Number of patients
Percentage of consults
Chief complaint
Back pain
385
18
Headache
192
9
Other pain
160
7
Altered mental status
521
24
Weakness
395
18
Sensory deficit
173
8
Ataxia/gait instability
156
7
Seizures
156
7
Vision deficit
54
2
Speech deficit
52
2
Neurologic diagnosis
Parenchymal brain metastasis
407
19
Epidural metastasis
298
14
Leptomeningeal metastasis
224
10
Other metastasis
407
19
Toxic metabolic encephalopathy
275
12
Cerebrovascular disease
169
8
Headache
67
3
Syncope
45
2
Peripheral neuropathy
40
1
Epilepsy
34
1
Paraneoplastic syndrome
7
0.3
Other
246
12
An estimated 1.7 million Americans will be diagnosed with cancer in 2015, of whom 68% will be alive at 5 years [7]. Many of these 1.2 million cancer survivors will have a neurologic symptom or disability and would benefit from neurologic expertise. This book seeks to address the broad scope of these issues and the large unmet clinical needs of these patients.
Management of the Neurologic Complications of Cancer
Neurooncology is the subspecialty of neurology that deals with the neurologic complications of cancer. Neurologic symptoms may arise from primary malignancies of the brain, and for that reason, one focus of neurooncology is the management of gliomas and other primary tumors of the CNS. A second, equally important focus is the diagnosis and management of neurologic complications of systemic cancer and its treatment which is the core of this book. This second focus extends far beyond brain metastases, a problem that is already ten times more common than malignant gliomas [3, 7].
The first step in managing a neurologic complication of cancer is the correct identification of the underlying problem. A cancer patient with a change in gait may have loss of proprioception from prior chemotherapy, disease within the CNS, or severe pain that limits function. Correct diagnosis and treatment of the patient’s complaint is contingent upon the same principles of neurology that apply to the non-cancer population. A careful history and detailed exam localizes the deficit in the nervous system to a focal, multifocal, or diffuse process. From that localization, a neurologic differential diagnosis can be developed that is based on specialized knowledge of the characteristic propensities of each cancer, the off-target effects of a wide array of conventional cytotoxic, novel small molecule and biologic therapeutics, and the complications of radiotherapy and surgical treatments. The most common neurologic complications of cancer and their association with different malignancies and treatment are provided in Table 1.2.
Table 1.2
Neurologic complications of cancer
Location | Complication | Cancer or treatment related causes | |
---|---|---|---|
Brain | |||
Direct complications | Brain metastasis | Lung, melanoma, renal, breast, and colon cancer | |
Primary brain tumor | Meningioma, glioma, pituitary adenoma, and schwannoma | ||
Leptomeningeal metastasis | Breast, lung, melanoma, and gastrointestinal cancer | ||
Complications associated with cancer | Epilepsy/status epilepticus | Brain metastasis, primary brain tumor, paraneoplastic limbic encephalitis, and meningitis/encephalitis | |
Paraneoplastic limbic encephalitis | Anti-VGKC | SCLC and thymoma | |
Anti-NMDA | Ovarian teratoma | ||
Anti-Hu | SCLC and gynecological cancer | ||
Anti-Ma2 | Testicular germ cell | ||
Paraneoplastic cerebellar degeneration | Anti-Yo | Ovarian and breast cancer | |
Anti-Tr | Hodgkin lymphoma | ||
Anti-Hu | SCLC and gynecological cancer | ||
Meningitis/encephalitis | Cancer-mediated immunosuppression | Hodgkin lymphoma, CLL, multiple myeloma, and Waldenstrom macroglobulinemia | |
Ischemic stroke | Hyperviscosity | Multiple myeloma, Waldenstrom macroglobulinemia, and leukemia | |
Cancer-mediated hypercoagulability | Pancreatic cancer, adenocarcinomas | ||
Tumor emboli | Rhabdomyosarcoma | ||
DIC | Sepsis from cancer-mediated immunosuppression | ||
Vasculopathy | Intravascular lymphoma | ||
Infectious vasculopathy (VZV) from cancer-mediated immunosuppression | |||
