Management of Brain Metastases and Superior Vena Cava Syndrome(1)

7/21/2019 Management of Brain Metastases and Superior Vena Cava Syndrome(1)

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Recognising and managing a

patient with brain metastasisPalliative Medicine Lecture Series

Dr Chay Wen Yee



• 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



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 toperform?



Further investigations you would liketo 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 compatiblewith metastases. There is some mass effect on to the 4thventricle and the left quadrigeminal cistern is effaced.

• - MRI brain : A solitary lobulated rim enhancing cystic lesion

in the left cerebellar hemisphere represents a cerebralmetastasis. Associated perilesional oedema is seen withsome mass effect on the 4th ventricle but nohydrocephalus is identified. Some old blood product withinthis cerebellar metastasis is also noted

• CT T/A/P : Metastatic deposits to the right lung upper lobeand right hilar nodal station and the left iliac bone arenoted.



CT Brain



MRI brain



• - patient started on IV dexamethasone andreferred to NES and TRD

• CT T/A/P : Metastatic deposits to the rightlung upper lobe and right hilar nodal stationand 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 Xeloxx 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





• 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

Brain metastases



• Then patient’s son starts to press the call bellurgently 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 fasterinfusion rates

– Cardiac monitoring required• IV midazolam infusion/ use of barbiturates if statusepilepticus• More details on fit management coming up from Pall med

lecture by Dr D Watkinson later…



• Thank you and any questions?



Pericardial Tamponade




Signs and SymptomsBreathlessness, chest pain, orthopnoea, lethargyBeck’s Triad tamponade

Raised JVPMuffled heart soundsHypotension

Pulsus Paradoxus



DiagnosisCXR: GLOBULARheart with distinct heartbordersECG small voltages

Small bilateral pleural effusions

*ACC/AHA definition for low QRS voltage is amplitude<5mm in standard limb leads or <10mm in precordialleads








Confirmatory Diagnosis2DE – separation of pericardial layers can be detectedwhen fluid exceeds 15 – 35 ml; early diastolic collapse ofRV wall (tamponade)CT Chest




Acute pericardial tamponade with diastolic collapse of theRV wall





ManagementIV Drip to maintain intravascular volume

Avoid diuretics

Refer to CVM and CTSPericardial windowIn the meantime - pericardiocentesis




Superior Vena Cava Obstruction



Superior Vena Cava Syndrome




>90% caused by malignant tumors85% by lung cancer (small cell lung cancer, squamous-cell lung cancer)Malignant lymphomas<2% thymoma or germ cell tumorsOther metastatic tumors

Non-malignantLong-term central venous catheters, thrombosis



SymptomsSOB 63%Facial swelling 50%Cough 24%

Arm swelling 18%Chest pain 15%Dysphagia 9%

Symptoms may be aggravatedby bending forward, stoopingor lying down

SignsNeck veins distended66%Venous distension ofchest wall 54%Facial oedema 46%Stridor from laryngealoedemaCyanosis 20%Facial plethora 19%Oedema of arms 14%Papilloedema




Investigations

CXR- superior mediastinal widening and pleuraleffusion most common

CT Chest




Rarely causes life threatening situationExcept with sudden obstruction leading to brain edema

>50% symptomatic before cancer diagnosis made












Management: Relieve symptoms + treat underlyingcause

ABCs of resuscitation

OxygenNurse at 45Diuretics (iv lasix 40mg) if SBP >100mmHgIV dexamethasone 8mg tds (withhold in patientswithout histological diagnosis as may precipitate tumorlysis syndrome in eg. lymphoma)IV in lower limbs




If goal is palliative or when urgent treatment ofvenous obstruction is required:

Radiation therapy to lesion is primary treatmentEndovascular stenting and angioplasty +/-thrombolysisSurgery (rare)




50% of malignant causes due to small cell lung ca,lymphoma, germ cell tumours- all are chemo-sensitive tumors and potentially curable – chemowill be primary treatment

If 1st presentation and no diagnosis esp in youngpts where lymphoma likely – intubate if necesssaryto protect airway and obtain biopsy




Chemotherapy- malignant lymphoma

- small cell lung carcinoma

- chemo-naïve non-small cell lung carcinomaSignificant 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

Management of Brain Metastases and Superior Vena Cava Syndrome(1)

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