1. 68 y/o. Caucasian M Brain Metastasis from Melanoma Shintaro Ono Neurosurgery

2. HPI The patient is a 68 y.o. gentleman with h/o metastatic melanoma primarily on his left neck with spread to adjacent lymph nodes as well as potential metastases to liver and lung. On May 21, 2009, He presented to the BI and underwent routine follow up with brain MRI which showed a large intracranial hemorrhagic lesion in the right frontal lobe. This was new since his prior scan which was on Nov. 11, 2008. Past Medical History - Metastic Melanoma to lung and liver - DM, HTN, and Af Past Surgical History - Left lung lower lobectomy for metastasis (12/11/08) - Appendectomy 60 years ago Medicatoin - lisinopril, aspirin, warfarin Allergy NKDA Family History - Non-contributory Social History - Farmer with extensive sun exposure - Tobacco; a cigar / week (stopped in 2009) - EtOH; No, - illicit drugs; No Case: 68 y/o. Caucasian M

3. Physical Examinations VS: T: 98.5 BP: 146/79 HR: 103 R: 16 O2Sats: 96RA Gen: WD/WN, comfortable, NAD. HEENT: Pupils: 3-->1.5, bilat EOMs intact, Neck: Supple. Lungs: CTA bilaterally. Cardiac: irregularly irregular. S1/S2. Abd: Soft, NT, BS+ Extrem: Warm and well-perfused. Mental status: Awake and alert, cooperative with exam, normal affect. Orientation: Oriented to person, place, and date. Recall: 3/3 objects at 5 minutes. Language: Speech fluent with good comprehension and repetition. Naming intact. No dysarthria or paraphasic errors. Case: 68 y/o. Caucasian M

4. Cranial Nerves: I: Not tested II: Pupils equally round and reactive to light. Visual fields are full to confrontation. III, IV, VI: Extraocular movements intact bilaterally without nystagmus. V, VII: Very slight left facial nerve droop, otherwise facial nerve intact and muscles intact, sensation intact to all fields VIII: Hearing intact to voice. IX, X: Palatal elevation symmetrical. XI: Sternocleidomastoid and trapezius normal bilaterally. XII: Tongue midline without fasciculations. Motor: Normal bulk and tone bilaterally. Strength full power 5/5 throughout. Sensation: Intact to light touch, propioception, pinprick and vibration bilaterally. Coordination: normal on finger-nose-finger, heel to shin Case: 68 y/o. Caucasian M

5. MRI Nov. 11, 2008. May. 21, 2009. Right frontal craniotomy was done on May 22, 2009. 4.5 x 3.7cm 4mm

6. Post-operative MRI May. 21, 2009. May. 22, 2009. He was discharged on May 26, 2009. He is taking a course of whole brain radiation therapy.

7. The most common intracranial tumors in adults (>50% in brain tumors). In patients with systemic metastasis, Brain Metastasis occurs 10 to 30 % in adults. The incidence of brain metastases is increasing due to improved imaging tools. Lung — 16 to 20 % Renal cell cancer — 7 to 10 % Melanoma — 7 % Breast cancer — 5 % Colorectal cancer — 1 to 2 % Brain Metastasis

8. 50% to 75% of malignant melanoma patient end up with brain metastasis. Melanoma is the third most common cause of brain metastases in US. The incidence of malignant melanoma is increasing at rate greater than any other human cancer. Brain Metastasis from Melanoma

9. Whole Brain Radio therapy WBRT after surgery reduce the rate of recurrence and possibly prolong survival. [Wen, PY, Loeffler, JS. Management of brain metastases. Oncology (Huntingt) 1999; 13:941.] [Skibber, JM, Soong, SJ, Austin, L, et al. Cranial irradiation after surgical excision of brain metastases in melanoma patients. Ann Surg Oncol 1996; 3:118.] Treatment Chemotherapy Brain Metastases from melanoma are generally resistant to chemotherapy. But, fotemustine and temozolomide have a possibility of treatment. [Jacquillat, C, Khayat, D, Banzet, P, et al. Final report of the French multicenter phase II study of the nitrosourea fotemustine in 153 evaluable patients with disseminated malignant melanoma including patients with cerebral metastases. Cancer 1990; 66:1873.] [Hwu, WJ, Lis, E, Menell, JH, et al. Temozolomide plus thalidomide in patients with brain metastases from melanoma. Cancer 2005; 103:2590. ]

10. Craniotomy –Large, single/dominant, and accessible lesions –Patients with good performance status –Patients with herniation or a posterior fossa mass effect Stereotactic Radiosurgery (SRS) –Small(<3cm), multiple(=or<3), and deep lesions –Patients unlikely to tolerate general anesthesia. There is no confirmed clear advantage of one treatment over the other. – No prospective randomized trials have been reported (M. L. Smith and J. Y. K. Lee 4 Neurosurg. Focus / Volume 22 / March, 2007) Craniotomy vs SRS

11. Resection, Craniotomy? SRS? Whole Brain Radiation Therapy (WBRT)? Chemotherapy? or Combination? Treatment for the patient What the reason for resection surgery and following WBRT?

12. The Patient Good performance status (KPS 90 > 70) Large (>3cm), dominant Lesion Mass Effect Resectable The lesion cannot be well controlled with external radiation alone. Reasons for Surgery

13. Mayo Clin Proc 2003; 78:1529.

14. Case: 68 y/o. Caucasian M with Brain Metastasis from Melanoma The incidence of malignant melanoma is increasing at a rate greater than any other human cancer. Patient with brain metastasis from melanoma still has poor prognosis. New treatment and medical progression is needed for better prognosis. Summary

15. Thank you!!

17. Patient Age; 68 y.o. (> 65 y.o.) Karnofsky Performance Score (KPS); 90 Metastasis; Lung, Liver, Brain Prognosis

18. RatingDefinition 100 percentNo evidence of disease 90 percentNormal activity with minor signs of disease 80 percentNormal activity with effort; signs of disease 70 percentCannot do normal activity but cares for self 60 percentRequires occasional assistance 50 percentRequires considerable assistance; frequent medical care 40 percentDisabled, requires special care 30 percentSeverely disabled; hospitalization may be indicated 20 percentVery sick; hospitalization necessary for supportive treatment 10 percentMoribund 0 percentDeath