Consenso sobre el tratamiento neuroquirúrgico de las metástasis intracraneales elaborado por el Grupo de Trabajo de Neurooncología (GTNO) de la Sociedad Española de Neurocirugía / Brain metastasis treatment guidelines: Consensus by the Spanish Society of Neurosurgery Tumor Section

Las metástasis cerebrales (MC) son tumores que se forman a partir de una célula tumoral originada en otro órgano y que a través de la sangre llega al cerebro donde es capaz de crecer e invadir los tejidos vecinos, como meninges y hueso. En la mayor parte de los pacientes existe un tumor conocido cuando se diagnostica la lesión cerebral, aunque es posible que el tumor del cerebro sea el primer hallazgo antes de que se tenga evidencia de la patología oncológica en otro lugar del organismo. Por este motivo, el neurocirujano debe conocer el manejo que ha demostrado mayor beneficio para estos sujetos, de manera que se agilicen y optimicen los tratamientos. Concretamente, en este documento se desarrollarán, entre otros temas: la selección del paciente oncológico candidato a la resección quirúrgica y el papel del neurocirujano en el equipo multidisciplinar, la importancia del diagnóstico inmunohistológico y molecular, técnicas quirúrgicas y de RT, actualización de tratamientos de quimioterapia e inmunoterapia y algoritmos de manejo en MC. Con este manuscrito de consenso, el Grupo de Tumores de la Sociedad Española de Neurocirugía (GT- SENEC) expone las cuestiones neuroquirúrgicas más relevantes y los aspectos fundamentales para armonizar el tratamiento multidisciplinar, sobre todo con las especialidades médicas que estén tratando o vayan a abordar a estos pacientes (AU)

Brain metastases are tumors that arise from a tumor cell originated in another organ reaching the brain through the blood. In the brain this tumor cell is capable of growing and invading neighboring tissues, such as the meninges and bone. In most patients a known tumor is present when the brain lesion is diagnosed, although it is possible that the first diagnose is the brain tumor before there is evidence of cancer elsewhere in the body. For this reason, the neurosurgeon must know the management that has shown the greatest benefit for brain metastasis patients, so treatments can be streamlined and optimized. Specifically, in this document, the following topics will be developed: selection of the cancer patient candidate for surgical resection and the role of the neurosurgeon in the multidisciplinary team, the importance of immunohistological and molecular diagnosis, surgical techniques, radiotherapy techniques, treatment updates of chemotherapy and immunotherapy and management algorithms in brain metastases. With this consensus manuscript, the tumor group of the Spanish Society of Neurosurgery (GT-SENEC) exposes the most relevant neurosurgical issues and the fundamental aspects to harmonize multidisciplinary treatment, especially with the medical specialties that are treating or will treat these patients (AU)

Brain metastasis treatment guidelines: consensus by the Spanish Society of Neurosurgery Tumor Section.

Brain metastases are tumors that arise from a tumor cell originated in another organ reaching the brain through the blood. In the brain this tumor cell is capable of growing and invading neighboring tissues, such as the meninges and bone. In most patients a known tumor is present when the brain lesion is diagnosed, although it is possible that the first diagnose is the brain tumor before there is evidence of cancer elsewhere in the body. For this reason, the neurosurgeon must know the management that has shown the greatest benefit for brain metastasis patients, so treatments can be streamlined and optimized. Specifically, in this document, the following topics will be developed: selection of the cancer patient candidate for surgical resection and the role of the neurosurgeon in the multidisciplinary team, the importance of immunohistological and molecular diagnosis, surgical techniques, radiotherapy techniques, treatment updates of chemotherapy and immunotherapy and management algorithms in brain metastases. With this consensus manuscript, the tumor group of the Spanish Society of Neurosurgery (GT-SENEC) exposes the most relevant neurosurgical issues and the fundamental aspects to harmonize multidisciplinary treatment, especially with the medical specialties that are treating or will treat these patients.

