Central nervous system metastasis

The examination of first choice is an MRI scan without and with contrast medium which, depending on the presumed site of the clinically based lesion(s), will be centered on the skull (suspected brain metastases) or on the spine (suspected vertebral or spinal metastases).

In case the clinical suspicion on the basis of cranial or spinal radicular nerve deficits is leptomeningeal metastasis MRI should include the study of both the encephalon and the medulla (i.e., study of the meninges of the entire CNS).

CT with contrast medium alone is not sufficient to evaluate small or localized metastases in the brainstem, nor to detect nodular or linear lesions on the leptomeninges, particularly at the level of the cerebellum and spinal cord.

Brain PET scan is particularly useful to distinguish between radionecrosis and tumor recurrence after radiosurgery treatments.

Total body PET, on the other hand, is used in the staging of disease at the systemic level and is especially crucial before deciding on access to local therapies such as radiation therapy or neurosurgery.

Surgical resection of CNS metastases is a strategic intervention in specific situations.

For single brain metastases larger than 3 cm or located in the posterior fossa with mass effect, the intervention aims to reduce pressure on brain structures, relieve neurological symptoms, and allow reduction or discontinuation of steroid therapy. In selected cases, surgery may also be considered for lesions between 2 and 3 cm in size after multidisciplinary discussion.

Resection also has prognostic value when the metastasis is solitary, in the absence of active systemic disease or when the latter is completely controlled.

In the case of multiple brain metastases, removal of the largest, edematous or symptomatic lesion may be indicated for palliative purposes before starting nonsurgical treatments. Postoperative MRI is critical to check for residual tumor.

For leptomeningeal metastases, the use of neurosurgery is limited and is mainly considered in cases of symptomatic secondary hydrocephalus in order to place a CSF shunt and relieve intracranial pressure.

In patients with brain metastases, drug treatment is planned considering the molecular and histological characteristics of the original tumor and previously administered therapies.

A key aspect is the collaboration with the radiation oncologist, which is necessary to define when and how to possibly combine with radiation therapy.

When a brain metastasis is surgically removed, it is useful to reevaluate the molecular profile of the tumor so as to better tailor any postoperative targeted therapies.

For leptomeningeal metastases, treatment options may include systemic treatments or administered directly into the CSF (intrathecal therapy), always after careful evaluation by the multidisciplinary team.

Radiation therapy for brain metastases can have several goals: to help after surgery, to attempt to eliminate the disease completely, or to relieve symptoms in more widespread cases.

Radiotherapy after surgery (adjuvant): is given after tumor removal to “clean” the surgical bed and reduce the risk of the disease returning. The most widely used techniques, such as stereotactic or intensity-modulated radiotherapy (VMAT), allow precise targeting of the affected area while sparing healthy brain tissue as much as possible.

Radical radiotherapy: aims to completely eliminate the metastasis. It can be done in one session (radiosurgery) or in a few split sessions, usually up to five, depending on the size and location of the lesion.

Palliative (pan-brain) radio therapy: when metastases have spread throughout the brain, radiotherapy is applied to the entire brain to reduce symptoms and help maintain quality of life. In selected patients with good general condition and limited disease burden, special techniques such ashippocampal sparing can be used to protect the hippocampus, a part of the brain important for long-term memory.

This approach allows the disease to be treated effectively while minimizing possible side effects on healthy brain tissue.

In the case of brain metastases, the steroids, particularly dexamethasone (4 to 16 mg/day depending on the severity of neurological symptoms) are indicated to control brain edema.

Possible prophylactic use in asymptomatic patients who need to undertake radiosurgery is at the discretion of the radiotherapist.

In the case of leptomeningeal metastasis, steroids are generally of little use, whereas nonsteroidal anti-inflammatory drugs, even at high doses, have a better palliative effect on symptoms.

A antiepileptic therapy is required if patients have presented with seizures.

Treatment for encephalic metastases often involves side effects that impact quality of life more or less severely. However, they can be mitigated and in some cases prevented by specific treatments and/or appropriate lifestyle.

At the Candiolo Institute, the doctors and nurses of the multidisciplinary team are available to provide the patient with all the support he or she needs to manage the various side effects he or she will face in the course of treatment.

The impact of cancer in a person’s life also affects the psychological sphere: falling ill with cancer is in fact always a traumatic event that affects all dimensions of the person and can generate anxiety, fear, anger, depression.

At the Candiolo Institute, alongside cutting-edge therapies, the treatment and care pathway always includes a qualified psycho-oncological support that helps the patient cope positively not only with treatment but also with the delicate phase of physical and psychological recovery.

It is also possible to participate in support groups psychological to compare with other people who have gone through or are going through the same experience.

To ensure timely and direct support and receive timely answers to concerns and questions, a dedicated helpline is in place at the Candiolo Institute for all patients.

From Monday to Friday, from 8 a.m. to 5 p.m., you can contact the secretariat of the oncology day hospital at 011.993.3775, reporting the need for urgent consultation.

The patient will be quickly put in touch with his or her medical specialist, to receive clear answers and immediate support.

The cancer patient is a person with complex needs that requires multidisciplinary support not only for the cancer disease, but also for all related issues.

At the Candiolo Institute, patients who need or require it have access to specialists in different areas to receive nutritional support, physical therapy, pain therapy and management of other associated conditions.

The Social Service Department of the Candiolo Institute conducts information and orientation interviews to patients and their families on how to access services in the area and how to obtain welfare and social security benefits provided by law (disability, benefits for aids and prostheses, work leave, etc.).

The service operates on Wednesdays and Fridays from 9 a.m. to 1 p.m. (phone: 011 9933059).

Follow-up after treatment is mainly based on performing periodic MRIs, usually every 3 to 4 months, to monitor the progress of the disease and possibly intercept early signs of recurrence.

In the case of leptomeningeal metastases, in addition to MRI, it may be necessary to perform spinal tap, which is the collection of cerebrospinal fluid. The frequency of this examination is not fixed, but is determined by specialists according to the clinical situation and the evolution of the disease.