cancer. A thorough assessment is essential in identifying the associated systemic malignancy and in
determining which site of disease is safest for tissue
diagnosis. In the differential diagnosis, conditions
apart from metastatic disease need to be considered (Table 1).
INITIAL PRESENTATION AND EVALUATION
A 54-year-old woman presents with a left
breast mass and is treated with a lumpec-
tomy and axillary lymph node dissection. Her
tumor is negative for hormonal receptors (estro-
gen receptor, progesterone receptor) and is also
negative for HER2/neu (human epidermal growth
factor receptor 2). She has positive lymph nodes
and receives local radiation therapy and 8 cycles
of adjuvant cyclophosphamide, methotrexate, and
5-fluorouracil. There are no other sites of meta-
static disease at diagnosis.
Eight months after her diagnosis, she develops
right-sided headaches. She has an excellent performance status. CT of the brain without contrast
reveals a right parietal hypodensity with significant
mass effect. MRI with gadolinium contrast does
not reveal any additional lesions (Figure 4). There
is no evidence of any active extracranial disease.
• What are important prognostic factors in
Several factors have been validated as important
prognostic factors in patients with brain metastasis.
These include age, performance status, and extent
of extracranial disease. These factors have been
used to stratify patients into several prognostic
Figure 1. Malignancies most commonly associated with brain metastasis. GI = gastrointestinal; GU = genitourinary; Gyn = gynecologic. (Data from Posner.3)