Metastatic Tumors to the Brain and Spine
All rights reserved. Copyright © 1993 by American Brain Tumor
Association ISBN 0-944093-26-4 Reproduction without prior written
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Printing of this publication was made possible in part by a generous
grant in loving memory of Earl H. Segal
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HOW TO USE THIS BOOKLET
We urge you to read the Introduction and Chapters one through
five. Those chapters contain explanations and information that apply
to metastases to the brain and spine, regardless of the primary
cancer. Chapter six contains information specific to selected primary
Terms printed in parentheses are technical names for the words
used before them.
All definitions in parentheses and explanations are in the glossary
. The glossary also contains additional terms.
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of our patient services, please contact the ABTA.
Cancer patients like you are living longer now because cancer
treatment is more effective than in the past. Probably, that is
the reason the number of people with spread [metastasis Metastasis
is singular; metastases is plural.] to the central nervous system
[The Central Nervous System (CNS) is the brain, cranial nerves,
and spinal cord.] (CNS) is increasing.
Many, if not most of these metastases, can be controlled or eliminated
with aggressive treatment.
If your cancer has spread to the central nervous system, we hope
this booklet will help you discuss treatment options with your doctors
If you have a metastatic central nervous system tumor but your
primary cancer is not yet known, we hope this booklet will help
you understand the purpose of the various tests your doctors are
If your type of cancer has a tendency to spread to the central
nervous system, we hope you will find the information in this booklet
1. ABOUT METASTASIS
Many cancers metastasize. Metastasis is the spread of cancer from
one part of the body to another. The original location is called
the primary tumor. Metastatic tumors are tumors that arise at sites
away from the original location.
Cancer cells from the primary site can break away and enter the
body's circulatory system blood stream [arteries and veins], lymph
system or spinal fluid [Spinal fluid is the liquid that flows between
the layers of the meninges. It circulates around the brain and spinal
cord.] and travel to distant locations. Stray cancer cells are often
destroyed by the immune system. But, if the number of stray cells
is too large, the immune system may be overwhelmed and allow some
cancer cells to survive. Those cells will grow at another site.
The most common pathway for metastasis to the central nervous system
is via the blood stream.
Many variables determine where metastatic tumors grow. Often,
the metastatic location is the nearest cluster of small blood vessels
found by the circulating cancer cells. Thus lung cancer commonly
metastasizes to the brain; colon cancer commonly metastasizes to
the liver. Or, the cancer may have a preferred site of metastasis.
The brain is a preferred site for melanoma and small cell lung cancer.
A metastasis of a metastasis may develop as well a colon cancer
may metastasize to the liver which in turn may metastasize to the
lung which may in turn metastasize to the brain.
Metastasis to the central nervous system There are three forms
of metastasis to the central nervous system:
METASTATIC BRAIN TUMORS
Tumors in the brain are the most common form of central nervous
system metastasis. There may be single or multiple tumors. Metastatic
brain tumors often have distinct characteristics that can be observed
on scans and help distinguish them from primary brain tumors [Primary
brain tumors originate in the brain; metastatic brain tumors originate
elsewhere in the body]. However, an exact determination of the type
of tumor can usually be made only after a sample of the tumor is
examined under the microscope.
SPINAL FLUID METASTASES
cancer cells circulating in the spinal fluid [meningeal carcinomatosis
or lymphomatosis The widespread presence of cancer cells in the
spinal fluid is called meningeal carcinomatosis. An older term for
this condition is leptomeningeal metastasis. Another term that may
be used is carcinomatous meningitis. Meningeal lymphomatosis is
the widespread pressence of lymphoma cells in the spinal fluid.]
Spinal fluid metastases may occur by themselves or in addition
to tumors in the brain. Acute lymphocytic leukemia and high-grade
non-Hodgkin's lymphomas often spread only to the spinal fluid. Small
cell lung cancer, breast cancer and melanoma commonly involve both
the brain and spinal fluid. Non-small cell lung cancer usually affects
only the brain.
METASTATIC SPINAL TUMORS Metastatic spinal tumors are usually
extra-dural they grow outside the dura mater in the bones of the
spine. Those tumors affect the spinal cord and spinal nerves by
About one-third of people with central nervous system metastases
have not been previously diagnosed with cancer. Their CNS symptoms
are the first indication of cancer. And, in half of those people,
the primary site will never be found.
Central nervous system metastases may be present before cancer
is found elsewhere; when you are first diagnosed with cancer; or
most commonly, after your cancer has been found and treated. Eighty-one
percent of people with central nervous system metastases are diagnosed
after their primary cancer has been diagnosed and treated. The thirty-five
percent of patients with metastatic brain tumors who have not been
previously diagnosed with cancer will undergo tests to determine
the primary site.
Some people will have central nervous system metastases without
their primary site developing. Those patients may have a very effective
immune system which has destroyed the cancer at its original location.
