00:01
In this lecture, we're going to talk
about brain metastases.
00:03
Tumors that develop
in the systemic circulation
and travel to the brain.
00:09
Let's start with a case.
00:10
A 32-year-old woman
who presents with
Bradyphrenia or slowed thinking.
00:15
32-year-old woman
with estrogen, progesterone,
and HER2 positive breast cancer,
that's a very common type
of breast cancer,
presents with who has metastases
to the bones and liver,
and presents with
a first-time seizure.
00:30
She previously underwent mastectomy
with axillary lymph node dissection,
chemotherapy, and radiation,
which are standard treatments
for breast cancer
to the left chest wall and axilla,
which she completed about
four years ago.
00:42
Further history reveals that she
elected to stop hormone therapy
with tamoxifen,
that's a hormonal active agent,
about two years ago,
and has been pursuing naturopathic
remedies for her treatment.
00:53
So she's been off standard treatment
for about two years.
00:57
About four months ago,
she began to develop confusion,
slowed thinking,
which we call bradyphrenia,
and occasional paroxysmal episodes
of left-sided tingling and weakness
that started in the hand
and progressed into her arm and face
evolving like a seizure.
01:14
Exam shows that she's returned
to baseline
but it's bradyphrenic
with slowed responses
and endorses constant headache
with gait dysfunction.
01:22
What's the diagnosis?
Well, let's start with some
of the features of the case.
01:26
First of all,
she has breast cancer
with metastasis
to the bones and the liver.
01:31
This indicates that this is a cancer
that has already metastasized
to common areas.
01:36
And she's out far enough
after her diagnosis
that we can start to see
brain metastasis.
01:42
She presents with
a focal neurologic deficit
or a focal neurologic sign
being this evolving seizure.
01:49
And that should indicate that we
need to look for that area of focus
why this focal event occurred?
And she needs imaging.
01:58
So what's the diagnosis?
Well, pituitary adenoma, doesn't
seem like a likely etiology here.
02:04
She may have
a pituitary adenoma.
02:06
They're very common
incidental findings,
but they don't commonly present
with seizure or confusion.
02:11
So that's an unlikely diagnosis
for this patient.
02:14
Vestibular schwannoma.
02:16
Those are tumors that arise
on the vestibulocochlear nerve
and present with hearing loss.
None of which this patient has.
02:22
Meningiomas are tumors that occur
in the brain and are very common,
but uncommon in a patient
with metastatic breast cancer
to present with first-time seizure.
02:32
Gliomas are common tumors
arising from the brain,
but this patient's history of
breast cancer really pushes us
to favor a diagnosis
of brain metastasis.
02:41
And a new onset seizure, and a
patient with metastatic cancer
should raise primary suspicion
for brain metastasis.
02:47
This is a classic case,
for breast cancer, brain metastasis.
02:52
This patient underwent imaging.
This is an MRI of the brain
and we see her MRI here.
02:58
This is a T1 post-contrast.
03:01
So gadolinium enhanced,
Contrast-enhanced image.
03:03
And we see innumerable
mini-contrast enhancing lesions
throughout the brain.
03:08
In the front part of the brain,
the back part of the brain,
the left, the right,
really throughout
the brain parenchyma.
03:14
When we look at these lesions,
it looks like there's just
a lot of lesions.
03:18
But we're really seeing two things.
03:20
The first is some of
these lesions are buried
at the Grey-white junction,
the border between
the cortical gray matter,
and the subcortical white matter
and that's a common location
for brain metastasis to occur.
03:32
And that should tip us off
to consider brain metastasis.
03:35
Other lesions are out near
the cortical surface
in the area where the CSF flows
and suggests that this patient
may also be suffering
Leptomeningeal metastases.
03:44
An important case that underscores
our need to understand
how to diagnose and treat
brain metastasis.