Brain metastases recurrence diagnosis

Brain metastases recurrence diagnosis

It is difficult to differentiate local brain metastases recurrence from radiation induced-changes in case of suspicious contrast enhancement. New advanced MRI techniques (perfusion and spectrometry) and Amino Acid Positron Emission tomography allow to be more accurate and could avoid a stereotactic biopsy for histological assessment, the only reliable but invasive method.

Whereas positron emission tomography (PET) with the widely used 18F-2-deoxy-2-fluoro-D-glucose (18F-FDG) has low diagnostic accuracy after SRS, the use of radiolabelled amino acids or amino acid analogues such as L-methyl-11C-methionine (11C-MET) and O-(2-18F-Fluoroethyl)-L-Tyrosine (18F-FET) reaches sensitivity and specificity values in the range of 78 and 100 % rendering especially 18F-FET a highly reliable tracer in glioma imaging.


In patients with MRI-suspected tumor recurrence after focused high dose radiotherapy, 18F-FET PET has a high sensitivity and specificity for the differentiation of vital tumor tissue and radiation-induced lesions 1).


Tran et al. performed a feasibility study to prospectively evaluate 11C methionine positron emission tomography and11C PBR28 positron emission tomography in 5 patients with 7 previously SRS-treated brain metastases demonstrating regrowth to differentiate tumor regrowth (TR) from radiation necrosis (RN).

Sequential imaging with dual tracers was well-tolerated. [11C]methionine was accurate for detecting pathologically confirmed TR in 7/7 lesions, whereas [11C]PBR28 was only accurate in 3/7 lesions. Tumor PBRTSPO expression was elevated in both melanoma and lung cancer cells, contributing to lack of specificity of [11C]PBR28-PET.

Sequential use of PET tracers is safe and effective. [11C]Methionine was a reliable TR marker, but [11C]PBR28 was not a reliable marker of RN. Studies are needed to determine the causes of post-radiation inflammation and identify specific markers of RN to improve diagnostic imaging 2).

The multimodal MRI has greatly contributed to refine the differential diagnosis between tumour recurrence and radionecrosis, which remains difficult. The FDG PET is helpful, in favour of the diagnosis of local tumour recurrence when a hypermetabolic lesion is found. Others tracers (such as carbon 11 or a fluoride isotope) deserve interest but are not available in all centres. Stereotactic biopsy should be discussed if any doubt remains 3).

An increase in FLAIR signal of the fluid within the resection cavity might be a highly specific and early sign of local tumor recurrence/tumor progression also for brain metastases. 4).


1)

Romagna A, Unterrainer M, Schmid-Tannwald C, Brendel M, Tonn JC, Nachbichler SB, Muacevic A, Bartenstein P, Kreth FW, Albert NL. Suspected recurrence of brain metastases after focused high dose radiotherapy: can [18F]FET- PET overcome diagnostic uncertainties? Radiat Oncol. 2016 Oct 21;11(1):139. doi: 10.1186/s13014-016-0713-8. PMID: 27769279; PMCID: PMC5073742.
2)

Tran TT, Gallezot JD, Jilaveanu LB, Zito C, Turcu G, Lim K, Nabulsi N, Huang H, Huttner A, Kluger HM, Chiang VL, Carson R. [11C]Methionine and [11C]PBR28 as PET Imaging Tracers to Differentiate Metastatic Tumor Recurrence or Radiation Necrosis. Mol Imaging. 2020 Jan-Dec;19:1536012120968669. doi: 10.1177/1536012120968669. PMID: 33147119.
3)

Patsouris A, Augereau P, Tanguy JY, Morel O, Menei P, Rousseau A, Paumier A. [Differentiation from local tumour recurrence and radionecrosis after stereotactic radiosurgery for treatment of brain metastasis.]. Cancer Radiother. 2014 Jan 13. pii: S1278-3218(13)00444-7. doi: 10.1016/j.canrad.2013.10.013. [Epub ahead of print] French. PubMed PMID: 24433952.
4)

Bette S, Gempt J, Wiestler B, Huber T, Specht H, Meyer B, Zimmer C, Kirschke JS, Boeckh-Behrens T. Increase in FLAIR Signal of the Fluid Within the Resection Cavity as Early Recurrence Marker: Also Valid for Brain Metastases? Rofo. 2017 Jan;189(1):63-70. doi: 10.1055/s-0042-119686. PubMed PMID: 28002859.

