Language area metastatic brain cancer

Introduction

An estimated 25% to 45% of patients with cancer will develop brain metastases. ^, The management of patients who develop brain metastases includes some combination of surgery, radiation therapy, and/or chemotherapy. Surgical resection of these lesions is typically offered for patients with good prognoses who have lesions that are large, accessible, and/or symptomatic. In this chapter, we present a case of a patient with a language area metastatic brain tumor.

Example case

Chief complaint: speaking difficulties and right-sided weakness

History of present illness

A 46-year-old, right-handed woman with a history of melanoma presented with acute onset of speech difficulties and right-sided weakness. Her melanoma was resected from her back 5 years ago but had not undergone recent surveillance imaging. On returning home from work, she presented with progressive headaches, difficulty getting words out, and right-sided weakness. She was taken to the emergency room where imaging revealed a large brain tumor ( Fig. 32.1 ).

Medications : None.
Allergies : No known drug allergies.
Past medical and surgical history : Melanoma back excision 5 years prior.
Family history : No history of intracranial malignancies.
Social history : Accountant. No smoking or alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: naming difficulties, impaired repetition; Cranial nerves I to XII intact, except slight right facial droop; Right upper extremity 4+/5, right lower extremity 5/5, left upper extremity 5/5, left lower extremity 5/5.
Computed tomography chest/abdomen/pelvis : Small punctate lesions with the lung and liver.

	Orin Bloch, MD, University of California–Davis, Sacramento, CA, United States	Francesco DiMeco, MD, Massimiliano Del Bene, MD, Carlo Besta Neurological Institute, Milan, Italy	Fernando Hakim, MD, Diego Gomez, MD, Hospital Universitario Fundacion Santafe de Bogota, Bogota, Colombia	Maciej S. Lesniak, MD, Northwestern University, Chicago, IL, United States
Preoperative
Additional tests requested	DTI CT chest/abdomen/pelvis Oncology evaluation Radiation oncology evaluation	DTI if possible fMRI if possible	fMRI Oncology evaluation Radiation oncology evaluation	None
Surgical approach selected	Left frontal craniotomy with asleep motor mapping	Left fronto-parietal craniotomy with asleep cortical and subcortical motor mapping	Left frontal awake craniotomy with motor and language mapping	Left frontal craniotomy
Anatomic corridor	Superior frontal gyrus	Middle frontal gyrus	Left frontal	Left SFG
Goal of surgery	Safe debulking of tumor to relive mass effect as adjuvant therapies effective at tumor control	Complete resection with 5-mm margins, reduce mass effect, improve neurologic function	Gross total resection without neurologic deficit	Gross total resection
Perioperative
Positioning	Left supine neutral	Left supine with right rotation	Left supine with 30-degree right rotation	Left supine
Surgical equipment	Surgical navigation IOM (MEP) Brain stimulator Surgical microscope Ultrasonic aspirator	Surgical navigation IOM (MEP/SSEP) Chisel Brain stimulator Surgical microscope Ultrasonic aspirator	Surgical navigation Brain stimulator Ultrasonic aspirator	Surgical navigation Ultrasonic aspirator
Medications	Mannitol Steroids Antiepileptics	Steroids Antiepileptics	Mannitol Steroids Antiepileptics	Mannitol Steroids
Anatomic considerations	Primary motor cortex, SMA, subcortical CST, AF	Central sulcus, precentral/postcentral gyri, CST, frontal operculum	Broca area, primary motor cortex, vein of Trolard	Broca area, primary motor cortex
Complications feared with approach chosen	Speech and motor deficit	Motor deficit from primary motor cortex or CST, language dysfunction	Speech and motor deficit	Speech and motor deficit
Intraoperative
Anesthesia	General	General	Asleep-awake-asleep	General
Skin incision	Linear	Retrocoronal linear	Curvilinear	Linear
Bone opening	Left frontal	Left frontal-parietal	Left frontal	Left frontal
Brain exposure	Left SFG	Left frontal-parietal	Left frontal	Left SFG
Method of resection	Approximate 4-cm craniotomy based on navigation above SFG where tumor comes closest the surface, open dura, 2-cm transverse corticectomy anterior to SMA in SFG, subcortical dissection to tumor margin, central debulking of tumor with bipolar and ultrasonic aspirator, work through superior lesion into deeper lesion, identify boundary between tumor and normal parenchyma leaving small margin at posterior/deep/lateral aspects	Wide craniotomy without burr holes using drill and chisel, dural tack up sutures, ultrasound to identify lesion and tailor dural opening, C-shaped dural opening based on midline, cortical strip and phase reversal to identify central sulcus, corticectomy based on cortical mapping, en bloc resection trying to find interface between tumor and healthy parenchyma aided with cortical and subcortical mapping and ultrasound, resection of 5-mm margin if negative mapping with ultrasonic aspirator, final ultrasound scan, watertight dural closure	Craniotomy guided by navigation, U-shaped dural opening, awake and extubate patient, cortical stimulation mapping, corticectomy centered over lesion in areas of negative mapping sites, intralesional debulking with aid of ultrasonic aspirator and bipolar coagulation, continuous speech and motor evaluation, periodic navigation checks, find gliotic plane to achieve gross total resection with special attention to neurologic examination, watertight dural closure	Craniotomy based on navigation, identify shortest distance to the lesion, internal debulking with ultrasonic aspirator, capsular resection to achieve gross total resection
Complication avoidance	Limit opening to SFG, work anterior to SMA, asleep motor mapping to identify motor cortex and CST, leave small remnant at deep margin	Craniotomy without burr holes, ultrasound, continuous MEP with cortical strip, cortical and subcortical mapping, en bloc resection, 5-mm resection margin	Language and motor mapping, corticectomy over negative mapping site, intralesional debulking	Superior to the Broca, anterior to motor cortex, intralesional debulking
Postoperative
Admission	ICU	Floor	ICU	ICU
Postoperative complications feared	Motor deficit, language deficit, seizure	Motor deficit, language deficit, SMA syndrome	Cerebral edema	Worsening speech deficit
Follow-up testing	MRI within 48 hours after surgery	CT within 24 hours after surgery MRI within 48 hours after surgery Radiation oncology evaluation	MRI within 72 hours after surgery	MRI within 24 hours after surgery
Follow-up visits	14 days after surgery	1 month after surgery prior to radiation therapy	7 days after surgery	14 days after surgery
Adjuvant therapies recommended	SRS Immunotherapy vs. BRAF inhibitor based on tumor genomics	SRS to cavity Oncology evaluation	SRS to cavity Chemotherapy per oncology	SRS to cavity