Discrepancy in the Ki67 labeling index of brain and orbital metastatic lesions from gastrointestinal neuroendocrine tumors: A case report / Discrepancia en el índice de etiquetado Ki67 de las lesiones metastásicas cerebrales y orbitales de los tumores neuroendocrinos gastrointestinales: Un informe de caso

Proliferative activity examined by Ki67 labeling index (LI) plays pivotal role for managing gastrointestinal neuroendocrine tumor (GI-NET). Few reports indicated the intra-patient heterogeneity of Ki67-LI among metastatic tumor sites. We report a case of brain and orbital metastases from GI-NET that showed discrepancy of the Ki67-LI. A 71 year-old woman who was diagnosed as GI-NET with liver and bone metastases and performed medical therapy, had headache, right exophthalmos, and pain of right eye and was referred to our department. Magnetic resonance image revealed that tumors in the left occipital region and right orbit. We diagnosed as metastatic brain and orbital tumors from GI-NET. Surgical removal of both symptomatic lesions was performed and the diagnosis was pathologically confirmed. Immunohistochemical studies revealed the discrepancy of the Ki67-LI of the lesions (brain tumor: 8% versus orbital tumor: 22%). Sampling of multiple metastatic sites may prevent underestimate tumor proliferative activity (AU)

La actividad proliferativa examinada por el índice de etiquetado Ki67 (LI) desempeña un papel fundamental en el tratamiento del tumor neuroendocrino gastrointestinal (GI-NET). Pocos informes indican la heterogeneidad intrapaciente del Ki67-LI entre las localizaciones de los tumores metastásicos. Presentamos un caso de metástasis cerebrales y orbitales de GI-NET que mostró discrepancia del Ki67-LI. Una mujer de 71 años a la que se le diagnosticó un GI-NET con metástasis hepáticas y óseas y que realizó tratamiento médico, presentó cefalea, exoftalmos derecho y dolor de ojo derecho, y fue remitida a nuestro departamento. La imagen de resonancia magnética reveló que los tumores en la región occipital izquierda y la órbita derecha. Diagnosticamos como metástasis tumores cerebrales y orbitales de GI-NET. Se realizó la extirpación quirúrgica de ambas lesiones sintomáticas y se confirmó patológicamente el diagnóstico. Los estudios inmunohistoquímicos revelaron la discrepancia del Ki67-LI de las lesiones (tumor cerebral: 8% frente a tumor orbitario: 22%). El muestreo de múltiples focos metastásicos puede evitar que se subestime la actividad proliferativa del tumor (AU)

Discrepancy in the Ki67 labeling index of brain and orbital metastatic lesions from gastrointestinal neuroendocrine tumors: A case report.

Proliferative activity examined by Ki67 labeling index (LI) plays pivotal role for managing gastrointestinal neuroendocrine tumor (GI-NET). Few reports indicated the intra-patient heterogeneity of Ki67-LI among metastatic tumor sites. We report a case of brain and orbital metastases from GI-NET that showed discrepancy of the Ki67-LI. A 71 year-old woman who was diagnosed as GI-NET with liver and bone metastases and performed medical therapy, had headache, right exophthalmos, and pain of right eye and was referred to our department. Magnetic resonance image revealed that tumors in the left occipital region and right orbit. We diagnosed as metastatic brain and orbital tumors from GI-NET. Surgical removal of both symptomatic lesions was performed and the diagnosis was pathologically confirmed. Immunohistochemical studies revealed the discrepancy of the Ki67-LI of the lesions (brain tumor: 8% versus orbital tumor: 22%). Sampling of multiple metastatic sites may prevent underestimate tumor proliferative activity.

Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases / Riesgo de necrosis sintomática por radiación en pacientes tratados con radiocirugía estereotáctica para metástasis cerebrales

Introductio Stereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases. Patients and methods We performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression. Results We identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p<0.0001), and thus larger V100% (p<0.0001), V50% (p<0.0001), V12Gy (p<0.0001), and V10Gy (p=0.0002), compared to the rest of the cohort. Single-fraction treatment (p=0.0025) and diabetes (p=0.019) were also significantly associated with symptomatic RN. Conclusion SRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12Gy, or V10Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN (AU)

