The principal symptom of spinal metastasis is pain, which may be local, radicular, or referred, and precedes other symptoms by a mean of 6 weeks [ 77 ]. Isolated back pain without neurologic symptoms should be evaluated first with plain spine radiographs. If an abnormality is found, then further evaluation should be performed with spinal MRI. If the diagnosis still remains uncertain, bone scan and high-resolution CT of the vertebrae may also be performed to distinguish benign lesions, such as hemangioma, from bone metastases.
Pain is usually worsened by lying supine, coughing, sneezing, or straining. Myelopathy can occur in the form of limb weakness, numbness, paresthesia, and alterations in bladder and bowel functions. Signs of myelopathy may include increased tone, clonus, hyperreflexia, bladder distension, or an abnormal sensory level.
In the setting of myelopathy, the entire spinal cord should be imaged with MRI. Left untreated, epidural spinal cord compression will inexorably lead to paraplegia or quadriplegia, depending upon the level of compression along the spine. Therefore, prompt evaluation is of the utmost importance when epidural spinal cord compression is suspected.
Once epidural spinal cord compression is diagnosed, steroids should be instituted immediately, along with emergent radiation therapy. A randomized study showed that high-dose mg loading dose dexamethasone preceding radiotherapy resulted in a greater proportion of patients who were able to ambulate after treatment [ 78 ]. Patients whose MRI demonstrates epidural disease without cord compression can be given a lower loading dose of 10 mg dexamethasone. Maintenance dosing consists of 4 mg of dexamethasone every 6 hours and should be slowly tapered once radiation therapy has begun and symptoms have stabilized.
Radiation therapy to the involved region is the treatment of choice for most patients with epidural spinal cord compression. For progressive or recurrent spinal cord progression in the previously irradiated spine, surgery is recommended because of the risk of radiation myelopathy from reirradiation.
Diagnosis and Management of Central Nervous System Metastases from Breast Cancer
Laminectomy is not highly effective, because most epidural metastases are located in the anterolateral location, which is difficult to decompress using a posterior approach, and may further weaken the spine. Vertebral body resection and stabilization with methylmethacrylate cement has been used to overcome problems with laminectomy. Results from nonrandomized studies suggest that vertebral body resection restores ambulatory function better than does radiation therapy [ 79 — 82 ].
However, the highly selected patient population in those studies and the use of historical controls may limit the generalizability and validity of such results. The median survival time in patients with breast cancer who develop spinal cord compression ranges from 4 to 13 months in those studies, yet ambulatory status following treatment is the most important prognostic factor for survival [ 9 , 85 ].
Current research in the treatment of metastatic spinal disease is aimed at developing image-guided SRS procedures that may be used to safely treat paraspinal metastases [ 86 , 87 ]. It is hoped that the metastasis control rates achieved with spinal SRS will be comparable with those achieved with intracranial SRS. Diagnosis should be made by indirect fundoscopic examination.
Brain and Central Nervous System Cancer
After a diagnosis of ocular metastasis has been established, it is important to image the brain for metastatic involvement, because simultaneous metastatic involvement to the brain is common. The median time from diagnosis of breast cancer to development of choroidal metastasis is 4 years [ 94 ]. Presenting symptoms include worsened visual acuity, blind spot, diplopia, and image distortion. Fundoscopic examination may reveal retinal detachment and hemorrhage [ 95 ].
For progressive visual symptoms, patients should be referred for palliative radiation therapy. The target volume to be irradiated is the entire choroid posterior to the equator.
go to link For bilateral disease, both eyes should be treated. For patients with synchronous brain metastases, the field includes the entire cranial contents and the posterior halves of the globes. Reported complications include retinopathy, keratopathy, optic neuropathy, and glaucoma [ ].
In a series of 42 breast cancer patients with choroid metastases treated with radiation therapy, the median survival time was 10 months [ 99 ]. The CNS remains a sanctuary site for metastases from breast cancer. The need for more effective CNS-directed treatments may become more pressing because improvements in systemic treatment for breast cancer could lead to a greater incidence of CNS metastases.
Radiation therapy remains the mainstay of treatment for CNS metastases. Technological advances have enabled focal treatment, such as surgery and SRS, to benefit patients with limited metastatic brain disease and good performance statuses. Similarly, it is hoped that focused treatments to the spine using spinal SRS, which are currently under active investigation, may be beneficial as well. The treatment of LM remains a significant challenge because of difficulties with neurotoxicity from combined intrathecal chemotherapy and radiotherapy.
Future research should be directed at developing more effective agents for LM that have less neurotoxicity. User Name Password Sign In. Chang, M. Accepted May 28, L earning O bjectives After completing this course, the reader will be able to: Select appropriate diagnostic tests for brain, spinal, leptomeningeal, and ocular metastases from breast cancer.
Previous Section Next Section. Figure 1. Medical Treatment Symptomatic therapy involving medical treatment is aimed at stabilizing the acute neurologic symptoms caused by peritumoral edema and controlling seizures. Whole-Brain Radiotherapy for Brain Metastases Whole-brain radiotherapy WBRT is considered standard treatment for patients with brain metastases and may prevent or delay progression of neurologic deficits, restore function, and decrease steroid dependency [ 19 — 22 ].
Figure 2. View this table: In this window In a new window. Table 1. Brain metastases series representing breast cancer patients. Toxicity of WBRT The acute toxicities of WBRT include headache, nausea, possible vomiting, blockage of ears, mild-to-moderate fatigue, hair loss, and mild scalp erythema leading to skin hyperpigmentation. Surgery for Brain Metastases The goals of surgery in the management of brain metastases are to obtain immediate symptom relief, gain local control of the metastasis, and confirm the diagnosis histologically [ 28 ].
Stereotactic Radiosurgery for Brain Metastases The hallmark of SRS is the rapid dose fall-off at the target edges, permitting a clinically significant dose to be given to the target while a clinically insignificant dose is delivered to the surrounding brain [ 28 ]. Adjuvant WBRT The role of postoperative radiation therapy for brain metastases not exclusive to breast cancer has been examined by several retrospective studies, most of which did not demonstrate any survival benefit associated with postoperative WBRT [ 26 , 38 — 42 ].
Figure 3. Chemotherapy for Brain Metastases The role of chemotherapy for the treatment of brain metastases has not been defined [ 5 ]. LM LM is an increasingly common complication of breast cancer [ 8 , 60 ], and breast cancer accounts for the largest number of patients in most large series evaluating LM [ 61 ]. Figure 4. Figure 5. Previous Section.
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