Certain cancers tend to metastasize earlier than others. Lung
cancer and renal (kidney) cancer tend to spread sooner; breast,
melanoma and colon cancer metastases to the central nervous system
METASTATIC BRAIN TUMORS
Lung, colon and renal cancers account for eighty percent of metastatic
brain tumors in men. Breast, lung, colon and melanoma cancers account
for eighty percent of metastatic brain tumors in women.
SPINAL FLUID METASTASES
Four percent of people whose cancer has spread to the central
nervous system have cancer cells circulating in their spinal fluid.
Non-Hodgkin's lymphoma, small cell lung cancer, breast cancer, leukemia,
lymphoma and melanoma most frequently spread to the spinal fluid.
Fewer than ten percent of acute lymphocytic leukemia patients have
metastases at the time of their initial diagnosis.
METASTATIC SPINAL TUMORS
Spinal metastases occur in five percent of cancer patients, most
commonly in those with breast cancer, prostate cancer and multiple
myeloma. Tumors growing in the bones of the spine (vertebrae) may
press on or displace the adjacent spinal cord if they are large.
There are three causes of symptoms of central nervous system metastasis:
those caused by mass effect [Mass effect is caused by blockage of
spinal fluid, space taken up in the skull by a growing tumor, or
swelling due to excess fluid (edema). Mass effect results in increased
intracranial pressure.]; those caused by irritation or destruction
of brain cells; and those caused by local pressure or displacement
due to a tumor growing outside the brain or spinal cord.
Metastatic brain tumors commonly cause widespread swelling (edema).
Edema is an increase in the amount of water in the brain. Vasogenic
edema, the type caused by metastatic tumors, is due to damaged blood
vessel linings. That damage allows substances to enter the brain
which would normally be prevented. The water content increases to
dilute those substances. That results in increased intracranial
pressure, because the bony skull cannot expand to accommodate the
enlarged size of its contents. The excess fluid may travel to distant
sites in the brain, far away from the site of the tumor and the
damaged blood vessels.
While specific signs and symptoms [Signs are what the doctor can
observe, either directly or as the result of various tests; symptoms
are the sensations and feelings you describe. We use symptoms for
both signs and symptoms.] may indicate a brain tumor, a definite
diagnosis cannot be made based on those indications alone because
many other conditions have similar symptoms. Tests used to confirm
the diagnosis are described in the next section of this booklet.
SYMPTOMS OF METASTATIC BRAIN TUMORS HEADACHE:
Headache is caused by stretching of sensitive structures such
as blood vessels or nerves due to edema, spinal fluid obstruction
or tumor growth, or by injury to the brain caused by the tumor.
Initially, the headache comes and goes, and is usually more common
in the morning, just after awakening. It gradually increases in
duration and frequency.
Localized (focal) weakness or weakness on one side of the body
(hemiparesis) may occur. That is caused by irritation or injury
to specific areas of the brain by the tumor.
Common behavioral changes include changes in judgment, reasoning,
behavior; impaired memory; emotional changes such as rapid mood
shifts; and confusion. Those symptoms are caused by edema and increased
Physical changes include changes in vision, language disturbances
(dysphasia [Dysphasia is the impairment of the ability to speak
or write, to understand speech or written words. Dysphasia may be
moderate or severe.]), sensory loss, and gait disorders (ataxia
[Ataxia refers to a clumsy, uncoordinated walk and problems with
balance.]). Those changes are due to increased intracranial pressure
or brain irritation. Ataxia is more common in people with spinal
fluid obstruction, or with tumors involving the cerebellum. Cerebellar
tumors often cause dizziness and vomiting.
Seizures [Seizures are convulsions. They are due to temporary
disruption in the electrical activity of the brain.] Seizures are
caused by brain irritation or increased intracranial pressure. They
may be the first indication of brain metastases, particularly in
people with melanoma.
Papilledema (swelling of the optic nerve)
Papilledema is due to increased intracranial pressure.
SYMPTOMS OF INCREASED INTRACRANIAL PRESSURE The common symptoms
of increased intracranial pressure are listlessness, confusion,
The most common symptoms of brain metastasis are headache, muscle
weakness and behavioral disturbances. These problems indicate to
your doctor the need to test for metastatic brain tumors, particularly
if you have already been diagnosed with cancer.
SYMPTOMS OF SPINAL FLUID METASTASES Spinal fluid metastases may
occur by themselves, or in addition to brain tumors. Common symptoms
of cancer cells circulating in the spinal fluid are: pain, particularly
in the neck and back; headache; progressive muscle weakness and
loss of sensation due to spinal and cranial nerve impairments. The
specific areas of your body affected by weakness and sensory loss
depend on which nerves are affected. Other common symptoms include
changes in behavior confusion, listlessness, impaired memory and
judgment, and frequent mood changes. Seizures may also occur. Hydrocephalus
[Hydrocephalus is excess water in the brain due to blockage of spinal
fluid pathways.] occurs in half the people with spinal fluid metastases.