Introducción La radiocirugía estereotáctica (RCE) es una opción de tratamiento en el tratamiento inicial de pacientes con metástasis cerebrales. Aunque su eficacia ha quedado demostrada en varios estudios previos, las complicaciones relacionadas con el tratamiento, en particular la necrosis por radiación (NR) sintomática, siguen siendo un obstáculo para una aplicación más generalizada de esta modalidad de tratamiento. Así pues, examinamos los factores de riesgo asociados al desarrollo de NR sintomática en pacientes tratados con RCE para metástasis cerebrales. Pacientes y métodos Realizamos una revisión retrospectiva de nuestra base de datos institucional para identificar pacientes con metástasis cerebrales tratados con RCE. El diagnóstico de NR sintomática se determinó por la aparición en resonancias magnéticas en serie, espectroscopia por resonancia magnética, la necesidad de tratamiento y el desarrollo de nuevas quejas neurológicas, sin signos de progresión de la enfermedad. Resultados Identificamos 323 metástasis cerebrales tratadas con RCE en 170 pacientes, entre 2009 y 2018. Trece pacientes (4%) experimentaron NR sintomática después del tratamiento de 23 (7%) lesiones. Después de la RCE, la mediana de tiempo hasta la aparición de NR sintomática fue de 8,3 meses. Los pacientes con NR sintomática tuvieron un volumen objetivo medio mayor (p < 0,0001), y por lo tanto, mayor V100% (p < 0,0001), V50% (p < 0,0001), V12 Gy (p < 0,0001), y V10 Gy (p = 0,0002), en comparación con el resto de la cohorte. El tratamiento de una sola fracción (p = 0,0025) y la diabetes (p = 0,019) también se asociaron significativamente a NR (AU)

Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases.

INTRODUCTIO: Stereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases. PATIENTS AND METHODS: We performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression. RESULTS: We identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p<0.0001), and thus larger V100% (p<0.0001), V50% (p<0.0001), V12Gy (p<0.0001), and V10Gy (p=0.0002), compared to the rest of the cohort. Single-fraction treatment (p=0.0025) and diabetes (p=0.019) were also significantly associated with symptomatic RN. CONCLUSION: SRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12Gy, or V10Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN.

Brain metastatic breast cancer: Epidemiology, survival and prognosis: Single center experience / Cáncer de mama metastásico cerebral: epidemiología, supervivencia y pronóstico; experiencia en un solo centro

Introduction Breast carcinoma is the most common malignancy in women worldwide. It is also one of the most frequent causes of brain metastasis (BM). Studies have identified BM as one of the worst prognostic signs. Methods We retrospectively analyzed data from 71 patients with BM from BC with the aim of clarifying the epidemiological criteria and management in our setting. We also aimed to identify predictors of survival and factors affecting the length of the BM-free interval in our group of patients. Results All the patients were female with a mean age at diagnosis of primary cancer of 41.6 years. The most common site of BM was the parietal lobe. The BM-free interval was longer with N1 disease (in comparison to N2 and 3) and in luminal B breast cancer subtype. Survival was shorter in older patients, those with hormone receptor negative and/or HER2-neu positive disease, synchronous BM, primary tumour not removed, soft tissue/non-regional nodes concomitant metastasis, and those who did not receive palliative chemotherapy. Survival tended to be longer in patients with temporal lobe metastasis, but this result was not statistically significant. Conclusion BM is a bad prognostic sign. Large scale prospective studies are needed to further delineate its nature. (AU)

Introducción El carcinoma de mama es la neoplasia maligna más común en las mujeres del mundo. Además, es una de las causas más comunes de metástasis cerebral (MC). Los estudios detectan MC como uno de los peores signos pronósticos. Métodos Analizamos retrospectivamente los datos de 71 pacientes con MC de origen mamario con el objetivo de clarificar los criterios epidemiológicos y el esquema de manejo en nuestra localidad de esta enfermedad, además de detectar predictores de supervivencia y factores que afectan la longitud del intervalo libre de MC en nuestro grupo de pacientes. Resultados Todos los pacientes fueron mujeres con una edad media de diagnóstico de cáncer primario de 41,6 años. El sitio más común de MC fue el lóbulo parietal. El intervalo libre de propagación cerebral fue más largo con la enfermedad N1 (en comparación con N2 y 3) y en el subtipo de cáncer de mama luminal B. La supervivencia fue menor en pacientes mayores, aquellos con receptores hormonales negativos y/o enfermedad HER2-neu positiva, MC sincrónica, tumor primario no extirpado, metástasis concomitantes de tejido blando nodos no regionales y aquellos que no recibieron quimioterapia paliativa. Además, aquellos con metástasis del lóbulo temporal tienden a tener una mejor supervivencia, aunque no alcanzaron significación estadística. Conclusión La MC es un mal signo pronóstico. Se necesitan estudios prospectivos a gran escala para delinear aún más su naturaleza. (AU)

Preliminary evaluation of cerebral 18F-DOPA PET/CT in the differential diagnosis of brain lesions in inconclusive MR.

