Diagnosis and Management of Central Nervous System Metastases from Breast Cancer

Abstract

The brain, cranial nerves, leptomeninges, spinal cord, and eye compose the central nervous system (CNS) and are at risk for the development of metastases from breast cancer. Such metastases are diagnosed on the basis of clinical suspicion and substantiated by neuroimaging, resection when indicated, and sampling of cerebrospinal fluid when leptomeningeal metastasis (LM) is suspected. Treatment is aimed at palliation of symptoms and preservation of neurologic function. Historically, conventional radiation therapy has been the mainstay of palliative treatment for brain, cranial nerve, spinal cord, and ocular metastases. However, additional treatment options for brain metastases have been brought about by technological advances in surgery to resect brain metastases, and stereotactic radiosurgery (SRS) to focally irradiate metastases, both of which have been substantiated by data from randomized trials. Ongoing research is aimed at refining criteria to select which patients with brain metastases should undergo surgery and SRS and how these focal therapies should be optimally integrated with whole-brain radiotherapy. Therapy for LM must carefully balance the potential risks and perceived benefits associated with CNS-directed therapies. Despite advances in neuroimaging, surgery, and radiation therapy, novel treatments are needed to improve the effectiveness of treatments for CNS metastases, especially LM, while reducing attendant neurotoxicity.

Symptom Management in Metastatic Breast Cancer

“…Breast cancer occasionally (2%-6%) involves the leptomeninges, with the diagnosis being made by finding malignant cells on lumbar puncture [16,17]. Leg weakness, multifocal abnormalities at more than one level of the neural system (spine, cranial nerves, cerebrum), headaches, and mentation changes are frequent symptoms associated with leptomeningeal disease [17]. The treatment of pain in the cancer patient involves several interventions.…”

Mystery of the brain metastatic disease in breast cancer patients: improved patient stratification, disease prediction and targeted prevention on the horizon?

“…On the other side, the brain is one of the predominant sites of the metastatic spread recorded for more than 20% of breast cancer patients in several individual subgroups [6,7]. Although highly clinically relevant, this mystery has not been yet adequately explained.…”

Intracranial Cystic Metastases from Breast Cancer

“…The most common histologies are lung, breast, melanoma and renal cell cancer. Breast cancer is the second most common cause of brain metastases (after lung cancer); it occurs in 10-15% of breast cancerpatients, although autopsy studies suggest that the actual incidence is twice this figure [1]. Distant breast cancer metastases are more common in the lungs, bones and liver.…”

“…Seizures, ataxia or nausea-vomiting can also be the presenting symptoms. Gadolinium-enhanced magnetic resonance imaging (MRI) is more sensitive than contrast-enhanced CT for identifying both parenchymal and leptomeningeal disease and is therefore the preferred noninvasive diagnostic test [1]. A stereotactic brain biopsy must be considered whenever the diagnosis of metastasis remains in doubt.The optimum therapy for brain metastases is still evolving.…”