1. NECN Lung NSSG April 2012 Managing Solitary Brain Metastases from NSCLC Dr Paula Mulvenna Consultant Clinical Oncologist Northern Centre for Cancer Care

2. NECN Lung NSSG April 2012 This Talk: Prevalence of solitary brain metastases Case histories Investigation – mandatory modalities Patients suitable for aggressive (radical) management Pathway Summary

3. NECN Lung NSSG April 2012 Incidence – a Global issue 2002: –10.2 million new cancers worldwide –1.35 million lung cancers 2020 –15 million new cases cancer –2 million lung 50% of these will develop intracranial metastatic disease Parkin et al CA Cancer J Clin 2005 Patients with brain metastases from lung cancer: –USA: ~85,000 patients per annum –UK: ~40,000 patients per annum 35% have solitary metastasis 65% multiple metastases Median survival < 6m

4. NECN Lung NSSG April 2012 Incidence, a Local Issue: NCIN e-atlas

5. NECN Lung NSSG April 2012 Crude Incidence, a Local Issue: NSCLC Referrals (to PMM) since 2001- 2008 (n=1810) Treatment Intent: –Palliative – 83% –Radical – 17% 10% presented with brain metastases 24% of those with stage III disease have then developed brain metastases (after combined modality treatment up front) i.e. in my day to day practice: 215 patients with NSCLC + Brain metastases between 2001-8 –1 per fortnight

6. NECN Lung NSSG April 2012 Case History 1 67 year old female – non-smoker Cough Feb 2010 RUL adenocarcinoma T2 N1M0 Staging – aiming for radical surgical approach… until CT head….. March 2010

7. NECN Lung NSSG April 2012 Case History 1 cont’d Chemotherapy (JG) Radiological Almost CR PS 0/1 (KPS 90) ?Role for radical management of intra and extra cranial Disease PET (renal CT) MRI brain Sept 2010 Radical RT to RUL remnant Oct 2010 Gamma Knife SRS to brain met Nov 2010 Intra-thoracic Local recurrence March 2012 – brain clear Further systemic treatment

8. NECN Lung NSSG April 2012 Case History 2 57 year old male Feb 2011: Post chest pain + haemoptysis Life long smoker (50 pack year) Alcohol xs; Lives alone RUL squamous cell cancer 2010 T3N2M0 (CT head clear) PS 1 (but other tobacco related co morbidities) Gem Carbo chemo Good PR Radical RT – Good PR Aug 2011

9. NECN Lung NSSG April 2012 Case History 2 cont’d Feb 2012 – unsteady, falls ++ MRI brain – 5x4 cm right cerebellar cystic mass Extra cranial disease - active

10. NECN Lung NSSG April 2012 Micro-Surgical resection or Stereotactic Radiosurgery (SRS)? For solitary metastasis – comparable outcomes –Kalkanis et al J. Neuro Oncology 2010; 96(1): 33-43 Surgical series: superficial, larger, midline shift –Best results if complete en bloc resection –Where possible, avoid piecemeal resection Do less well if >9.5cm or if removed piecemeal

11. NECN Lung NSSG April 2012 Micro-Surgical resection or Stereotactic Radiosurgery (SRS)? SRS smaller (<3cm) Deep seated Less mid line shift Both (Sx or SRS) provide comparable local control and overall survival (ms >10m) Addition of WBRT – further intra cranial control; no further benefit seen in OS

12. NECN Lung NSSG April 2012 Pathway Patient Presents with possible solitary metastasis from confirmed NSCLC –PS 0/1 (KPS 90 – 100) –MRI Head –Full Staging of extra-cranial Disease - PET-CT Lung MDT Neuro-Oncology MDT (central) Decision re microsurgical resection or SRS De novo presentation - ?surgery for thoracic component / non-surgical oncological radical approach

13. NECN Lung NSSG April 2012 Summary Solitary metastasis Good PS (ECOG 0-1) No extra cranial metastatic disease Radically treatable primary