AIM: To evaluate the utility of brain 18F-DOPA PET/CT in the differential diagnosis of brain lesions with inconclusive MRI. MATERIAL AND METHODS: Twelve patients were studied, with a total of 16 lesions, without definitive diagnosis after brain MRI. A double acquisition PET/CT brain scan was acquired at 20 and 90min. Visual and semiquantitative assessment was performed with SUVmax calculation of the lesions and calculation of the T/S Ratio (tumor/contralateral striatum) and T/N Ratio (contralateral healthy tumor/parenchyma) for each time. RESULTS: Based on the visual assessment scale and using T/S ratio ≥1 and T/N ratio ≥1.3 to determine malignancy, the values of sensitivity (S), specificity (E) and positive predictive value (PPV) were: visual assessment (S 100%, E 33.3%, VPP 71.4%), T/S Ratio (S 90%, E 100%, VPP 100%) and T/N Ratio (S 100%, E 16.6%, VPP 66.6 %). No lesion showed an increase in SUVmax in late acquisition. 18F-DOPA PET/CT modified treatment in 75% of the patients. CONCLUSION: 18F-DOPA PET/CT is a useful tool in the study of brain lesions with inconclusive MRI. Late imaging (dual-point) has no added value in the final diagnosis. FDOPA has an impact on patient management modifying therapeutic behavior.

Discrepancy in the Ki67 labeling index of brain and orbital metastatic lesions from gastrointestinal neuroendocrine tumors: A case report.

Proliferative activity examined by Ki67 labeling index (LI) plays pivotal role for managing gastrointestinal neuroendocrine tumor (GI-NET). Few reports indicated the intra-patient heterogeneity of Ki67-LI among metastatic tumor sites. We report a case of brain and orbital metastases from GI-NET that showed discrepancy of the Ki67-LI. A 71 year-old woman who was diagnosed as GI-NET with liver and bone metastases and performed medical therapy, had headache, right exophthalmos, and pain of right eye and was referred to our department. Magnetic resonance image revealed that tumors in the left occipital region and right orbit. We diagnosed as metastatic brain and orbital tumors from GI-NET. Surgical removal of both symptomatic lesions was performed and the diagnosis was pathologically confirmed. Immunohistochemical studies revealed the discrepancy of the Ki67-LI of the lesions (brain tumor: 8% versus orbital tumor: 22%). Sampling of multiple metastatic sites may prevent underestimate tumor proliferative activity.

Caracterización clínica, epidemiológica y anatomopatológica de los tumores cerebrales supratentoriales y su morbilidad posanestésica / Clinical, Epidemiological and Anatomopathological Characterization of Supratentorial Brain Tumor and its Post-Anesthetic Morbidity

Introducción: Los tumores cerebrales no son frecuentes, pero tienen efectos devastadores. Objetivo: Caracterizar según criterios clínicos y anatomopatológicos a los pacientes con tumor cerebral supratentorial. Métodos: Se realizó un estudio observacional y descriptivo de casos clínicos en el período de enero 2017 - enero 2019, en el Hospital Provincial Saturnino Lora de Santiago de Cuba. El universo estuvo constituido por la totalidad de los 117 pacientes a los que se les realizó una tomografía computarizada de cráneo y con diagnóstico histológico postoperatorio de neoplasia primaria del sistema nervioso central (supratentorial) y metástasis cerebral, a los que se les realizó neurocirugía transcraneal. Resultados: Predominó el sexo masculino y las edades entre 40 a 59 años, clínicamente la mayoría de los casos presentó cefalea como signo de hipertensión endocraneana 76,1 por ciento. El 87,2 por ciento presentó la tumoración en los hemisferios cerebrales. El glioblastoma multiforme fue el tipo histológico prevaleciente con 45,3 por ciento. La hipopotasemia fue la complicación post anestésica más frecuente (21,4 por ciento). Conclusiones: Los tumores cerebrales supratentoriales en la edad adulta constituyen un problema de salud, principalmente en los hombres después de los 45 años de edad; la cefalea, las convulsiones y los vómitos son los síntomas cardinales. Durante la excéresis de los tumores supratentoriales los pacientes presentaron diversas complicaciones anestésicas(AU)

