metastatic brain tumors - her2 supporther2support.org/pdf/mbraintumors.pdf · introduction the...

Metastatic Brain Tumors

American Brain Tumor Association

F O C U S I N G O N T U M O R S

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A Word About ABTA Founded in 1973, the not-for-profit AmericanBrain Tumor Association has a proud historyof funding research, providing patient services,and educating people about brain tumors. Ourmission is to eliminate brain tumors throughresearch and meet the needs of brain tumorpatients and their families.

We gratefully acknowledge Deneen PotterHesser, RN, BS, OCN for the research andwriting of this pamphlet and Raymond Sawaya,MD, University of Texas MD Anderson CancerCenter, Department of Neurosurgery, Houston,Texas for technical review.

This publication was made possible throughthe generosity of the Circle of ServiceFoundation.

ISBN 0-944093-58-2

COPYRIGHT © 1992, 1998, 2001, 2004 ABTA

REPRODUCTION WITHOUT PRIOR WRITTEN PERMISS ION IS PROHIB ITED.

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IntroductionThe terms metastatic brain tumor, metastasis tothe brain, or secondary brain tumor are differentnames for the same type of brain tumor. Ametastatic brain tumor begins as a cancer elsewhere in the body and spreads to the brain. Metastatic brain tumors are treatable.Often, the symptoms caused by these tumorscan be reversed, allowing the person with cancer to live a quality life.

Cancer cells usually metastasize to the brain viathe blood stream. They may give rise to a singletumor or multiple tumors. The number, andlocation, of those tumors is important whenconsidering treatment options.

Lung, breast, melanoma (skin cancer), colonand kidney cancers commonly spread to thebrain. Breast cancer and kidney cancer usuallycause single tumors in the brain. Lung,melanoma, and colon cancers tend to causemultiple tumors. Sometimes the body’simmune system is able to destroy the primarycancer, but not the metastasized cells whichtraveled to the brain. This is called an“unknown” primary site, which may never be found. Or, the primary site may have beentoo tiny to be seen or cause symptoms. In thissituation, the metastatic brain tumor is foundfirst, then the primary site is discovered.

The metastatic brain tumor usually contains thesame type of cancer cells found at the primary

METASTAT IC BRA IN TUMORS | 1

M E TA S TA S I S means one tumor.

M E TA S TA S E S is plural — it means two or more tumors.

M E TA S TA S I Z E is the process of cells traveling throughthe body to reach another part of the body.

P R I M A R Y S I T E refers to the location of the original cancer.

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site. For example, small-cell lung cancer whichmetastasizes to the brain forms small-cell cancerin the brain. Squamous-cell breast cancer formssquamous-cell cancer in the brain.

IncidenceThe risk of developing cancer increases withage. As more effective treatments are found for primary cancers and as larger numbers ofpeople live longer, the number of metastaticbrain tumors appears to be rising. About150,000 people in the US each year are diagnosed with a metastatic brain tumor. Theincidence begins to increase in those ages 45-64, but is highest in people over 65. Slightlymore men than women develop these tumors.Researchers have also found that women withbreast cancer appear to be at higher risk ofdeveloping a meningioma — a benign type ofprimary brain tumor — than those who havenot had breast cancer. Please call us if youwould like information about meningiomas.

CauseMetastatic brain tumors are caused by cancerelsewhere in the body. Tiny cancer cells, toosmall to be seen under a microscope, may moveaway from the primary tumor. Scientists believethose cells enter the blood or lymph system,make a stop in the lungs, then move on to othersites. The immune system attempts to destroythese moving cancer cells. However, if the number of cancer cells becomes very high the immune system may become overwhelmed,or tolerant, of these cells.

Because blood from the lungs flows directly to the brain, lung cancer is capable of quicklyspreading to the brain. Sometimes, this happensso quickly the brain metastasis is found before

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the primary lung cancer is found. Metastaticbrain tumors can also appear many years afterthe diagnosis of a primary cancer. In that situation, the cancer cells may have been dormantfor the years in-between. It is unknown whatreactivates those stray cells.

Scientists do know that primary cancers tend to move, or metastasize, to certain organs. Forexample, colon cancer tends to metastasize tothe liver and the lung. Breast cancer tends tometastasize to the bone, the lung and the brain.Some scientists believe these preferences maybe caused by hormones or proteins whichattract tumor cells to that site. Other scientistsbelieve cancer cells may be able to adhere, orstick, only to select organs. Some cancer cellsfind hiding places in ‘protected’ parts of thebody such as the brain. The blood vessels ofthe brain contain a shield called the blood brainbarrier. That barrier allows microscopic cancercells to enter the brain, but may block the

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A R T E R Y B R I N G I N G B L O O D F R O M T H E H E A R T T O T H E B R A I N A O R TA / H E A R T


entrance of larger-sized particles such aschemotherapy drugs. “Safe” from the effects of cancer-killing drugs, these cells may sit in the brain quietly until they begin to grow.Those growing cells may eventually form a metastatic tumor.