Symptoms of spinal fluid metastases are caused by irritation or
compression of the brain and/or spinal cord and increased intracranial
This type of metastasis is more common in people with leukemia
SYMPTOMS OF METASTATIC SPINAL TUMORS The usual indication of metastasis
to the spine is pain directly over the area of metastasis or radiating
along the nerve. The pain often precedes other symptoms by days
or even weeks. The pain may be worsened by standing, by lifting
heavy objects, or any movement. Bed rest may relieve the pain initially,
but it usually progresses. Later symptoms are progressive muscle
weakness, loss of sensation and loss of bladder or bowel control.
The initial diagnosis of central nervous system metastasis is
based on your medical history, a neurologic examination, and a range
of tests. Those tests may include x-rays, blood, urine and stool
tests, spinal fluid tests, and CT or MRI scans with contrast enhancement.
Various conditions may imitate the symptoms of central nervous
system metastases. These include primary brain tumors, infections,
cysts, stroke, and complications from medications. A correct diagnosis
is important because treatment depends on it.
The exact location of the metastasis must be determined during
the diagnostic process. Treatment recommendations are based on the
location of the tumor and if cancer cells have entered the spinal
fluid. The radiation therapist needs location information for treatment
planning; the surgeon needs it to plan the operative approach and
About one-third of the people with symptoms of central nervous
system metastases have not been previously diagnosed with cancer.
If there is no history of cancer, it is necessary to undergo more
extensive testing to determine the primary cancer. A chest x-ray,
bone or liver scans, an abdominal CT scan and mammography may be
indicated, depending on the symptoms. Even after thorough testing,
it is not always possible to determine the original cancer. The
primary cancer site is never found in fifteen percent of people
with central nervous system metastases.
DIAGNOSIS OF METASTATIC BRAIN TUMORS The doctor suspects a metastatic
brain tumor rather than a primary brain tumor if there has been
a prior diagnosis of cancer. That suspicion is furthered by the
nature of the symptoms. The MRI [MRI is Magnetic Resonance Imaging.
MRI is a scanning device that uses a magnetic field, radio waves
and a computer. Signals emitted by normal and diseased tissue during
the scan are assembled into an image. Contrast enhancement is the
use of an agent such as Gadolinium-DTPA, administered shortly before
the MRI is performed, to enhance the images obtained so that tumors
are more readily detected and their characteristics are move obvious.]
scan with contrast enhancement is the primary diagnostic tool for
metastatic brain tumors.
Metastatic brain tumors have distinctive characteristics that
can be observed on scans. Those characteristics suggest a metastatic
rather than a primary brain tumor.
CHARACTERISTICS OF METASTATIC BRAIN TUMORS:
They most frequently occur in the cerebrum (80%), the cerebellum
(13-16%), and the brain stem (3%).
They are usually solid and spherical in shape with well-defined
margins, their center is often soft and filled with dead cells,
and they have a zone of active tumor cells that frequently appear
as a ringlike structure on the scan.
They commonly grow in the junction between the white and grey
matter, the area with the most blood vessels.
Fifty percent of the time multiple tumors are present, particularly
in people with non-small cell lung cancer, breast cancer or melanoma.
Renal and colon cancers are more likely to give rise to single tumors.
They are usually accompanied by widespread edema.
An exact diagnosis of brain metastasis requires microscopic examination
of a sample of the tumor tissue. A biopsy [Biopsy is the process
of removing a sample of tumor tissue to establish an exact diagnosis.
The tumor sample is obtained during a surgical procedure and then
examined under a microscope in the laboratory. Biopsies may either
by open or needle and often are performed using stereotactic techniques.]
is sometimes recommended to eliminate the chance of misdiagnosis.
DIAGNOSIS OF SPINAL FLUID METASTASES A lumbar puncture [Lumbar
puncture, also called spinal tap, is the insertion of a hollow needle
into the subarachnoid space of the lumbar spine to withdraw a sample
of spinal fluid for examination in the laboratory. A local anesthetic
is administered prior to the procedure.]
(LP) is performed to obtain a sample of spinal fluid. The sample
is examined in the laboratory for the presence of cancer cells,
protein, sugar and tumor markers. (Tumor markers are substances
that identify the presence of a tumor, and possibly the tumor type.)
Two or more samplings of spinal fluid may be required for definitive
results. LP is routinely performed if spinal fluid metastasis is
suspected. LP is not routinely performed in other circumstances
as it may be risky in people with increased intracranial pressure.
Myelography [Myelography is a specialized x-ray technique. A radio-opaque
substance injected into the subarachnoid space followed by x-rays
may depict blockage or growths.] also may be required for diagnosis
if meningeal metastases are suspected.
DIAGNOSIS OF METASTATIC SPINAL TUMORS Spinal tumors occur most
commonly in the vertebrae of the thoracic region of the spine (60%),
followed by the cervical and lumbar regions (20% each). Symptoms
are due to compression of the spinal cord and nerve roots.
Treatment goals vary depending on the patient and other factors.
The goal may be cure, improvement, or relief of symptoms (palliation).
