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Metastatic lesions of the brain and spinal cord - treatment in Germany. Metastases in the spine: symptoms

Metastatic lesions of the spine and spinal cord are classified as secondary malignant neoplasms and are much more common than primary tumors of this location. They are centers of screening out oncological formations localized in another, often very distant, part of the body.

The most common cancers that metastasize to the spinal column and spinal cord are breast, lung, and prostate cancers. Less commonly, cancer of the digestive organs, thyroid gland and kidneys. In childhood, metastases to the spinal cord from malignant brain tumors (medulloblastoma, germinoma, etc.) are especially common. In adults, intradural metastasis of melanoma can sometimes be observed.

Young men who are bothered by back pain must undergo an examination to exclude testicular cancer, since sometimes it may well become the very first symptom of this pathology, even before visualized metastases penetrate the spinal area.

Pain is the main clinical sign of any metastatic lesion of the spine. Their distinctive feature, for example, from pain due to intervertebral hernias, is their persistence and long duration, they practically do not stop and literally exhaust a person. Resting in bed does not bring any relief to patients; pain not only bothers them day after day, but also steadily increases in intensity.

If the patient is not treated and the malignant tumor continues to grow unhindered, it can also cause numbness in the limbs, weakness in them, and lead to dysfunction of internal organs. Thus, with metastatic damage to the lumbosacral spine, the function of the pelvic organs will suffer: urinary and fecal incontinence will occur, and impotence may develop.

It should be taken into account that the clinical manifestations of metastases of the spine and spinal cord in most cases make themselves known earlier than the primary tumor. In this regard, it is necessary to keep in mind the likelihood of asymptomatic progression of some types of cancer. In addition, the detection of osteochondrosis or intervertebral hernia in a patient is not a basis for excluding the possibility of the presence of other pathologies, including serious oncological diseases, which, in turn, can be complicated by metastasis to the spine and spinal cord.

Based on this, people suffering from back pain and visiting the clinic for the first time need to undergo a thorough examination, which, depending on the specific situation, may include magnetic resonance imaging and computed tomography (with or without myelography), radiography of the spine, lungs, ultrasound examination of internal organs, thyroid gland, osteodensitometry (measurement of optical density of bone tissue), skeletal scintigraphy (bone scan using short-lived radioactive substances), a wide range of laboratory tests, etc.

Cancer is a disease that cannot be ignored. Moreover, it is important not only to respond to the occurrence of a malignant tumor, but to do it as early as possible. It is also important to know that some forms of cancer often appear in the back, causing noticeable symptoms. Metastases in the spine, therefore, deserve special attention.

Relevance of the problem

The appearance of metastases in the back area can be a consequence of the formation of a malignant tumor of the prostate and breast, adrenal glands, kidneys and more. In fact, any form of cancer can appear in the spine area.

Sometimes such reactions are possible even several years after the end of treatment. In some cases, such signs - metastases in the spine - can make themselves felt after a twenty-year period of healthy life. At such moments you need to take it extremely seriously, otherwise an extremely sad outcome is possible.

As for the fact in which part of the spine the secondary cancerous formation will appear, it largely depends on the location of the primary tumor. For example, metastases to symptoms appear against the background of lymphosarcoma or nasopharyngeal sarcoma. It is also worth knowing that secondary signs can make themselves felt earlier than the main focus. Because of this, in some cases the initial diagnosis is made incorrectly, although the fact that the patient is being diagnosed is already positive.

Why is this happening

In general, of all diagnosed tumors, 13% are metastatic tumors located in the spinal canal. In this case, the tumors themselves can be located both inside the spinal cord and outside it. In the case of the latter type, the location is possible under the dura mater and above it.

Often it is secondary damage to the epidural space that leads to spinal cord compression in cancer patients. This process is caused by the spread of a paravertebral tumor through the intervertebral foramina.

With a problem such as metastases in the spine, symptoms can accurately diagnose the impact of the tumor in 90% of cases. Cancer cells enter this area of the body through the blood, and in some cases through the lymphatic tract and the lymph itself.