Meningioma scalp metastases

Meningioma scalp metastases

Scalp metastases of meningiomas seldom have been reported.

Avecillas-Chasin et al report a series of 4 cases of this rare event and discuss the relevant potential risk factors.

They performed a retrospective review of patients treated for scalp metastases of meningiomas at our institution. A literature review was performed for the terms “scalp meningioma,” “cutaneous meningioma,” “skin meningioma,” “extracranial meningioma,” and “subcutaneous meningioma.”

Four patients showed scalp metastases of recurrent meningiomas with the following associated clinical features: multiple reoperations (n = 4), immunosuppression (n = 2), radiation therapy (n = 3), surgical wound complications with cerebrospinal fluid fistula (n = 2), and histologic grade progression (n = 2). The timescale for development of scalp metastasis was between 5 months and 13 years after intracranial meningioma surgery. In all cases, the metastases were located close to the surgical scalp incision for the craniotomy. Previously, 11 cases of meningioma with scalp metastasis, with similar features to those described here, were reported in the literature.

Spreading of meningioma cells during surgery is a possible mechanism for scalp metastases of recurrent meningiomas. Factors associated with scalp metastases include reoperations, immunosuppression, radiation therapy, torpid course of the surgical wound with cerebrospinal fluid fistula, and histologic progression. Awareness of these features is advisable for neurosurgeons involved in the care of patients with similar profiles 1).

Case reports

A 69-year-old man presented with an atypical meningioma scalp metastases. Six years after the right frontoparietal meningioma lesion was completely resected, an isolated subcutaneous metastasis developed at the right frontal region of the scalp, originating at the scar left by the first surgery. Postoperative histological examination of the subcutaneous tumor revealed the features of an atypical meningioma.

This study highlights that resection of meningiomas is still associated with a risk of iatrogenic metastasis. Surgeons should carefully wash out the operative field and change surgical tools frequently to avoid the potential risk of metastasis 2).


A 79-year-old man presented with a large subcutaneous mass in the midline parietooccipital region and progressive right hemiparesis. The contrast-enhanced millimetric computed tomography scans of the head showed the intracranial parasagittal enhanced mass invading the superior sagittal sinus and the subcutaneous mass without any bony destructive, osteoblastic, or osteolytic changes. Under the operative microscope, no visible communication was found between the intracranial and extracranial mass lesions. Histopathologic examination of both intracranial and extracranial tumors demonstrated the same atypical meningioma (World Health Organization grade II). The possible route of extracranial extension of the tumor may be the sizable parietal foramen 3).


Li et al present a rare case of a giant malignant meningioma with multiple recurrences. The patient was a 73-year-old woman who was evaluated to have a malignant meningioma of the frontal part of the skull 3 years before being admitted to our hospital and received surgical treatment. The tumor recurred 3 years after the first surgery and was classified as a giant meningioma on admission to our hospital. We performed total resection of the giant meningioma and reconstructed the defect with artificial dura, skull, and a local rotating flap. The patient recovered and lived well for 1 year. However, 15 months after surgery, the patient died of the recurrent tumor after refusing any treatment. Meningiomas are usually common and benign intracranial tumors; however, the anaplastic subtype of meningiomas is rare and malignant. Despite the high rates of recurrence and metastasis, surgery is still an option. For giant invasive tumors, the cooperation of neurosurgeons and plastic surgeons is essential 4).

References

1)

Avecillas-Chasin JM, Saceda-Gutierrez J, Alonso-Lera P, Garcia-Pumarino R, Issa S, López E, Barcia JA. Scalp Metastases of Recurrent Meningiomas: Aggressive Behavior or Surgical Seeding? World Neurosurg. 2015 Jul;84(1):121-31. doi: 10.1016/j.wneu.2015.02.041. Epub 2015 Mar 9. PubMed PMID: 25765926.
2)

Liu Y, Li J, Duan Y, Ye Y, Xiao L, Mao R. Subcutaneous metastasis of an atypical meningioma: a case report and literature review. World Neurosurg. 2020 Mar 4. pii: S1878-8750(20)30403-4. doi: 10.1016/j.wneu.2020.02.128. [Epub ahead of print] PubMed PMID: 32145423.
3)

Nawashiro H, Nawashiro T, Nawashiro A. Subcutaneous Extension of Parasagittal Atypical Meningioma Through Parietal Foramen. World Neurosurg. 2019 May;125:104-105. doi: 10.1016/j.wneu.2019.01.185. Epub 2019 Feb 8. PubMed PMID: 30743032.
4)

Li ZY, Cen Y, Gu M, Wei Y. Giant malignant meningioma invading the calvarial bone and scalp. J Craniofac Surg. 2012 Mar;23(2):599-602. doi: 10.1097/SCS.0b013e31824cd718. PubMed PMID: 22446424.