FACTORS CONSIDERED BEFORE TREATMENT IS RECOMMENDED
The recommended treatment is based on answers to the following
Are there single or multiple tumors? Where is the tumor located?
Surgery is often preferred for single, accessible [Accessible tumors
can be approached surgically without causing undue neurological
damage.] tumors if other factors are favorable.
Is the primary cancer under control? If it is not, there is a
chance that new metastatic tumors will form. Radiation therapy may
be more practical in this instance.
What is the primary cancer? Some metastases, such as those from
small cell lung cancer or lymphoma, are very responsive to radiation
therapy and surgery is often not considered. Other types of metastases
may respond to systemic [Systemic chemotherapy is delivered in the
bloodstream or orally as opposed to delivery to the central nervous
system directly.] chemotherapy.
What is the patient's age and general health?
There are different classification systems used to evaluate general
health. One of these is the Karnofsky Performance Scale.
- 100 Normal; no complaints; no evidence of disease
- 90 Able to carry on normal activity; minor signs or symptoms
- 80 Normal activity with effort; some signs or symptoms of disease
- 70 Cares for self; unable to carry on normal activity or to
do active work
- 60 Requires occasional assistance but is able to care for most
Generally, if the Karnofsky score is greater than 60 or 70, surgery
could be considered, if other factors are favorable.
Other performance scales are used by various institutions. They
are all similar, however.
How long is it since the primary cancer was diagnosed? If it has
been a long time, aggressive treatment of your brain tumor in the
form of both surgery and radiation may result in long term control
of the disease because the cancer is probably somewhat slow growing.
Are cancer cells present in the spinal fluid? Chemotherapy followed
by radiation therapy may be beneficial in that situation.
Treatment modalities [Modalities is plural for modality. Modality
is the treatment method: surgery; irradiation; hormone therapy;
chemotherapy; immunotherapy; etc.] for central nervous system metastases
Steroids act rapidly to decrease the symptoms of increased intracranial
pressure due to the edema that accompanies metastatic brain tumors.
Although steroids do not kill cancer cells, they can decrease the
amount of leakage from damaged blood vessel linings, decrease the
production of spinal fluid, and increase blood flow in the brain.
Improvement is noticeable within six to twenty-four hours relief
of headache, confusion and other behavioral problems. This therapy
is effective in sixty to eighty percent of people with metastatic
brain tumors. Dexamethasone (Decadron),
methylprednisolone, and prednisone are steroids. Steroid use is
monitored by the doctor because of its potential side effects.
Steroids are frequently prescribed during the course of radiation
therapy, to reduce the swelling caused by that therapy.
Mannitol and glycerol are agents used to treat edema and intracranial
pressure by removing water from the brain. Glycerol is given orally;
mannitol is administered into a vein. Osmotics have high concentrations
of substances that the body seeks to dilute thus drawing water out
of the brain in the exact opposite way the edema was formed originally.
Conventional radiation therapy Radiation kills cancer cells directly,
or interferes with their growth. The tumor shrinks as cells die
and are disposed of. Radiation therapy is the most common treatment
for CNS metastases. It may also be the only treatment used. It is
the treatment of choice for patients with small cell lung cancer
and lymphoma metastases, because those tumors are very radiosensitive
[Radiosensitive tumors usually respond positively to radiation therapy
the tumors shrink.]. Sixty to eighty-five percent of all patients
respond to irradiation of their metastases by experiencing immediate
relief of their symptoms.
METASTATIC BRAIN TUMORS In general, conventional, external irradiation
for brain metastases is a total dose of 3000 cGy [cGy is the standard
measurement of ionizing radiation, and stands for centiGray.], to
the entire brain. It is delivered in 300 cGy portions five days
a week, for two weeks. This may be followed by a booster dose of
900 cGy to the tumor. There are slight variations of this dosage
plan in use. Radiation therapy often follows brain surgery for those
people who have surgery.
SPINAL FLUID METASTASES
If there are cancer cells in the spinal fluid and there is no
brain tumor, treatment will usually consist of a total dose of 2400
cGy, divided into eight portions, together with intrathecal [Intrathecal
drug administration into the spinal fluid. An Ommaya reservoir or
a ventricular access device may be used to delivery the drug into
a ventricle. This is called intraventricular delivery. The drug
then circulates from the ventricle throughout the spinal fluid.]
METASTATIC SPINAL TUMORS The usual treatment for spinal metastases
is radiation, followed by systemic chemotherapy. Surgery is also
advised for some people. Hormone therapy may be administered, depending
on the primary cancer.
NEWER FORMS OF RADIATION THERAPY Several newer forms of radiation
therapy are under investigation. These include:
Stereotactic radiosurgery uses a large number of narrow, precisely
aimed, highly focused beams of ionizing radiation to destroy brain
tumors. The beams are aimed from many directions circling the head,
and all converge at a specific point the tumor. That method necessitates
knowledge of the exact location of the tumor and of any critical
brain structures between the tumor and the scalp. This treatment
is planned so that each part of the brain through which the beams
pass receives only a small amount of the total dose. At the same
time, it allows for a large dose to be delivered to the tumor itself.