SymptomsThe symptoms of a brain tumor are related tothe location of the tumor within the brain.Each part of the brain controls specific bodyfunctions; symptoms appear when the braincan no longer do its work properly.

Headaches, weakness on one side of the body,an unbalanced walk, and/or seizures are someof the most common symptoms. Behavior,memory, and personality changes may also signal a tumor. When these symptoms begingradually, they are usually due to increased pressure within the brain caused by the growingtumor. Swelling around the tumor may occur,or the blood vessels around the tumor may


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bleed and cause the sudden onset of symptoms.Metastatic tumors in the spine may cause backpain, weakness or changes in sensation in anarm or leg, or loss of bladder/bowel control.For additional information about the symptomsof a brain or spinal cord tumor, please see APrimer of Brain Tumors.

DiagnosisMetastatic tumors are diagnosed using a combination of neurological examination and contrast-enhanced MRI or CT scan. Yourphysician will determine if an MRI or CT scanis the preferred test. The contrast dye makesthe tumor(s) easier to see on the scan.

An MRI scan of the brain may be part of theinitial screening process when the primary cancer is diagnosed, or a scan may be ordered if a person living with cancer begins to havesymptoms of a brain or spinal cord tumor.The scan helps the doctor determine the size,location, number and probable type of brain or spinal cord tumor(s). However, only examination of a sample of tumor tissue undera microscope confirms the exact pathologicdiagnosis. The tissue sample may be obtainedduring surgery to remove the tumor, or duringa biopsy. A biopsy is a surgical procedure to remove a small amount of tumor for diagnosis. The sample is then examined under a microscope by a pathologist.

If a metastatic tumor is diagnosed before theprimary site is found, tests to locate the primarycancer will be done. The pathology report canalso help the doctor determine possible sites ofthe primary cancer if testing fails to do so. Ifyou already have a history of cancer, you maynot require a biopsy or surgery. Your doctorwill determine if this is necessary.



Specific Types of MetastasesL U N G M E TA S TA S E S

● The most common type of brain metastases

● About 35% of lung cancers metastasize to the brain

● The brain tumor may be found before,or at the same time, as the primary lung tumor

● Multiple brain metastases are common

B R E A S T M E TA S TA S E S

● Second most common type of brain metastases

● About 10-30% of breast cancers metastasizeto the brain

● Metastases tend to occur a few years after the breast cancer is found

● Are generally found in younger and pre-menopausal women

● A single metastatic tumor is just as commonas multiple tumors

M E L A N O M A M E TA S TA S E S

● Third most common type of brain metastases

● About 30-40% of melanomas metastasize tothe brain or the meninges (the covering of thebrain and spinal cord)

● Metastases tend to occur several years afterthe primary melanoma

● Multiple brain metastases are common

● The metastatic tumors are rich with bloodvessels which have a high tendency to bleed



K I D N E Y M E TA S TA S E S

● Fourth most common type of brain metastases

● About 5-10% of kidney tumors metastasize to the brain

● Metastases tend to occur within a few yearsafter the primary tumor

● Single tumors are common

● The metastatic tumor often containsblood vessels

C O L O N M E TA S TA S E S

● Fifth most common type of brain metastases

● About 5% of colon cancers metastasize to the brain

● Metastases tend to occur a few years after the primary tumor is found

● A single metastatic tumor is common



TreatmentWhen planning your treatment, your doctorwill take several factors into consideration:

● The type of primary cancer

● Your overall health

● The number of metastatic tumors

● The location of the metastatic tumor(s) within the brain or spine

● Your body’s response to the treatment of the primary cancer

The first steps in treating metastatic braintumors are controlling pressure in the brain andcontrolling seizures. Steroids are drugs used to reduce the swelling that can occur around abrain tumor. Reducing the swelling in the braincan remarkably reduce the pressure, and thus,the symptoms of a metastatic brain tumor.Antiepileptic drugs are used to control seizures.

S I N G L E O R L I M I T E D B R A I N M E TA S TA S E S

If you have a limited number of metastatic braintumors (generally 1 or 2 tumors, or a smallnumber of tumors that are close to each other)and if your primary cancer is treatable and undercontrol, surgery may be the next step in treatment.The surgeon will determine if your tumors canbe surgically removed. He or she will also consider the type of primary cancer and thenumber of tumors that particular cancer tendsto form in the brain. If surgery is not possible orthe primary cancer has not been identified, abiopsy may be done to confirm the tumor type. Aform of radiation therapy may follow the surgery;your doctor will make this determination.