Non small cell lung cancer intracranial metastases radiosurgery

Non small cell lung cancer intracranial metastases radiosurgery

Multisession radiosurgery (M-GKS) may be an effective alternative for large brain metastases from Non small cell lung cancer (NSCLC). Specifically, severe radiation induced toxicity (≥ grade 3) did not occur in M-GKS for large-volume metastases. Although the long-term effects and results from larger samples remain unclear, M-GKS may be a suitable palliative treatment for preserving neurological function 1).

Traditionally, whole brain radiotherapy (WBRT) has been the cornerstone of Non small cell lung cancer intracranial metastases treatment, but its indication is a matter of debate. A randomized trial has shown that for patients with a poor prognosis, WBRT does not add quality of life (QoL) nor survival over the best supportive care. In recent decades, stereotactic radiosurgery (SRS) has become an attractive non-invasive treatment for patients with BM. Only the BM is irradiated to an ablative dose, sparing healthy brain tissue. Intracranial recurrence rates decrease when WBRT is administered following SRS or resection but does not improve overall survival and comes at the expense of neurocognitive function and QoL. The downside of SRS compared with WBRT is a risk of radionecrosis (RN) and a higher risk of developing new BM during follow-up. Currently, SRS is an established treatment for patients with a maximum of four BM. Several promising strategies are currently being investigated to further improve the indication and outcome of SRS for patients with BM: the effectivity and safety of SRS in patients with more than four BM, combining SRS with systemic therapy such as targeted agents or immunotherapy, shared decision-making with SRS as a treatment option, and individualized isotoxic dose prescription to mitigate the risk of RN and further enhance local control probability of SRS.

The review of Hartgerink et al., discusses the current indications of SRS and future directions of treatment for patients with BM of NSCLC with focus on the value of SRS 2).


Radiosurgery for multiple BMs is controversial, yet patients with EGFR Non small cell lung cancer intracranial metastases and Anaplastic lymphoma kinase non small cell lung cancer may be uniquely suited to benefit from this approach. These results support single and multiple courses of radiosurgery without WBRT for patients with oncogene-addicted NSCLC with four or more BMs 3).

References

1)

Park K, Kim JW, Chung HT, Paek SH, Kim DG. Single-Session versus Multisession Gamma Knife Radiosurgery for Large Brain Metastases from Non-Small Cell Lung Cancer: A Retrospective Analysis. Stereotact Funct Neurosurg. 2019 May 22:1-7. doi: 10.1159/000496154. [Epub ahead of print] PubMed PMID: 31117101.
2)

Hartgerink D, van der Heijden B, De Ruysscher D, Postma A, Ackermans L, Hoeben A, Anten M, Lambin P, Terhaag K, Jochems A, Dekker A, Schoenmaekers J, Hendriks L, Zindler J. Stereotactic Radiosurgery in the Management of Patients With Brain Metastases of Non-Small Cell Lung Cancer: Indications, Decision Tools and Future Directions. Front Oncol. 2018 May 9;8:154. doi: 10.3389/fonc.2018.00154. eCollection 2018. Review. PubMed PMID: 29868476; PubMed Central PMCID: PMC5954030.
3)

Robin TP, Camidge DR, Stuhr K, Nath SK, Breeze RE, Pacheco JM, Liu AK, Gaspar LE, Purcell WT, Doebele RC, Kavanagh BD, Rusthoven CG. Excellent Outcomes with Radiosurgery for Multiple Brain Metastases in ALK and EGFR Driven Non-Small Cell Lung Cancer. J Thorac Oncol. 2018 May;13(5):715-720. doi: 10.1016/j.jtho.2017.12.006. Epub 2017 Dec 19. PubMed PMID: 29269007.
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