Conventional, external radiation to the entire brain often follows
There are three methods of delivering stereotactic radiosurgery:
Gamma Unit, adapted linear accelerators and cyclotrons.
The size of the tumor is a determining factor in deciding whether
stereotactic radiosurgery is appropriate. Is the tumor small having
a diameter of about one inch or less (three centimeters)? If so,
radiosurgery may be appropriate. Larger tumors require more beams
of radiation. That results in a greater effect on normal brain tissue.
Other factors need to be considered to determine if this form of
treatment is appropriate. Are there multiple tumors? If so, what
is their size and location? It may be possible to treat as many
as three or four tumors, depending on their locations. Has the diagnosis
of metastatic brain tumor been confirmed by biopsy? If there was
prior radiation, is there an increased risk of side-effects with
Stereotactic radiosurgery requires minimal hospitalization. There
is no risk of infection, and it requires only a short period of
time for recuperation. However, the results of treatment are not
immediate and there is some risk of damage due to the radiation.
Stereotactic radiosurgery does not offer the opportunity for confirmation
of the diagnosis.
Stereotactic radiosurgery may be useful as a boost to other forms
of radiation therapy for metastatic brain tumors. The characteristics
of those tumors appear to be ideal for that type of focused treatment.
Investigational studies are still ongoing since radiosurgery has
been used for metastatic brain tumors for only a few years.
INTERSTITIAL RADIATION THERAPY Interstitial radiation therapy
is accomplished by surgically implanting radioactive seeds (sources
of radiation energy) directly into a tumor. This technique delivers
a large dose of radiation while reducing the effect on normal tissue.
Small tumors less than five centimeters, about 2 inches in diameter
that are surgically accessible may be considered for this treatment.
Since surgery is required, only single tumors can be treated with
Interstitial radiation therapy may be beneficial to patients with
radioresistant brain tumors such as metastatic melanoma, since larger
doses of radiation can be delivered. It can be used with patients
who have been treated with external radiation previously. However,
this technique is a local therapy and does not address possible
undetected cancer cells elsewhere in the brain. A second surgery
may be required later to remove the mass of dead tumor cells.
DIFFERING SCHEDULES AND DOSAGES OF RADIATION THERAPY
This is more than one radiation treatment per day, of traditional
portions, usually with higher total doses.
This is larger portions delivered over fewer days, usually with
traditional total dosage.
In general, surgery (resection) is recommended if the patient's
general health is good, the primary cancer is under control, there
are no systemic metastases, and there is a single, accessible tumor.
Although metastatic brain tumors are malignant, they usually have
well-defined margins and often can be totally removed if favorably
located. Surgery is rarely recommended to lymphoma patients, because
metastases from this cancer are extremely sensitive to radiation.
Resection followed by whole-brain irradiation is recommended to
approximately twenty-five percent of people with brain metastases.
The remaining seventy-five percent are treated only with radiation
Other types of surgery are:
Biopsy to confirm the exact nature of the tumor, or to help diagnose
the primary cancer if not yet determined.
Placement of a chemotherapy delivery device such as an Ommaya
Interstitial radiation therapy
Surgery for spinal metastases may be advised. The surgery involves
resecting the affected vertebra (laminectomy). Indications for surgery
include partial paralysis due to compression of the spinal cord,
previous spinal irradiation, and patients with undiagnosed primary
Chemotherapy is recommended for spinal fluid metastases, but is
still under investigation for use against metastatic brain tumors.
The chemotherapy given is that which is effective against the primary
METASTATIC BRAIN TUMORS
Generally, chemotherapy that does not pass the blood brain barrier
is of no value in the treatment of metastatic brain tumors. The
blood brain barrier is a natural protective mechanism that restricts
the entry of substances into the brain. There have been a few studies
that demonstrated the effectiveness of some drugs. Some forms of
chemotherapy can be effective against metastatic brain tumors from
breast cancer including cyclophosphamide, 5-FU, and methotrexate.
Tamoxifen may also be effective.
Currently, clinical trials are testing a variety of drugs. Intra-arterial
chemotherapy is being tested for the treatment of lung cancer metastases
to the brain. Manipulating the blood brain barrier so that drugs
can enter the brain is also being studied. The ultimate role of
chemotherapy, alone or in addition to radiation and surgery, remains
to be determined.
SPINAL FLUID METASTASIS
The standard treatment for spinal fluid metastases is intraventricular
[Intraventricular is drug delivery into a ventricle in the brain.
An Ommaya reservoir is often used to insert the drug.] or intrathecal
chemotherapy with methotrexate or cytarabine during and following
radiation therapy. Thiotepa may be used with patients who do not
respond to the above agents. Intrathecal chemotherapy consisting
of methotrexate or thiotepa is especially effective against spinal
fluid metastases from breast cancer. Cytosine arabinoside has also
been used for breast metastases. Additional drugs are under clinical
mercaptopurine, and diaziquone alone and in combination with methotrexate,
in varying dosages.