Hemorrhagic stroke | Coagulopathy/DIC | APL | |
Sepsis from cancer-mediated immunosuppression | |||
Liver metastases | |||
Thrombocytopenia | Leukemia, lymphoma, and multiple myeloma | ||
Hemorrhage from a metastasis | Renal cell carcinoma, melanoma, choriocarcinoma, and papillary thyroid cancer | ||
Treatment complications | Encephalopathy | Methotrexate, ifosfamide, and 5-FU | |
PRES | Bevacizumab, sorafenib, cyclophosphamide, high-dose corticosteroids, l-asparaginase, cisplatin, gemcitabine, and tacrolimus | ||
Ischemic stroke | Bevacizumab, sunitinib, sorafenib, and cisplatin | ||
Radiation-induced vasculopathy from treatment of head and neck cancers | |||
Infectious vasculopathy and DIC from treatment-induced immunosuppression | |||
Hemorrhagic stroke | Chemotherapy-induced thrombocytopia | ||
Bevacizumab | |||
Hemorrhage due to vascular changes secondary to radiotherapy | |||
Venous sinus thrombosis | l-asparaginase | ||
Pseudoprogression | Radiation to a primary or metastatic brain tumor | ||
Radiation necrosis | Radiation to the head and neck; SRS to brain metastases | ||
Bacterial meningitis/abscess/empyema | Neurosurgical procedure | VP shunt, burr hole, craniotomy, transsphenoidal resection, and laminectomy | |
Treatment-induced immune suppression | Cytotoxic chemotherapy, hematopoietic stem cell transplant, and immune-modulating biologics | ||
Spinal cord | |||
Leptomeningeal Metastasis | Breast, lung, melanoma, and gastrointestinal cancers | ||
Cord compression/cauda equina syndrome | Lung, breast, prostate, renal, colorectal, and hematologic malignancies | ||
Paraneoplastic myelopathy | Anti-amphiphysin | Breast cancer | |
Anti-CRMP5 | SCLC and thymoma | ||
Anti-Hu | SCLC and gynecological cancer | ||
Anti-ANNA-3 | SCLC | ||
Anti-NMO | Carcinoma and lymphoma | ||
Radiation myelopathy | Radiation to the vertebral column, thorax, abdomen, or neck | ||
Radiculomyelitis | Cancer-mediated and treatment-induced immunosuppression | ||
Plexus | |||
Neoplastic infiltration | Brachial | Breast and lung cancer | |
Lumbosacral | Prostate, colorectal, cervical, bladder cancers, and retroperitoneal sarcoma | ||
Radiation plexopathy | Radiation near the plexus | ||
Peripheral nerve | |||
Neoplastic infiltration | Leukemia, lymphoma, Waldenstrom macroglobulinemia, prostate cancer, and squamous cell of head and neck (to cranial nerves) | ||
Drug-associated neuropathy | Platinum agents, vinca alkaloids, thalidomide, bortezomib, and ipilimumab | ||
Immune-mediated neuropathy | POEMS syndrome, MGUS, and multiple myeloma | ||
Paraneoplastic neuronopathy | Anti-Hu | SCLC and gynecological cancer | |
Peripheral nerve hyper-excitability | Anti-VGKC | SCLC and thymoma | |
Neuromuscular junction | |||
Myasthenia gravis | Anti-acetylcholine receptor | Thymoma | |
Lambert–Eaton myasthenic syndrome | Anti-Ca channel | SCLC | |
Muscle | |||
Steroid myopathy | Pituitary adenomas/carcinomas, adrenal adenomas/adrenocortical carcinomas, and exogenous steroids | ||
Dermatomyositis/polymyositis | Cervical, lung, ovarian, pancreatic, bladder, and gastric cancer |
Direct Effects of Cancer on the Nervous System
Cancer frequently metastasizes to the nervous system, primarily to the brain, dura, subarachnoid space, spinal cord, and plexus. Considered together, the direct complications of cancer on the nervous system are responsible for a major burden of disability and death. Ironically, enhanced therapeutics and longer systemic disease control may be responsible for increasing the incidence of these complications, making the need for better therapeutics for CNS disease ever more pressing.
![](https://freepngimg.com/download/social_media/63059-media-icons-telegram-twitter-blog-computer-social.png)
Stay updated, free articles. Join our Telegram channel
![](https://clinicalpub.com/wp-content/uploads/2023/09/256.png)
Full access? Get Clinical Tree
![](https://videdental.com/wp-content/uploads/2023/09/appstore.png)
![](https://videdental.com/wp-content/uploads/2023/09/google-play.png)