American Brain Tumor Association Webinar Metastatic Brain Tumors: What Patients Need to Know >>Welcome to the American Brain Tumor Association’s Free Educational Webinar Series. Thank you for participating in today’s webinar. Today’s Webinar is on Metastatic Brain Tumors: What Patients Need to Know. The webinar will be presented by: Michael Lim, MD. Please note that all lines during our webinar today are muted. If you have a question you would like to ask, type and submit it using the "Question" box in the control panel on the right-hand side of your screen. Dr. Lim will answer questions at the end of his presentation. In the next few days, you will receive an email asking you to take a brief survey to evaluate the webinar. Please take a few minutes to share your feedback, which is important to us as we plan for future webinars. Today’s webinar is being recorded- the recording will post to the ABTA’s website on the Anytime Learning page shortly. Registered participants will receive the webinar recording link in a follow- up email message once it is available. Let’s pause for a moment so we can begin our webinar recording here. >>The American Brain Tumor Association is pleased to welcome you back to our Webinar Series. Our webinar today will discuss: Metastatic Brain Tumors: What Patients Need to Know. My name is Antoinette Tiu, Program Manager here at the American Brain Tumor Association. I’m delighted to introduce our speaker today, Dr. Michael Lim. As an associate professor of neurosurgery in the Johns Hopkins Department of Neurosurgery in Baltimore, Michael Lim, M.D., focuses on the surgical treatment of primary and metastatic brain tumors, as well as pituitary and skull base tumors and trigeminal neuralgia. He uses the most advanced techniques in neurosurgery including image-guided surgery, radiosurgery, microsurgery, minimally invasive techniques, and endoscopic surgery, as well as immunotherapy. Thank you for joining us, Dr. Lim. You may now begin your presentation. >>Thank you Antoinette. Welcome everybody to our presentation on metastatic brain tumors. My name is Dr. Michael Lim and I'm the director of the metastatic brain tumor Center at John Hopkins. These are my relevant disclosures. We have a group of oncologists who focus on taking care of patients who have metastatic brain tumors. With this afternoon session I would like to try to focus a little bit and breakdown my talk into three parts. First, the background for brain metastases and then I will talk about different forms of treatments that we have for patients who present with brain metastasis and then I will talk with the management algorithms that we use. How do we decide who to treat, when to treat, and with what modality do we treat. So to start up our talk it turns out we have known about brain metastases for a very long time. It was first described in 1898 by Dr. Bucholz. About 30% of patients with systemic cancers present with brain metastases. These numbers are going up because we're doing better and better at taking care of patients with systemic cancers and patients are living longer. Often times immediate things doctors have been doing to help people live longer is steroids and radiation. We will talk about that later especially in light of exciting therapy such as the immunotherapy, I think we will see more patients with brain metastases. In terms of what types of systemic cancers routinely for brain metastasis this is not a comprehensive list but certainly the most common types of tumors known to go into the brain are lung cancer, breast cancer, colon cancer, melanoma, and kidney cancers. Interestingly enough prostate cancer does not. That is one of the most common types of tumors that are in the population. If they do go to the brain, it is often because the seed the skull on the head but they don't generally go into the brain itself. When patients present with brain metastases the goals of what we think about when we encounter a patient with a metastasis is to first improve quality of life. That often means trying to improve neurologic symptoms with some sort of deficit -- for example speech and vision problems or weakness. Often times we think about when we think about taking care of patients with brain metastases we often think about the side effects of the therapies and weigh that against overall benefits for our patients which is quality of life and trying to improve survival. In addition, we have done quite well with the therapy for brain metastasis. We are trying to come up with strategies to minimize the risk of the deterioration for patient neurologically. In terms of treatment modalities, it really boils down to three options. Observation, doing nothing, surgery, and/or radiation. In terms of surgery interestingly enough until the 1990s there was no uniformity and practice patterns. There were some centers that believed that all patients should get surgery and there were other centers who did not believe in that and recommended either radiation or palliative therapy. It wasn't until a paper came out in 1990 by Dr. Roy Patchell in the New England Journal where we began trying to distill patients who would benefit from surgery. >>In terms of deciding who would benefit from surgery, we think of multiple factors for our patients. This is the individualized therapy for our patients. Things that we take into consideration are things such as age, the performance status. I will talk about this a little later, is really just a measure of seeing how independent and functional a patient is. For example if someone is able to work and carry out their activities of daily living, they have a very good performance status compared to someone who is wheelchair-bound and very moribund they may be poor in terms of their performance status. And you can see how someone could benefit how surgery may be difficult for someone with a poor performance status. It turns out the number of metastases in the brain play an important role in deciding whether or not surgery is appropriate. In addition, the size of the lesions which often correlate to mass effect on the brain and or symptoms of the patient are very important in deciding for surgery. The location of the lesions: for example if it is in the middle speech it might not be something we can do and surgery may not benefit someone whose lesions are in the middle of speech. Of course the comorbidities, those that have had previous strokes or heart attacks, they are poor surgical candidates that need to be weighed against the benefits of surgery. So in terms of approach we all look at our brains and everybody's brain and even if we have these terms that we see are eloquent and non-eloquent in our brain we all consider every part of the brain critical. Just like when a sushi chef is trying to get into the puffer fish to get to the correct part to get the good sushi, there are many parts that are dangerous that we want to avoid. And because of technology, we are able to do wonderful things in the operating rooms for our patients. We are able to do image guided surgery. GPS devices for skulls and brains where we can know where we are in a person’s brain within a millimeter of accuracy. In addition, we can integrate into that GPS function. We can do things like functional MRIs in patients and figure out where the speech area is and the hand and foot areas of the brain are to try to help develop a roadmap for our surgeries. In addition, we can do intraoperative mapping for our patients and it can be anything from the awake craniotomy to stimulating various parts of the brain. >>As a result we are able, patients can do very well from surgery. On average when I take a patient to surgery to take out a brain metastasis, when we choose the appropriate patients correctly, patients can often be out of the hospital in under 48 hours. Often times their neurologic deficits can be either stopped or even reversed within days. In terms of contraindications for surgery, these are what I call relative contraindications. Poor surgical candidates are patients who have significant core morbidity, advanced stage is not an absolute indication. I have patients who are 80 or 90 who look physiologically like they were 50 or 60 and did well from surgery. A phenomenon called Leptomeningeal Spread. If the cancer cells have spread into the cerebral spinal fluid or the fluid that surrounds the brain, often time’s surgery is not a good way to go. When we decide who to take to surgery as I alluded to earlier, we work very closely with our oncologist to decide what the overall best therapy is for each patient. We always need to keep in mind the systemic cancer and trying to get at the systemic cancer with systemic therapies. In the most expeditious manner. And this can only be done as a team. As I said earlier, surgery can have very minimal morbidity and patients can do extremely well and have reversals in their neurological deficits very quickly. >>In terms of radiation, sometimes patients have a stigma that they think they will have terrible damage to the brain and it's a non-specific amount of toxic therapy to their brain like three-mile island. I tried to tell my patients that radiation is very, very elegant.