I was
tempted to call him later and tell him a lot more
than
that, but I just changed doctors. One of my very
significant symptoms, according to the doc, was
headaches upon
waking in the morning. If they come
later in the day, it isn't so significant.
-Marilyn
The Dura Mater
The outermost of the three meninges is the dura mater (or pachymeninx), a strong, thick, and dense membrane. It is composed
of dense fibrous tissue. It can be regarded as a sac that envelops the arachnoid and that has been modified to serve several
functions.
Within the skull the dura mater surrounds and supports the large venous channels (dural sinuses) carrying blood from the brain
toward the heart. It also is prolonged into several partitions, or septa, which lend support to the brain. One of these, the
falx cerebri, is a sickle-shaped partition lying between the two hemispheres of the brain. Another, the tentorium cerebelli,
provides a strong, membranous roof over the cerebellum. A third, the falx cerebelli, projects downward from the tentorium
cerebelli between the two cerebral hemispheres. The outer portion of the dura mater over the brain serves as a covering, or
periosteum, of the skull bones' inner surfaces.
Within the vertebral canal the dura mater splits into two sheets. These are separated by a space, called the epidural space,
which is filled with fat and thin-walled veins. The outer of these two sheets constitutes the periosteum of the vertebral
canal. The inner sheet is separated from the arachnoid by the narrow subdural space, which is filled with fluid.
In a few places, however, the subdural space is absent, and the arachnoid is intimately fused with the dura mater. The most
important area of fusion between these two meninges is in the walls of the large venous channels of the dura mater. There
elongations of the arachnoid, like fingers, penetrate the dura mater and project into the veins. These fingerlike processes
of the arachnoid, which are referred to as arachnoid villi, or arachnoid granulations, are involved in the passage of cerebrospinal
fluid from the subarachnoid space to the dural sinuses.
Beverly was dxd stage four (lungs bones liver) 2003 after reoccurance in her
reconstructed breast (MRM w/tram). First MRI of brain two years ago showed what was
thought to be a menginoma. Now, it seems that is really dural mets. She had
FEC x 6 after original occurance then taxol and gemzar followed by phase II
trial of sugen, avastin and gemzar and now zelota. She was just having some
very mild headaches and some numbness on her lower lip. We meet with our onc
and then an interventional radiologist tomorrow. This is really scary but our onc says its better to have mets in dura rather
than the brain.
Eric and Beverly
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Metastasis to the brain is the most feared complication of systemic
cancer. Incidence is rising with improved survival of cancer patients. Currently,cancer patients live longer as a result of
important advances in cancer diagnosis and management, and in particular, the widespread use of MRI to detect small metastases.
Approximately 40% of intracranial neoplasms are metastatic. Multiple, large autopsy series suggest that, in order of decreasing
frequency, lung, breast, melanoma, renal, and colon cancers are the most common primary tumors to metastasize to the brain.
Early diagnosis and aggressive treatment of brain
metastases may result in remission of brain symptoms
and
may enhance the quality of the patient's life and
prolong survival. The radiologist plays a primary role in the
management of cancer patients by helping detect, localize, and diagnose the lesion. Metastatic tumor growth in the brain depends
on complex organotropic factors as well as passive
vascular delivery of tumor cells. Lesions are located in the cerebrum
(80-85%), in the cerebellum (10-15%), and in the brain stem (3-5%). Slightly more than 50% of the time, multiple as opposed
to solitary metastases occur, but this varies with the type of primary tumor. Melanoma, lung, and breast primaries are more
likely to produce multiple metastases.
Intracranial metastases can be categorized by location as skull, dura, leptomeninges,
and parenchymal brain metastases. Lesions of the brain and leptomeninges account for 80% of intracranial metastases. Meningeal
carcinomatosis most commonly occurs in patients with breast carcinoma, malignant melanoma, and, less commonly, with lymphoma,
leukemia, and other tumors. Patients usually present with headache, vague
neurologic complaints, and one or more cranial
nerve palsies.
Brain metastases represent the most common neurologic
manifestation of cancer, occurring in 15% of cancer
patients.
Mortality/Morbidity: Prognosis typically is poor. Therapeutic considerations must be individualized and depend
on many factors, which include the patient's neurologic status, extent of systemic tumor, number and location of brain metastases,
and sensitivity of the tumor to radiation and chemotherapy. Patients with the best prognostic indicators often die within
18-24
months. Of particular relevance to imaging, patients with a solitary
brain metastasis treated by surgical resection show an approximately doubled rate of survival after 1 year. Most available
treatment is palliative; however, consider prolonging the patient's quality of life through specific therapy to the brain.
Clinical
Details: Approximately two thirds of brain metastases are symptomatic at some point. Symptoms primarily are caused by (1)
increased intracranial pressure resulting in headache, nausea, vomiting, confusion, and lethargy and (2) focal irritation
or destruction of neurons resulting in hemiparesis,visual field defects, aphasia, focal seizures, ataxia,
and other focal
neurologic signs or deficits. The most common symptoms in order of decreasing frequency are headache, focal weakness, and
mental status changes. Symptoms typically have a gradual onset. However, if seizures are excluded, 5-10% of
patients may
develop other acute symptoms. An acute strokelike presentation may occur and often is precipitated by hemorrhage into the
tumor. Hemorrhage is present in 3-14% of metastases and most likely is seen in metastases from melanoma,choriocarcinoma, renal,
thyroid, lung, breast, and
germ-cell tumors. Generalized or focal seizures may occur in 20% of patients with brain
metastases. Different primary tumors spread to the brain at different points in the disease course. The median latent interval
between the initial diagnosis of a primary tumor and diagnosis of brain metastases varies from 6-9 months for lung cancer
and 2-3 years for
melanoma, breast, and colon cancer. In 20% of patients, metastases are detected
during diagnosis of the primary tumor, and in 50% of patients, they are detected within 1 year following diagnosis.Surgical
resection is the preferred treatment in patients with one apparent metastasis detected on enhanced CT or MRI. Radiosurgery
provides a simple, effective, noninvasive, cost-effective method to treat surgically inaccessible lesions and is a therapeutic
option for 2-6 metastases. MRI in patients with primary cancers that frequently metastasize to the brain is probably cost-effective.
Numerous studies have shown that contrast-enhanced MRI detects 2-3 times as many lesions as contrast-enhanced
CT, especially lesions less than 5 mm in diameter. In addition,
approximately 20% of patients with solitary metastatic
lesions
on CT show multiple lesions on MRI. Perform
imaging on patients with other cancers based on their
clinical evaluation.
If a lesion is found and a definitive diagnosis
cannot be established, perform a biopsy. Surgical removal of the lesion
is indicated for single or solitary brain metastasis in patients with good systemic performance status, since surgery is both
diagnostic and therapeutic. Patients with multiple
brain metastases or poor systemic performance status are possible candidates
for whole-brain radiation therapy or radiosurgery. Preferred Examination: Most patients with a known primary tumor receive
imaging studies when neurologic
signs and symptoms develop. MRI with contrast enhancement currently
is the procedure of choice, since MRI is more sensitive and specific than other imaging techniques in determining the
presence, location, and number of metastases. Contrast-enhanced CT is used widely because of its easy
accessibility and low cost.
Findings: Metastases frequently are multiple and seen at the junction of gray and
white matter, usually with significant surrounding edema Currently, FDG-PET is not considered superior
to CT or MRI in the initial evaluation of suspected brain metastases.
(part
of an article I borrowed, I didn't put a link because the link wouldn't take you to the site without a membership)
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