METASTATIC SPINAL TUMORS
Treatment for spinal metastases consists of chemotherapy and radiation
therapy. In addition, surgery or hormone therapy may be advised
for some patients. The choice of drugs depends on the primary cancer.
Hormone therapy may help patients with breast or prostate cancers.
Spinal metastases are not uncommon in women with breast cancer.
Chemotherapy is given to women with bone pain who have no indication
of spinal cord compression. Radiation therapy may follow if the
chemotherapy is not effective or if spinal cord compression is present.
Surgery also may be advised.
If the primary tumor is hormone-dependent, hormones or hormone-blocking
agents may be prescribed. Breast cancers that are estrogen-receptor
positive are treated with tamoxifen, which may also shrink the metastatic
tumors. Prostate cancer metastases may also be affected by hormones.
Steroids may act as hormones in patients with lymphoma.
Immunotherapy is a treatment that uses the body's natural defense
mechanism the immune system. The goal is to stimulate the immune
system so that it can effectively fight the cancer. Immunotherapy
uses immune cells or substances called biological response modifiers
(BRMs). BRMs either kill tumor cells directly, or stimulate the
immune system to produce substances on its own to restrict tumor
growth. BRMs can by produced by the body or manufactured in the
laboratory. A number of investigational studies are underway using
BRMs to treat spinal fluid metastasis.
Recurrent central nervous system metastases
Re-irradiation may be considered for recurrent central nervous
system metastases. A second surgery is also possible for some patients.
Chemotherapy for that condition is under
6. COMMON CENTRAL NERVOUS SYSTEM METASTASES
BY PRIMARY CANCER
Often, metastatic brain tumors are multiple. There is a long interval
between the time the breast cancer is initially diagnosed and the
onset of central nervous system metastases. Few women have CNS metastases
at the time of their initial diagnosis.
Twenty to twenty-five percent of women with breast cancer may
develop central nervous system metastases. Those metastases may
occur as brain tumors, spinal tumors, or spinal fluid metastases.
Usually, they are associated with extensive edema.
Some women with breast cancer may have a type of benign primary
brain tumor called meningioma rather than a metastatic brain tumor.
If that is suspected on the basis of a brain scan, surgery often
will be recommended to remove the tumor.
Colon cancer (and cancer of the rectum) A single brain tumor is
more common than multiple tumors. There is a long interval between
the time of initial colon cancer diagnosis and the diagnosis of
central nervous system metastases.
Spinal fluid metastasis is more common with acute lymphocytic
leukemia (ALL) than acute non-lymphocytic leukemia (ANLL); and more
common in children than adults. Approximately five percent of people
with ANLL may develop meningeal metastases. Fifteen percent of adults
with ALL and up to fifty percent of children with ALL may develop
spinal fluid metastases. A diagnostic lumbar puncture is done to
obtain a sample of spinal fluid for diagnosis. Prophylactic irradiation
[Prophylactic irradiation is radiation therapy administered to prevent
the occurrence of metastases. Because of the high incidence of non-detectable
leukemia cells in the spinal fluid, prophylaxis is administered
to prevent meningeal carcinomatosis.] may be recommended for some
children with ALL. The incidence of spinal fluid metastases in children
drops to five percent with prophylaxis. The usual recommended prophylactic
dose is 1800 cGy.
Headache is the most common symptom of spinal fluid metastasis,
and is due to increased intracranial pressure. Cranial nerve paralysis
may occur suddenly in a person with ALL, indicating metastasis.
The sixth (VI) cranial nerve (the nerve that controls eye movement)
and seventh (VII) cranial nerve (the nerve that controls facial
movements) are most often affected. Immediate irradiation to the
affected area is necessary to preserve use of the nerve.
Multiple metastatic brain tumors are more common than single ones.
Spinal and meningeal metastases are rare.
Fifteen percent of people with squamous cell lung cancer may develop
brain metastases. Multiple tumors are more common than single ones.
Spinal and meningeal metastases are rare.
Ten percent of people diagnosed with small cell lung cancer have
brain metastases at the time of their initial diagnosis. Another
twenty to twenty-five percent may develop that form of metastasis
later. In general, the interval between initial diagnosis of small
cell lung cancer and the diagnosis of central nervous system metastases
is short. The likelihood of developing brain metastases increases
with time. They may occur in as many as fifty to eighty percent
of people after two years. Single brain tumors are more common than
People with brain metastases are at increased risk to develop
spinal and meningeal involvement. Less than two percent of people
will have spinal metastases and less than one-half of one percent
will have meningeal involvement at the time of initial diagnosis.
Five percent of patients may develop metastatic spinal tumors and
two and one-half percent may develop spinal fluid metastases.
Prophylactic radiation therapy is recommended only for patients
in systemic remission. When radiation is administered, it will generally
not be given on the same days as chemotherapy, and the time period
between drug and radiation treatment should be as long as possible.