Introduction: Brain tumors are not frequent, but they have devastating effects. Objective: To characterize patients with supratentorial brain tumor, according to clinical and pathological criteria. Methods: An observational and descriptive study of clinical cases was carried out, in the period from January 2017 to January 2019, at Saturnino Lora Provincial Hospital in Santiago de Cuba. The universe consisted of the 117 patients who underwent computed tomography of the skull and with a postoperative histological diagnosis of primary neoplasia of the central nervous system (supratentorial) and brain metastases, who underwent transcranial neurosurgery. Results: The male sex predominated, together with the ages 40-59 years old. Clinically, most of the cases (76.1 percent) presented headache as a sign of intracranial hypertension. 87.2 percent presented the tumor in the cerebral hemispheres. Glioblastoma multiforme was the prevalent histological type, accounting for 45.3 percent. Hypokalemia was the most frequent post-anesthetic complication, accounting for 21.4 percent. Conclusions: Supratentorial brain tumors in adulthood constitute a health concern, mainly in men after 45 years of age; headache, seizures and vomiting are the cardinal symptoms. During excision of supratentorial tumors, the patients presented various anesthetic complications(AU)

Risk of symptomatic radiation necrosis in patients treated with stereotactic radiosurgery for brain metastases.

INTRODUCTIO: Stereotactic radiosurgery (SRS) is a treatment option in the initial management of patients with brain metastases. While its efficacy has been demonstrated in several prior studies, treatment-related complications, particularly symptomatic radiation necrosis (RN), remains as an obstacle for wider implementation of this treatment modality. We thus examined risk factors associated with the development of symptomatic RN in patients treated with SRS for brain metastases. PATIENTS AND METHODS: We performed a retrospective review of our institutional database to identify patients with brain metastases treated with SRS. Diagnosis of symptomatic RN was determined by appearance on serial MRIs, MR spectroscopy, requirement of therapy, and the development of new neurological complaints without evidence of disease progression. RESULTS: We identified 323 brain metastases treated with SRS in 170 patients from 2009 to 2018. Thirteen patients (4%) experienced symptomatic RN after treatment of 23 (7%) lesions. After SRS, the median time to symptomatic RN was 8.3 months. Patients with symptomatic RN had a larger mean target volume (p<0.0001), and thus larger V100% (p<0.0001), V50% (p<0.0001), V12Gy (p<0.0001), and V10Gy (p=0.0002), compared to the rest of the cohort. Single-fraction treatment (p=0.0025) and diabetes (p=0.019) were also significantly associated with symptomatic RN. CONCLUSION: SRS is an effective treatment option for patients with brain metastases; however, a subset of patients may develop symptomatic RN. We found that patients with larger tumor size, larger plan V100%, V50%, V12Gy, or V10Gy, who received single-fraction SRS, or who had diabetes were all at higher risk of symptomatic RN.

Supervivencia prolongada luego de pequeñas dosis de terapia con radioyodo en metástasis cerebral de cáncer de tiroides / Long-term survival after small doses of radioiodine therapy for brain metastases of thyroid cancer

Resumen El cáncer diferenciado de tiroides generalmente se acompaña de una supervivencia a largo plazo. Sin embargo, en algunos casos pueden desarrollarse metástasis a distancia y, entre ellas, las localizaciones cerebrales son de mal pronóstico. El objetivo de esta presentación es comunicar el caso clínico de una mujer de 65 años que consultó por diplopía en la mirada vertical que había aparecido un mes antes. La resonancia magnética mostró una gran masa a nivel del cóndilo occipital. Se realizó el diagnóstico de tumor cerebral primario, por lo que fue operada dos veces con resección tumoral incompleta. El estudio histopatológico confirmó una lesión metastásica de carcinoma de tiroides. Se realizó una tiroidectomía total con resección de un cáncer papilar de la variante folicular. Luego, fue tratada con éxito con pequeñas cantidades repetitivas de yodo radiactivo para una dosis total acumulada de 325 mCi 131I, con una supervivencia a largo plazo.

Abstract Differentiated thyroid cancer is generally accompanied by a long term survival. However,in some cases distant metastases can develop and among them, brain localizations are of poor prognosis. The aim of this presentation is to communicate the clinical case of a 65 year-old woman who consulted for diplopia in vertical gaze which had appeared one month earlier. MRI showed a big mass at the level of the occipital condyle. Diagnosis of primary brain tumor was made so she was operated twice with incomplete tumor resection. The pathological study was confirmatory of a metastatic lesion of thyroid carcinoma. A total thyroidectomy with resection of a papillary cancer of the follicular variant was performed. Then, she was successfully treated with small repetitive radioiodine amounts for a total accumulated dose of 325 mCi 131I, with a long-term survival.