Main features

No matter what health problem you have, there are always symptoms. Metastases in the spine indicate that a cancerous tumor is developing in the body. At the same time, there are a number of features that distinguish them from other diseases that form in the back area:

Possible rapid development of complete or partial paralysis;

The pain manifests itself quickly, and such sensations in the affected part of the spine do not actually change even after the use of painkillers;

When the position of the body changes, the degree of pain increases significantly, which leads to a noticeable limitation of mobility;

Along with other signs of the disease, neurological symptoms such as loss of sensitivity, numbness and tingling quickly appear.

It is worth understanding that such a change in the patient’s condition may also be accompanied by a significant deterioration in overall health. As a result, the patient experiences rapid weight loss, disturbances in sleep patterns and appetite. All this indicates metastases in the spine. Symptoms of this kind are difficult to ignore, but sometimes people, even in severe conditions, put off visiting a doctor. This should not be done, since timely diagnosis and qualified treatment radically affect life expectancy in the case of cancer.

What are the forecasts?

Initially, it is worth understanding the fact that the rapid development of symptoms is associated with the rapid progression of metastases. Primary tumor formations grow more slowly (a year or even longer), but with secondary tumors the situation is diametrically opposite.

It is for this reason that when a diagnosis such as metastases in the spine is made, the prognosis is often unfavorable. However, it largely depends on the stage of development of the disease. In this regard, it is worth repeating once again the idea that the earlier a problem such as secondary cancer is identified, the greater the chances of a positive outcome.

Also, a significant role is played by the fact which metastases are recorded in the spine. Symptoms and manifestations that indicate secondary formations of a previously removed tumor require special treatment.

Clinical picture

Depending on the size and number of formations, symptoms may vary. Metastases in the spine can also affect the patient’s condition differently, developing in certain parts of the spine. This is not surprising, because each vertebra is in close proximity to arteries and nerve roots connected to various organs and parts of the body.

When metastases are observed in the cervical spine, the symptoms are reduced to pain when trying to turn the head or tilt it. Also, due to the fact that compression occurs, many patients begin to suffer from headaches and periodic dizziness.

Metastases in the lumbar spine manifest themselves somewhat differently. Symptoms and changes in condition require professional diagnosis because they are very similar to problems that accompany various kidney diseases.

Sometimes, with such metastases, strong static stress is possible, which can lead to a type of fracture that significantly distorts the posture. But that’s not all, such fractures sometimes cause damage to the spinal cord, resulting in partial or complete paralysis of the lower extremities.

When metastases are diagnosed, the symptoms mainly take the form of discomfort or pain in the area between the shoulder blades. It is also worth knowing that this type of tumor manifestations becomes noticeable later than others, due to the anatomical features of this area.

Radicular disorders

In this case, the occurrence of so-called radicular pain is implied. They can appear in the cervical region, and sometimes make themselves felt through lumbosacral radiculitis. It all depends on where exactly the lesion is located. In some cases, the pain may be girdling.

Positive symptoms of tension and pain when palpated are also observed. Often, such symptoms are accompanied by the formation of zones of decreased and increased sensitivity of the radicular type. We are talking about damage to the thoracic and cervical spine. Other symptoms are also possible - metastases in the spine sometimes lead to inhibition of the Achilles and

Sometimes the pain completely goes away for a while, but in most cases this does not mean recovery, but the complete destruction of the initially affected nerve root. Subsequently, when the tumor spreads to other nerve fibers, the pain resumes.

Myelitic syndrome

This condition is a consequence of compression of the spinal cord by a tumor. Similar cases often occur with prostate cancer, thyroid cancer, and when a malignant tumor affects the lung and breast.

Compression of this type can occur in any part of the spine, but most often the impact on the spinal cord occurs in the thoracic region. Often the degree of increase in pressure increases rapidly, but a slow change in the patient’s condition is also possible.

In this case, the pain syndrome appears much earlier than other symptoms. Metastases in the spine can also lead to the development of a conductive type causing complete loss of sensitivity. But this only happens with sudden compression.

The pain itself is local in nature and is felt in the area of the tumor lesion of the spine.

Polyneuropathic syndrome

This syndrome is characterized by the development of paresthesia, increased sweating of the feet and hands, as well as concomitant hyperemia with suppression of the Achilles and knee reflexes and malnutrition. In addition, decreased sensitivity similar to stockings and gloves in the arms and legs may be recorded.