Your tumors may also be treated with radiation



and chemotherapy rather than surgery if you havea known history of cancer and that type of canceris known to be sensitive to radiation therapy,such as small-cell lung cancer or lymphoma.


M R I O F A S I N G L E B R A I N M E TA S TA S I S

The picture on the left is taken after the injection of the contrast dye. The picture on the right is called the“T2” image and shows the edema (brain swelling)around the tumor. MRI courtesy of Dr. Sawaya

M U LT I P L E B R A I N M E TA S TA S E S

Your treatment plan will take into considerationthe numbers of tumors, their location, and thestatus of your primary cancer. Generally, theprimary treatment for multiple metastatic braintumors (usually 3 or more tumors, or multipletumors that are not close to each other) iswhole-brain radiation. The goal of this therapyis to treat not only the tumors seen on scan, butthose that may be too small to be seen. Thus,whole brain radiation may be preventive as wellas therapeutic.

Surgery may be used for symptom relief if yourtumors are close to each other and can beremoved. Or, a biopsy may be done to confirmthe tumor type if your primary cancer site hasnot been identified.


S P I N A L M E TA S TA S E S

Spinal metastases are most often caused bybreast, lung or prostate cancers. These tumorsgenerally involve the bones of the vertebrae orthe surface of the spinal cord. Radiation therapy alone, or surgery plus radiation, may be used to treat metastatic tumors to the spine.

Spread of cancer cells to the meninges or to the spinal fluid is called leptomeningeal cancer.This type of metastases occurs most commonlywith melanoma, breast or lung cancers, andmay be treated with a regional form ofchemotherapy. “Intrathecal” chemotherapy isdelivered between the layers of the meningesusing a pump or implanted chemotherapydevice. An “Ommaya reservoir” is a small container, surgically placed under the scalp,with a tube that leads into a ventricle of thebrain. The purpose of these devices is to placechemotherapy drug into the spinal fluid,allowing it to “bathe” the cancer cells.The treatments may be given with or withoutradiation therapy. Your doctor will decidewhich treatment plan is best for you based onthe type of primary cancer and the amount ofcancer cells present in the spinal fluid.


B R A I N , S P I N A L C O R D , & V E R T E B R A E

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Radiation therapy can be used to treat single or multiple metastases. It may be used therapeutically (to treat a brain tumor), it maybe used prophylactically (to help prevent brainmetastases in people newly diagnosed withsmall-cell lung cancer or acute lymphoblasticleukemia), or it may be used as palliative treatment (to help relieve symptoms caused bythe brain tumor).

There are several different types of radiationused for metastatic brain tumors. Whole-brainradiation is radiation therapy delivered in 10 or more reduced doses called “fractions.” Bydividing the doses in smaller amounts, the nor-mal brain is somewhat protected from the toxiceffect of radiation. This is a common form ofradiation for metastatic brain tumors, especiallywhen multiple tumors are present. Focusedradiation (such as stereotactic radiosurgery orconformal radiation) delivers shaped beams ofradiation to a specified area in an attempt toavoid normal brain tissue. Focused radiation ismost commonly used for small tumors whichare limited in number. It may be used for recur-rences if whole brain radiation was previouslygiven, or it may be used as a local “boost”following whole brain radiation. Interstitial radi-ation, or brachytherapy, is the use of radioactivematerials surgically implanted into the tumor toprovide local radiation. Radioenhancers, whichmake the tumor more sensitive to the effects ofradiation, are under investigation.

C H E M O T H E R A P Y

Chemotherapy is not widely used to treatmetastatic brain tumors, however, recent studiesshow that some tumors may be sensitive todrug therapy. Small-cell lung cancer, breast cancer, germ cell tumors, and lymphoma areamong these tumors. Intrathecal chemotherapy




(drugs placed within the lining of the spinalcord) may be used for leptomeningeal metastases — cancer cells which metastasize tothe covering layers of the brain and spinal cord.

In choosing to use chemotherapy, your doctorwill take into account the size and number oftumors, the type of tumors, the status of the primary cancer site, the drugs available andyour previous history of chemotherapy treatment, if any. Some tumors which are sensitive to chemotherapy in other parts of thebody may become resistant to the chemotherapyonce in the brain. Why this happens isunknown. A different drug may be consideredif you received chemotherapy for your primarycancer, or a different type of therapy may be considered.

