1. Brain imaging prior to lung cancer resection
Dr Z Hudson
Dr A Addeo
Bristol Cancer Institute
Bristol 24/05/16

2. Background
Consider MRI or CT of the head in patients selected for treatment with curative intent, especially in stage III disease. [new 2011]
Offer patients with features suggestive of intracranial pathology, CT of the head followed by MRI if normal, or MRI as an initial test. [new 2011]
NICE 2011; Lung Cancer: Diagnosis and Management CG121
Hudson et al; 2015; Clinical radiology;

3. Methods List of patients generated from pathology database
Search of ICE, including OpenNet for brain imaging
When patient out of area additional local searches undertaken in Bath, Cheltenham and Gloucester for brain imaging
Documentation of whether brain metastases present
Documentation of date of radiological diagnosis with brain metastases
Data subset created of patients with brain metastases identified and further analysis undertaken
Data analysis using Microsoft Excel
Poster presentation at BTOG

4. Results (1)
585 patients underwent lung resection between Jan 2012 and December 2014
471 with accessible radiology records
25 patients had radiological evidence of brain metastases
5 diagnosed concurrently with primary tumour and treated radically
1 patient dual malignancies with brain metastases from bowel cancer more likely
1 patient with clinical diagnosis of cerebral abscess

5. Results (2)
18 patients with radiological evidence of brain metastases that presented after their primary lung surgery
Appearance of brain metastases by days post resection
Date of metastases not available in two patients
Mean
371 days
Range
days
Median
295 days

6. Results (3) 4 presented within 6-12 months of resection
2 no evidence of systemic relapse
1 received SRS and is alive
1 no information available
2 local and nodal relapse
Both died after palliative chemotherapy
5 presented within 6 months of resection
1 received SRS but died of pneumonia 1/12 later
1 no outcome available
3 no information available
2 died
1 alive

7. Results (4)
Overall patients had 5.3% (25/471) chance of having radiological evidence of brain metastases
3.8% (18/471) chance of having radiological evidence of brain metastases after surgery
2% (9/471) of patients had radiological evidence of brain metastases within 12 months of their surgery
1% (5/471) of patients had radiological evidence of brain metastases within 6 months of their surgery

8. Brain metastases following radical surgical treatment of non-small cell lung cancer: Is preoperative brain imaging important? Lung Cancer ,November 2014 Volume 86, Issue 2, Pages 185–189
Methods
We performed a retrospective analysis of 646 patients who underwent surgery for lung cancer with curative intent at a regional thoracic surgical centre in the United Kingdom. We identified those who developed brain metastases in the postoperative period and, by using volume doubling times, estimated the size of the metastasis at the time of surgery. We then determined the proportion of metastases that would have been seen on preoperative MR brain at detection thresholds of 2 and 5 mm diameter.
Results
There was a 6.3% incidence of postoperative brain metastases, with the majority occurring within 12 months of surgery. Those who developed metastases were more likely to have adenocarcinoma and the majority had early stage malignancy (73% stage I or stage II).
We estimate that 71% of those who developed cerebral metastases might have been detected had they undergone MR brain as part of their staging (4.4% of all patients).
Conclusion
Based on our findings we suggest that, in addition to standard staging investigations, patients have brain imaging (MR or equivalent) prior to curative surgery in NSCLC regardless of preoperative stage.

9. Discussion points Is it time for a change? y/n Which scan? MRI/CT?
New PET-CT changes it?