In addition to selecting definitive treatment of the
central nervous system neoplasm, managing neurological symptoms is an important aspect of care
of patients with metastatic brain tumors. There are
several measures which can be taken to improve
quality of life.
Cerebral edema and mass effect from the tumor
may result in many neurological symptoms. Surgical resection of tumor, when feasible, is the most
direct way of ameliorating this problem. Corticosteroids improve vasogenic edema and are a
mainstay in treating cerebral edema from primary
or metastatic brain tumors. A typical dose of dexamethasone consists of an intravenous bolus of 10
to 20 mg followed by 4 to 24 mg/day in divided
doses. Vigilance is needed for side effects including hyperglycemia, peptic ulcer disease, weight
gain, edema, psychosis, immunosuppression, and
proximal weakness due to steroid myopathy. Corticosteroids are often continued until tumor control
is achieved with definitive treatment (eg, surgery or
WBRT) and should then be tapered.
Seizures can occur in patients with brain metastasis. However, anticonvulsants should be reserved for patients who have actually experienced
a seizure.71 Anticonvulsants that do not induce
hepatic enzymes, such as levetiracetam, valpro-ate, gabapentin, and pregabalin, are less likely to
interact with chemotherapy and are preferred.
CASE 1 CONTINUED
The single metastasis is surgically resected
without significant neurological sequelae
(Figure 4). The pathological review is consistent
with metastatic breast cancer. The patient then
receives WBRT to a total dose of 30 Gy in 15
fractions. She receives surveillance brain MRI
with gadolinium every 3 months. She remains
clinically and radiologically stable 6 months after
the completion of WBRT. After the eighth month,
she reports impaired balance and urinary incon-
tinence. Contrast MRI of the brain reveals sulcal
enhancement within the cerebellum. MRI of the
spine shows leptomeningeal enhancement near
the conus medullaris (Figure 5). Lumbar puncture
is performed; cerebrospinal fluid (CSF) analysis
reveals elevated protein (121 mg/dL) and the pres-
ence of malignant cells on CSF cytology. These
cells are consistent with the primary cancer cells.
The clinical, radiological, and laboratory findings are suggestive of leptomeningeal metastasis
(LM). LM refers to infiltration of the leptomeninges
(arachnoid and pia mater) with neoplastic cells.
Synonyms for this condition include neoplastic
Figure 5. (A) Sulcal enhancement of the cerebellum (arrows) on
brain magnetic resonance imaging (MRI), consistent with leptomeningeal metastasis. (B) Leptomeningeal metastasis on lumbar
spine MRI with enhancement near the conus medullaris (arrows).