Spinal tumors and spinal fluid metastases are the most common
forms of central nervous system involvement; lymphomas rarely spread
to the brain. Two percent of patients may experience spinal cord
compression. The incidence of central nervous system metastases
is low in Hodgkin's and low-grade non-Hodgkin's lymphomas. Nine
to eighteen percent of people with higher grades of lymphoma may
experience that form of metastasis. Prophylactic radiation therapy
is advised for some forms of lymphoma.
The incidence of central nervous system metastasis of lymphoma
is increasing because the incidence of that form of cancer is increasing.
More than fifty percent of patients with melanoma develop brain
metastases; that type of cancer has the highest brain metastasis
incidence rate. Spinal fluid metastasis is also common, often in
addition to brain metastases. Metastatic spinal tumors are rare.
The interval between initial diagnosis and central nervous system
involvement may be long; people with melanoma should see their doctors
regularly for follow-up exams. Metastatic brain tumors are most
frequently multiple in number (about seventy-five percent of the
time), and are associated with a high incidence of seizures (twenty-five
to thirty-seven percent of people).
Renal (kidney) cancer Renal metastatic brain tumors are usually
single in number.
7. WHAT YOU CAN DO TO HELP YOURSELF
You may find it is easier to cope with your illness when you understand
the reasons for the doctor's
recommendations, know in advance what to expect, know what symptoms
to look for and what to do should they occur. Or, you may want to
be assured you are receiving state-of-the-art treatment, and that
no possible option has been overlooked. Or you may want to explore
investigational treatments. For all those reasons, you may want
to read more about your illness.
To obtain a copy of the publications, contact the ABTA. Other
organizations that provide information are:
- The Leukemia Society of America Chicago, IL (312) 726-0003
- The American Lung Association. Check your local phone book.
- The American Cancer Society. Check your local phone book.
- Cancer Information Service offices throughout the country can
provide you with current information on investigational treatments
for your cancer and its metastases. Their telephone number is:
We maintain a computerized list of brain tumor support groups
and clearinghouses. Call us at (800) 886-2282, or if you are in
the Chicago area at (847) 827-9910, for a list of groups in your
Other support group information is available. Breast cancer patients
can contact the local chapter of Y-ME, or their headquarters in
Homewood, IL at (800) 221-2141 or (847) 799-8228 (24 hours).
The American Cancer Society sponsors I CAN COPE groups and offers
a variety of services. Refer to your telephone directory for the
number of the local chapter, or contact their headquarters in Atlanta,
Georgia at (800) 227-2345 or (404) 320-3333.
The National Coalition for Cancer Survivorship in Silver Spring,
Maryland, (301) 585-2616 is a clearinghouse for information and
can direct you to local support groups. The NCCS has prepared a
sourcebook: An Almanac of Practical Resources for Cancer Survivors.
It is available at your local library, or can be purchased from
Consumer Reports Books, Fairfield, Ohio, (513) 860-1178.
The social worker at your hospital can be an excellent resource
The yellow pages of your telephone directory is also a good potential
resource. Under the heading Social Service Agencies are many helpful
We may be able to advise you of other agencies that meet your
needs. Call us at (800) 886-2282, or if you are in the Chicago area,
at (847) 827-9910.
8. CANCER STATISTICS
American Cancer Society, CA-A Cancer Journal for Clinicians, Jan/Feb
1992, Vol. 42, No. 1. Adapted with permission.
According to the American Cancer Society, the estimated number
of new cancer cases in the United States, for selected sites, for
Site Total Number of New Cases
All sites 1,130,000
Lung (all types) 168,000
Lymphoma (all types) 48,400
Renal (kidney) 26,500
- Refers to tumors that can be approached by a surgical procedure
without causing undue neurological damage; tumors that are not
deep in the brain or beneath vital structures.
- One of the three layers of the meninges.
- See meninges.
- A clumsy, uncoordinated walk often associated with balance problems.
- Not malignant, not cancerous, slow-growing.
- biopsy (open or needle)
- Biopsy is the process of removing a sample of tumor tissue to
establish an exact diagnosis. The tumor sample is obtained during
a surgical procedure and then examined under a microscope in the
laboratory. Biopsies may either be open or needle and often are
performed using stereotactic techniques.
- blood brain barrier
- A protective barrier formed by the linings of the blood vessels
of the brain. It prevents some substances in the blood from entering
- carcinomatous meningitis See meningeal carcinomatosis.
- A flexible piece of tubing used in body cavities to insert or
- central nervous system
- The brain, cranial nerves and spinal cord. The spinal cord is
an extension of the brain.
- centiGray. The standard of measurement of ionizing radiation.
- contrast enhancement See MRI scan.
- cranial nerves
- Twelve pairs of nerves originating in the
- CSF Cerebral spinal fluid. See spinal fluid in this glossary.
- CT scan
- Computerized Tomography. An x-ray device linked to a computer
that produces an image of a predetermined cross-section of the
- dura mater
- See meninges.
- The impairment or loss of the ability to speak or write, to
understand speech or written words. Dysphasia may be moderate
- Swelling due to excess water.