Valoración preliminar de la 18F-DOPA PET/TC cerebral en el diagnóstico diferencial de lesiones cerebrales con RM no concluyente.

AIM: To evaluate the utility of brain 18F-DOPA PET/CT in the differential diagnosis of brain lesions with inconclusive MRI. MATERIAL AND METHODS: Twelve patients were studied, with a total of 16 lesions, without definitive diagnosis after brain MRI. A double acquisition PET/CT brain scan was acquired at 20 and 90 minutes. Visual and semiquantitative assessment was performed with SUVmax calculation of the lesions and calculation of the T/S ratio (tumor/contralateral striatum) and T/N ratio (tumor/contralateral healthy parenchyma) for each time. RESULTS: Based on the visual assessment scale and using T/S ratio ≥ 1 and T/N ratio ≥ 1.3 to determine malignancy, the values of sensitivity (S), specificity (E) and positive predictive value (PPV) were: visual assessment (S 100%, E 33.3%, VPP 71.4%), T/S ratio (S 90%, E 100%, VPP 100%) and T/N ratio (S 100%, E 16.6%, VPP 66.6%). No lesion showed an increase in SUVmax in late acquisition. 18F-DOPA PET/CT modified treatment in 75% of the patients. CONCLUSION: 18F-DOPA PET/CT is a useful tool in the study of brain lesions with inconclusive MRI. Late imaging (dual-point) has no added value in the final diagnosis. F-DOPA has an impact on patient management modifying therapeutic behavior.

Surgical approach of non-small cell lung cancer with extrapulmonary metastasis. / Abordaje quirúrgico del carcinoma broncogénico de células no pequeñas con metástasis extrapulmonar.

Bronchogenic carcinoma is the leading cause of death due to cancer worldwide. Nearly 75% of patients have a disseminated carcinoma at diagnosis. Up to 50% of patients with a localized disease will develop metastasis. Nevertheless, the current scientific evidence has demonstrated that when the metastatic disease is limited, particularly in specific locations such as the brain and the adrenal glands, a multidisciplinary approach with radical intent could achieve a longer survival. This review analyses the clinical evidence available in the literature that supports the treatment of both the primary and the metastatic disease, as well as the preoperative study and the most widely accepted indications.

Metástasis cerebrales en cáncer de pulmón de células no pequeñas con mutación EGFR / Cerebral metastases in lung cancer of non-small cells with egfr mutation

El cáncer de pulmón es uno de los tumores que tienen la capacidad de metastatizarse en el cerebro y tienen la capacidad de penetrar la barrera hematoencefálica, la clínica es variada dependiendo del sitio afectado, así como los riesgos asociados de convulsión. Por lo tanto, la elección del tratamiento es compleja, considerando el primario, el número de metástasis y los sitios afectados. La radioterapia ha sido durante mucho tiempo la elección de los pacientes que no son candidatos a la cirugía, La presencia de mutaciones han permitido brindar terapias dirigidas como los inhibidores tirosin kinasas que penetran la barrera hematoencefálica y han sido clave para el manejo terapéutico.

Lung cancer is one of the tumors that have the ability to metastasize in the brain and have the ability to penetrate the blood-brain barrier, the clinic is varied depending on the affected site, as well as the associated risks of seizure. Therefore, the choice of treatment is complex, considering the primary, the number of metastases and the affected sites. Radiotherapy has long been the choice of patients who are not candidates for surgery. The presence of mutations have allowed targeted therapies such as tyrosine kinase inhibitors that penetrate the blood-brain barrier and have been key to therapeutic management.

[Metástasis en el lóbulo frontal como primera manifestación clínica de un carcinoma folicular de tiroides]. / Frontal lobe metastases as the initial presentation of follicular thyroid carcinoma.

