1. Palliative Care Eyad Al-Saeed, MD,FRCPC Consultant Radiation Oncology Prince Sultan Hematology Oncology Center

2. Brain Metastases Most common intracranial tumor ( Most common primary (lung,breast,melanoma Hemorrhagic Metastases( renal cell CA, ( choriocarcinoma,melanoma

3. Clinical Presentation %Signs%Symptoms 58Impaired cognition49Headache 59Hemiparesis30Focal weakness 21Hemisensory loss32Mental disturbance 20Papilledema21Gait Ataxia 19Gait Ataxia18Seizures 18Aphasia12Speech diff 7Visual field cut6Sensory disturbance 6Limb Ataxia6Visual disturbance 4LOC6Limb Ataxia

4. Diagnostic Studies CT MRI ? Primary

5. 5 a = anterior cerebral artery m = middle cerebral artery fh = frontal horn - lateral ventricle ph = posterior horn - lateral ventricle cc = corpus callosum

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7. 7 Cranial structures 1.Hard Palate 2.Nasopharynx 3.Sphenoid air sinus 4.Pituitary gland 5.Frontal sinus 6.Frontal lobe 7.Corpus callosum 8.Septum pellucidum 9.Parietal lobe 10.Fourth ventricle 11.Occipital lobe 12.Cerebellum 13.Sinus Confluence 14.Pons 15.Medulla Oblongata 16.Spinal Cord

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9. Prognostic Factors SurvivalCharacteristicsClass 7.1 moKPS 70-100 Primary Controlled Age < 65 Mets to brain only 1 4.2 moAll Others2 2.3 moKPS < 703

10. Treatment Steroids improved headache and neurological function No impact on survival Start dexamethason 4mg q 6h if patient has neurological symptoms Taper as tolerated No role for steroids in asymptomatic patients

11. CONT.. OptionsCharacteristics Surgical resection +WBRT WBRT+SRS SRS alone (with SRS or WBRT for salvage prn) WBRT alone Single lesion (1 – 2) WBRT alone WBRT + SRS SRS alone (with SRS or WBRT for salvage prn) controversial 2-4 lesions ( 1-2) WBRT alone WBRT + SRS controversal SRS alone ( with SRS or MBRT for salvage prn ) controversal  4 lesion  (1-2) WBRT alone class 3

12. Spinal cord compression Anatomy Extends from foramen magnum to L1 – L2 Below the termination of the cord it contains the lumber cistern, an enlargement of the subarachonoid space that surrounds the cauda equina. SAS terminates inferiorly at S2 – S3.

13. Clinical Presentation Pain (90%-95%),usually precedes all other symptoms by several weeks to months Weakness is rarely the first symptom (2%)but is fairly common at diagnosis (75%). Sensory loss (50%) Autonomic dysfunction associated with unfavorable prognosis and late (50%) Once neurologic deficits develop, impairment progresses rapidly.

14. Diagnostic imaging (MRI (Gold standard if neurological symptoms CT Conventional Myelography XRay

15. Treatment Steroid to be started immediately and then taper as tolerated Surgery as a first line if 1- diagnosis unknown or doubtful for malignancy 2-instability of spine or bony compression of the cord 3- previous radiation of the site of compression 4- progression during radiation 5- contra indication of radiation or radiation resistant tumor.

16. CONT.. Radiation Post op Alone if multiple levels of compression or poor performance status patient.

17. Superior Vena Cava Syndrome Superior Vena Cava Syndrome is a medical emergency occasionally seen in patients with malignant tumor that requires immediate action Causes 1- bronchogenic carcenoma 80 % 2- Malignant lymphoma 10 - 18% 3- Benign 2-3%

18. Diagnosis Biopsy CT

19. 1 = carina 2 = left main bronchus 3 = right main bronchus 4 = right upper lobe bronchus 5 = descending aorta 6 = superior vena cava

20. Treatment 1- Radiation 2- Chemotherapy in case of Small Cell Lung Cancer Or Lymphoma 3- Steroids 4- ? Diuretics

21. Bone Metastases Common cause of severe cancer pain Good pain control may improve OS Sites of mets : Spine (Lumber > Thoracic) > Pelvis > Ribs >femur >Skull Primary ( breast, Prostate, Thyroid, Kidney. Lung)

22. Workup Bone scan is the primary imaging modality Plain films looking for fracture MRI for Spinal cord Biopsy if unknown primary

23. Treatment 1- Supportive including pain control 2-Surgery incase of fracture or impending fracture 3- Radiation