Left perirolandic metastatic brain cancer

Introduction

The most common type of brain tumor in adults is metastatic brain tumors, with an incidence 3 to 14 per 100,000 people per year. ^, Approximately 10% to 20% of these metastatic brain tumors occur in eloquent locations, which include primary motor, somatosensory, speech, and/or visual cortices. The general management of large, symptomatic metastatic brain tumors is surgery followed by radiation therapy. ^, ^, However, lesions in eloquent regions are surgically more challenging, and therefore typically undergo radiation therapy to minimize the risk of surgically induced morbidity. Radiation without surgical therapy, however, does little to improve symptomatic mass effect in the immediate period. ^, ^, In this chapter, we present a case of a patient with a dominant hemisphere perirolandic metastatic brain tumor.

Example case

Chief complaint: headaches and right-hand weakness

History of present illness

An 80-year-old, right-handed man with a history of hypertension, coronary artery disease, and bladder cancer status postresection and radiation therapy presented with headaches over the past couple of weeks unresponsive to pain medications, and difficulties with writing and buttoning his shirts over the same time frame. He saw his oncologist who ordered systemic imaging, and a brain lesion was seen ( Fig. 33.1 ).

Medications : Aspirin, irbesartan, hydrochlorothiazide.
Allergies : No known drug allergies.
Past medical and surgical history : Hypertension, coronary artery disease, bladder cancer status postresection 5 years prior.
Family history : No history of intracranial malignancies.
Social history: Retired, independent with activities of daily living, remote smoking history, and no alcohol.
Physical examination : Awake, alert, oriented to person, place, and time; Language: naming difficulties, impaired repetition; Cranial nerves II 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 : Several liver lesions concerning for metastatic disease.

	Sunit Das, MD, PhD, St. Michael’s Hospital, University of Toronto, Toronto, Canada	Peter E. Fecci, MD, PhD, Duke University, Durham, NC, United States	Alessandro Olivi, MD, Giuseppe Maria Della Pepa, MD, A. Gemelli University Hospital, Rome, Italy	Ganesh Rao, MD, Baylor College of Medicine, Houston, TX, United States
Preoperative
Additional tests requested	DTI fMRI	DTI Oncology evaluation for prognosis	DTI fMRI	DTI
Surgical approach selected	Left parietal craniotomy or SRS	Left fronto-parietal craniotomy with awake speech and motor mapping	Left fronto-parietal craniotomy with asleep motor mapping	Left parieto-occipital craniotomy with asleep motor mapping
Anatomic corridor	Left parietal, transsulcal, MIPS	Left parietal	Left fronto-parietal	Left parieto-occipital
Goal of surgery	Gross total resection and neurologic preservation	Gross total resection, local disease control, palliative symptom control	Gross total resection and neurologic preservation	Gross total resection
Perioperative
Positioning	Left supine semilateral	Left lateral	Left supine with right rotation	Left three-quarter prone
Surgical equipment	Surgical navigation Surgical microscope Ultrasonic aspirator Ultrasound	Surgical navigation Surgical microscope Brain stimulator	Surgical navigation IOM (SSEP/MEP) Brain stimulator	Surgical navigation Ultrasound Brain stimulator IOM (SSEP, EMG)
Medications	Steroids	Steroids Antiepileptics Mannitol	Steroids Antiepileptics	Steroids
Anatomic considerations	Motor and somatosensory cortex, CST	Receptive speech area, motor cortex, CST, AF, optic radiations	Central sulcus, motor and sensory cortices, CST, IFOF	Motor and somatosensory cortex, CST
Complications feared with approach chosen	Motor and sensory deficits	Language dysfunction, motor deficit	CST injury	Injury to motor cortex and CST, Gerstmann syndrome
Intraoperative
Anesthesia	General	Asleep-awake-asleep	General	General
Skin incision	Linear	Linear	Linear	Linear/curvilinear
Bone opening	Left parietal	Left parietal	Left parietal	Left parietal
Brain exposure	Left fronto-parietal	Left fronto-parietal	Left parietal and possible central lobe	Left parieto-occipital
Method of resection	Craniotomy based on navigation, ultrasound to identify lesion, dural opening, determine suitability of sulcal opening, sulcal dissection under microscopic visualization, pial opening to access tumor, sequential mobilization with internal debulking, goal of gross total resection, ultrasound assessment, dural tack up sutures	Craniotomy based on navigation while patient asleep, patient awakened and following commands, dura opened, cortical stimulation of speech and motor areas starting at 1 mA, corticectomy planned based on negative mapping sites, en bloc vs. piecemeal resection depending on tumor consistency, patient sedated for closure	Craniotomy based on navigation with preoperative identification of planned trajectory posterior to somatosensory cortex, C-shaped dural opening, place strip electrode for MEP or phase reversal to identify central sulcus, stimulate electrode to find negative mapping area to enter tumor, corticectomy but ideally transsulcal, internal debulking of tumor, tumor margins dissected from parenchyma, ultrasound to check for residual, dural closure with pericranium if necessary	Craniotomy based on navigation, dura opened, cortical mapping to identify motor and sensory cortices, transcortical approach based on negative mapping sites, subcortical stimulation along trajectory, intralesional resection because of the size of the lesion, ultrasound to verify extent of resection
Complication avoidance	Transsulcal, ultrasound assessment, internal debulking	Cortical and subcortical mapping, method of resection depending on tumor consistency	Trajectory posterior to sensory cortex, internal debulking to minimize manipulation, ultrasound	Cortical and subcortical mapping, intralesional resection, ultrasound
Postoperative
Admission	Floor	ICU	ICU	ICU
Postoperative complications feared	Motor and sensory deficit	Language dysfunction, motor deficit	Seizures, ischemia	Motor deficit
Follow-up testing	MRI within 48 hours after surgery	MRI within 24 hours after surgery	MRI within 24 hours after surgery	MRI within 24 hours after surgery
Follow-up visits	1 month after surgery	14 days after surgery and 4 weeks after surgery	10 days and 1 month after surgery	7–10 days after surgery and 1 month after surgery for MRI
Adjuvant therapies recommended	SRS or hypofractionated radiation to cavity	SRS	Radiation therapy	SRS or hypofractionated radiotherapy