- Outside the dura mater. Between the skull or spine and the dura
mater. See meninges.
- Local; the opposite of widespread.
- Muscle weakness on one side of the body.
- Bulging of tissue through an opening in a membrane, muscle or
- Excess water in the brain due to the blockage of spinal fluid
- increased intracranial
- Increased pressure within the skull. Caused by pressure mass
- Within an artery.
- Within the subarachnoid space of the meninges.
- Within a vein.
- Within a ventricle in the brain. Drugs are often delivered intraventricularly
using an Ommaya reservoir.
- Radiation therapy.
- Refers to the arachnoid and pia mater membranes of the meninges.
- Tumor. May also refer to a wound or injury.
- lumbar puncture
- Also called a spinal tap. The insertion of a hollow needle into
the subarachnoid space of the spine to withdraw a sample of spinal
fluid for examination in the laboratory.
- A fluid collected throughout the body. It flows through the
lymphatic system and
- eventually ends up in the veins.
- mass effect
- An effect caused by blockage of spinal fluid, space taken up
by a growing tumor, swelling or edema. May result in increased
intracranial pressure, herniation.
- Middle value. Equal quantities appear on either side of the
- meningeal carcinomatosis
- The widespread presence of cancer cells in the spinal fluid.
An older term for
- this condition is lepto meningeal metastasis. Another term used
is carcinomatous meningitis.
- meningeal lymphomatosis
- The widespread presence of lymphoma cells in the spinal fluid.
- The meninges are thin layers of tissue that completely cover
the brain and spinal cord. The three layers of meninges are the
dura mater, the arachnoid, and the pia mater. Spinal fluid flows
in the space between the arachnoid and the pia mater. This is
called the subarachnoid space.
- The spread of cancer cells from one part of the body to another.
Metastatic tumors are tumors that arise at sites distant from
the original location. Metastasis is singular; metastases is plural.
- Treatment method: surgery; irradiation; hormone therapy; chemotherapy;
- MRI scan
- MRI is Magnetic Resonance Imaging. MRI is a scanning device
that uses a magnetic field, radio waves and a computer. Signals
emitted by normal and diseased tissue during the scan
- are assembled into an image.
- Contrast enhancement is the use of an agent such as Gadolinium-DTPA,
administered shortly before the MRI is performed, to enhance the
images obtained so that tumors are more readily detected and their
characteristics are more obvious.
- A specialized x-ray technique. A radio-opaque substance injected
into the subarachnoid space is followed by x-rays.
- Ommaya reservoir
- A device with a fluid reservoir implanted under the scalp with
a catheter to a ventricle. It allows for medication to be given
directly into the spinal fluid. See intraventricular.
- Reduction of symptoms, relief.
- Swelling of the optic nerve, due to increased intracranial pressure.
- The brain itself. Excludes the meninges
- and spinal fluid.
- pia mater
- See meninges.
- primary brain tumor
- A tumor that originates in the brain; metastatic brain tumors
originate elsewhere in the body.
- Radiation therapy administered to prevent occurrence irradiation
rather than to treat that which has already occurred.
- Tumors that do not respond well to conventional radiation therapy.
- Tumors that respond positively to conventional radiation therapy
the tumors shrink.
- Referring to the kidney, part of the
- urinary system.
- Remove by surgery.
- Convulsions. Due to the temporary disruption in electrical activity
of the brain.
- signs and symptoms
- Signs are what the doctor can observe, either directly or as
the result of various tests; symptoms are the sensations and feelings
the patient describes.
- spinal fluid
- The liquid that flows between the layers of the meninges. It
circulates around the brain and spinal cord.
- spinal tap
- See lumbar puncture.
- Precise positioning in three dimensional space. Refers to surgery
or radiation therapy directed by various scanning devices.
- See meninges.
- Has an effect on the entire body, not just one
- organ or system.
- A hollow space. There are four connected ventricles in the brain.
Inside each ventricle are structures that form spinal fluid. Spinal
fluid flows from and through the ventricles and the subarachnoid
space surrounding the brain and spinal cord.
- Bones of the spine. A single bone is a vertebra.
We gratefully acknowledge the volunteer efforts of Gail Segal
for the research and writing of this publication. We also extend
our appreciation to Raymond Sawaya, M.D., Professor and Chairman,
Department of Neurosurgery, U.T.M.D. Anderson Cancer Center, Houston,
Texas for technical review.
A WORD ABOUT ABTA
The American Brain Tumor Association is a national, non-profit
organization dedicated and committed to funding brain tumor research,
providing patient services, and educating people about brain tumors.
This publication is but one in the library of booklets and pamphlets
we write and distribute as part of our patient services program.
If you find this publication helpful, help us to continue our fight
against brain tumors. Your financial support is necessary. Please
give as generously as you can we need each other
Return to the ABTA Homepage
To learn more about American Brain Tumor Association, contact
the office at 847-827-9910, or the Patient and Family Line: (800)
886-2282, or by email: email@example.com.