As in any disease, there are possible sideeffects from brain tumor treatment. Ask yourdoctor to explain these effects. He or she canalso help you and your family balance therisks against the benefits of treatment.

RecurrenceAfter your brain tumor treatment is completed,MRI or CT scans of the brain are usually doneevery three months for a year. Your doctor will determine the frequency thereafter. Thescans are used to monitor for possible tumorrecurrence. Metastatic brain tumors, just liketumors elsewhere in the body, may recur.

Treatment for a recurrent metastatic braintumor begins with evaluating the original cancer site. If the primary cancer appears to be under control, treatment for the metastaticbrain tumor may include additional surgery,radiosurgery, conformal radiation, or in



some situations, whole brain re-irradiation.Chemotherapy or immunotherapy may also be an option.

Finding Clinical TrialsNew, investigative treatments called “clinical trials” are available for those with metastaticcancer. We maintain a resource listing of physicians participating in clinical trials forbrain tumors, including metastatic tumors.Our office can be reached at 800-886-2282.

ResourcesMany families living with metastatic braintumors find assistance through cancer supportresources. Support groups and pen-pal programs allow you to share experiences withothers in the same situation. Social workers can help you find these networks as well assources of financial assistance, transportationhelp, home-care needs or hospice programs.Nurses can provide you with information about

For additional information about both standard and research treatments (clinical trials) for metastatic brain tumors, call theNational Cancer Institute's Cancer InformationService at 800-422-6237. They can provideinformation specific to the primary site of thecancer, such as lung cancer or breast cancer.

We also offer our Focusing on Treatmentsseries of booklets which address Surgery,Steroids, Conventional Radiation Therapy,Stereotactic Radiosurgery, and Chemotherapy.If that information is of interest to you, please call us at 800-886-2282.



how to care for yourself or your loved one.Reach out to neighbors, family, and friends forhelp with daily chores. You are not alone —there are extensive resources available to you.If you would like help finding them, please callour social work office at 800-886-2282.

A Next Step“Becoming Well Again” is an ABTA Quality

of Life series exploring fatigue management,caregiver stress, rehabilitative medicine, financialaid, and care options. Call us, or send an e-mailto [email protected] and request a copy of the series. Our web site — www.abta.org — offersextensive brain tumor information, treatmentand research updates, and patient/family stories. The thread that runs through each ofour services and programs is hope. Becomeinvolved — join us in some way, to make surethere is a cure, and ultimately, a way to preventbrain tumors.

We hope that the information in this pamphlet willhelp you communicate better with your healthcareteam. Our purpose is not to provide answers,rather, we encourage you to ask questions.



Questions I Want to Ask


Publications & ServicesB U I L D I N G K N O W L E D G E

A Brain Tumor – Sharing HopeTumor del Cerebro – Compartiendo la EsperanzaDictionary for Brain Tumor PatientsLiving with a Brain TumorA Primer of Brain Tumors

F O C U S I N G O N T U M O R S

EpendymomaGlioblastoma Multiforme and Anaplastic AstrocytomaMedulloblastomaMeningiomaMetastatic Brain TumorsOligodendroglioma and Oligoastrocytoma Pituitary Tumors

F O C U S I N G O N T R E AT M E N T

ChemotherapyConventional Radiation TherapyStereotactic RadiosurgerySteroidsSurgeryPhysician Resource List: Physicians Offering Clinical Trials for Brain Tumors

F O R & A B O U T C H I L D R E N

Alex’s Journey: The Story of a Child with a Brain Tumor (Video or Booklet)Education Packet (Parent or Teacher)When Your Child Returns to School

S U P P O R T R E S O U R C E S

BibliographyCare OptionsEmergency Alert Wallet CardsEmployment InformationEnd-of-Life CareFinancial Aid ResourcesHealth Insurance ResourcesHousing During Treatment ResourcesNet-Working LinksScholarship & Educational Financial Aid ResourcesSocial Security Disability ResourcesSpanish-Language ResourcesTransportation Assistance ResourcesWig and Head Covering ResourcesWish Fulfillment Resources

N E W S L E T T E R

Messageline NewsletterSharing Knowledge, Sharing Hope e-News

F O C U S I N G O N S U P P O R T

Connections – A Pen Pal ProgramListing of Brain Tumor Support GroupsListing of Bereavement (Grief) Support GroupsOrganizing and Facilitating Support GroupsResources for Online SupportTLC (Tips for Living and Coping) e-bulletin

Single copies of these publications are available free of charge.


Sharing knowledge. Sharing hope.

American Brain Tumor Association�� River Road, Suite�� Des Plaines, Illinois ��

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