ANTECEDENTES: El carcinoma folicular de tiroides puede producir metástasis a distancia, siendo las localizaciones más habituales el pulmón y el hueso. Las metástasis cerebrales son inusuales, y es poco habitual que aparezcan como primera manifestación de cáncer. CASO CLÍNICO: Paciente varón de 80 años, que tras una caída al suelo comenzó con alteración del comportamiento, desorientación y pérdida del control de esfínteres. La tomografía computarizada cerebral evidenció una masa en el lóbulo frontal derecho. Se realizó la extirpación de la lesión cerebral, cuyo estudio histológico informó de metástasis de carcinoma folicular de tiroides. CONCLUSIÓN: La manifestación de la enfermedad con metástasis cerebrales es muy infrecuente, y empeora el pronóstico notablemente. BACKGROUND: Follicular thyroid carcinoma can produce distant metastases, generally occur to lung followed by bone. Brain metastases are unusual, and onset manifestation is little frequently. CLINICAL CASE: A 80-years old men presented disturbance behavior, desorientation and loss of sphincters after fallin to the ground. Computed tomography scan showed a lesion in the right frontal lobe. The patient underwent a craniotomy to remove the brain tumor, histopathology confirmed of follicular thyroid carcinoma metastases. CONCLUSION: At initial diagnosis brain metastasis are extremely rare, with adverse prognosis.

[Experience with the radiosurgical treatment of brain metastases]. / Experiencia en el manejo de metástasis cerebrales tratadas con radiocirugía estereotáctica.

OBJECTIVE: To analyse the survival rate of a cohort of patients with intracranial metastases treated with radiosurgery, and to determine the factors that influence the results. PATIENTS AND METHOD: Retrospective analysis performed on a cohort of 126 patients undergoing radiosurgery for brain metastases. Patients treated with surgery before or after radiosurgery were excluded. Survival is analysed based on clinical (age, sex, primary tumour), radiological (number, location and volume of lesions), and radiotherapy factors (treatment dose, holocraneal radiation). Univariate and multivariate analyses were performed to determine significant prognostic factors. RESULTS: A total of 225 brain metastases in 126 patients, with a mean age of 59.8±11.6years, were treated between February 2008 and April 2015. The mean survival was 8.2 months. The overall survival rates at 6months, 1year, and 2years were 60.3%, 31.5%, and 12.8%, respectively. Lung (59.5%) and breast (14.3) were the most common primary tumours, and the most common site for metastases was the cerebral hemisphere (77%) and the average volume was 10.35 cc (0.2-43.5). Significant survival factors were: age under 60 (P=.046), female (P<.001), breast cancer (P<.001), KPS >80 (P=.001), SIR6 >5 (P=.031), and GPA ≥2.5 (P=.003). CONCLUSIONS: Radiosurgery is an appropriate technique for the treatment of brain metastases, and the main prognostic factors include being age under 65, female, breast cancer, and good scores on Karnofsky, SIR, and GPA scales.

Evaluación de la seguridad del nimotuzumab en pacientes con cáncer de pulmón de células no pequeñas, portadores de metástasis cerebral / Assessment of the safety of nimotuzumab in patients suffering from non-small cell lung cancer with brain metastasis

Fundamento: nimotuzumab es un novedoso anticuerpo monoclonal humanizado, con efecto antitumoral, que reconoce el receptor del factor de crecimiento epidérmico sobrexpresado en muchos tumores malignos de origen epitelial, como: esófago, pulmón, glioblastoma multiforme y próstata. Es usado en combinación con las terapias oncoespecificas, como quimioterapia o radiosensibilizador. Hasta la fecha se han tratado más de 2000 pacientes con este producto, además, es el primer anticuerpo monoclonal registrado en el país para pacientes pediátricos.Objetivo: describir los eventos adversos asociados con el nimotuzumab en pacientes con cáncer de pulmón de células no pequeñas, portadores de metástasis cerebral, incluidos en un ensayo clínico.Métodos: se analizaron las características de base de los pacientes, así como la frecuencia, intensidad y relación de causalidad de los eventos reportados. La población de estudio la conformaron todos los pacientes incluidos en el ensayo clínico.Resultados: la mayoría de los eventos fueron de intensidad leve a moderada y no requirieron la suspensión del tratamiento. Los eventos adversos más frecuentes fueron: astenia, anorexia, cefalea y vértigos; efectos reportados en estudios previos.Conclusiones: nimotuzumab es un fármaco seguro para el tratamiento de pacientes aquejados de cáncer de pulmón de células no pequeñas y metástasis cerebral (AU)

Background: nimotuzumab is a novel humanized monoclonal antibody, with antitumor effect, that recognizes the receptor of epidermal growth factor over-expressed in many malignant tumors of epithelial origin such as esophagus, lung, glioblastoma multiforme and prostate. It is used in combination with onco-specific therapies, such as chemotherapy or radio-sensitizer. Up to date, more than 2000 patients have been treated with this product and this is the first monoclonal antibody for pediatric patients registered in the country.Objective: to describe the adverse events associated to Nimotuzumab in patients suffering from non-small cell lung cancer with brain metastasis in a clinical trial.Method: the basic characteristics of the patients, as well as the frequency, intensity and causality relation of the reported events were analyzed. The study population was made up of all the patients included in the clinical trial.Results: most of the adverse effects were: asthenia, anorexia, headache and vertigos, which have been reported in previous studies.Conclusions: the Nimotuzumab is a safe drug for the treatment of patients suffering from non-small cell lung cancer and brain metastasis (AU)

[Erdheim-Chester disease, an incredible simulator. Cases reports and review of literature]. / Enfermedad de Erdheim-Chester, una gran imitadora. Presentación de casos y revisión de la literatura.

Erdheim-Chester disease is a non-Langerhans histiocytosis. Until 2014 at least 550 cases have been reported. According to European Rare Disease Organization and National Organization for Rare Disorders it is a rare disease. The most common symptom is bone pain in the lower extremities and it usually appears between the 5th and 7th decades of life. The diagnostic is based on immunohistochemical results: S100(+/-), CD68(+), and CD1a(-), the latter 2 are mandatory. The best treatment nowadays is alpha-interferon or pegylated alpha-2. The overall survival is 96% at one year and 68% at 5 years. Central nervous system involvement is associated with a worse outcome. Two cases are presentedwith central nervous system lesions in the absence of lesions in other organs on their onset. Very few cases have been reported with this kind of presentation. We also noted that these patients had recurrences or new lesions at 8 months. A follow-up is proposed with brain MRI and thoraco-abdominal PET every 3-4 months.

Combinación de radioterapia y Nimotuzumab en paciente con metástasis cerebral / Combination of radiotherapy and Nimotuzumab in a patient with brain metastasis

El cáncer de pulmón es la principal causa de muerte por cáncer en el mundo. El 80 porciento corresponden a carcinomas de células no pequeñas y el 70 porciento se diagnostican con enfermedad localmente avanzada o metastásica. Las metástasis cerebrales están presentes en el 20-30 por ciento de los pacientes en el momento del diagnóstico, con una mediana de supervivencia sin tratamiento de cuatro meses. Se presenta el caso de un paciente de 53 años con antecedentes de hipertensión arterial, fumador inveterado, que se estudia en el servicio de medicina interna por presentar síntomas neurológicos. Se le realizaron estudios correspondientes, diagnosticándose un carcinoma de pulmón de células no pequeñas con metástasis cerebral. Es valorado en consulta central de oncología, se clasifica como T2a N2 M1b, estadio IV y se propone incluir en el ensayo clínico “Uso del anticuerpo monoclonal hR3 y radioterapia en el tratamiento de pacientes con cáncer de pulmón de células no pequeñas portadores de metástasis cerebral”, indicándose tratamiento con quimioterapia + radioterapia y anticuerpo monoclonal Nimotuzumab, con el cual se encuentra hasta la fecha, destacándose la respuesta positiva al tratamiento, clínica e imagenológica, con una supervivencia superior al promedio de la descrita en la literatura para éstos pacientes y buena calidad de vida (AU)

Lung cancer is the main cause of death because of cancer all over the world. The 80 percent belong to non-small cell lung cancer and the 70 percent are diagnosed with locally advanced or metastatic disease. The brain metastases are present in 20 to 30 percent of patients at the moment of diagnosing, with an average of survival without treatment of 4 months. This is a case of a 53-year-old patient with a history of hypertension, being a heavy smoker, who was studied in the internal medicine service for presenting neurological symptoms, undergoing the appropriate studies and being diagnosed with a non-small cell lung cancer with brain metastasis. He was assessed at the oncology central consultation office, being classified as T2a N2 M1b, stage IV and was proposed to be included in the clinical trial "Using the monoclonal antibody hR3 and radiotherapy in the treatment of patients with non-small cell lung cancer carriers of brain metastasis", being indicated chemotherapy + radiotherapy and monoclonal antibody Nimotuzumab, following this treatment up today, emphasizing the positive clinical and imaging response to treatment, with a patients survival higher than the one reported in the specialized literature and a good quality of life (AU)