In 4% of cases of tumor lesions of the spine, intramedullary metastases to the spinal cord make themselves known.

It is also worth knowing about the fact that the diagnosis is most accurately made in patients with radicular or localized pain, as well as with enlargement of the spinal cord and progressive bilateral paresis.

Metastases in the spine: symptoms before death

In an advanced state, cancer leads to disruption of metabolic processes throughout the body. Local symptoms also noticeably increase.

This means that the destruction of the spine in the areas affected by the tumor reaches a critical level. Severe vomiting and nausea, headaches, and anemia are also observed.

Pre-death symptoms include a change in breathing rhythm: it is either fast or almost stops. In severely ill patients, there is also a decrease or increase in temperature significantly below the permissible norm. Symptoms of this kind include apathy, indifference and loss of interest in everything that is happening.

Also, a person whose death is near eats almost nothing and drinks very little. All this is accompanied by excessive weakness and drowsiness. Even hallucinations are possible.

Bottom line

Cancer is a disease whose outcome largely depends on timely diagnosis. Therefore, if you notice any signs reminiscent of metastases in the spine, you should immediately go to the hospital. If suspicions are confirmed, then professional treatment can significantly prolong the patient’s life.

Neurological disorders occur in 15-30% of patients with malignant tumors. In some cases, these are the first clinical manifestations of the disease. For example, about 10% of lung cancer patients visit a doctor for the first time due to neurological disorders.

In recent years, the incidence of neurological disorders in patients with malignant tumors has increased. This is due to several reasons:

the frequency of detection of metastases in various parts of the nervous system has increased, as their diagnosis has improved due to the widespread use of CT and MRI;
as a result of increasing the effectiveness of antitumor treatment and increasing life expectancy, patients began to live to see the development of metastases in the nervous system;
Iatrogenic neurological disorders associated with the intensification of antitumor treatment and the widespread use of new cytostatics with neurotoxicity have become more frequent. In addition, as cancer patients live longer, late toxic effects of anticancer therapy have begun to appear, such as decreased cognitive function after whole-brain irradiation.

The main causes of neurological disorders in patients with malignant tumors are as follows:

malignant tumors of any location (except the nervous system) - metastatic tumors of the brain and spinal cord, meningeal carcinomatosis, compression and invasion of various structures of the nervous system by the tumor or its metastases, paraneoplastic syndromes, metabolic disorders caused by the tumor (for example, hypercalcemic encephalopathy), etc. .;
iatrogenic complications - neurotoxicity of chemotherapy, neurological complications of radiation therapy, immuno- and hormonal therapy; complications from the nervous system caused by taking narcotic analgesics, hypnotics, antiemetics, glucocorticoids, etc.;
reasons not related to the tumor or its treatment - neurological diseases concomitant with the tumor (for example, encephalopathy of various origins, vascular diseases of the brain and spinal cord, etc.); infections, etc.;
primary tumors of the nervous system (brain, spinal cord and peripheral nerves).

Metastatic lesions.Metastatic brain tumors. Brain metastases occur in 10-30% of patients with malignant tumors. The source of metastases can be almost any neoplasm, in adults it is mainly lung cancer (40-50%), breast cancer (15-20%), melanoma (10-11%), tumors without an identified primary focus (5-15%), kidney cancer (6%), tumors of the gastrointestinal tract (5%), uterus (5%), ovaries (2%). It should be remembered that metastatic brain damage occurs 5-10 times more often than primary tumors of the central nervous system. Therefore, all patients who are diagnosed with a brain tumor for the first time should undergo a thorough examination, including X-ray or CT of the chest, ultrasound or CT of the abdominal organs, endoscopic examination of the gastrointestinal tract, since there is a high probability that the tumor in the brain is metastatic (secondary). ).The main route of metastasis of malignant tumors to the brain is hematogenous; in addition, spread through the lymphatic and cerebrospinal fluid routes is possible. The frequency of damage to a particular part of the brain approximately corresponds to the intensity of its blood supply. Thus, 80-85% of metastases are detected in the cerebral hemispheres, 10-15% in the cerebellum, 3-5% in the brainstem. For unclear reasons, prostate cancer, tumors of the uterus and gastrointestinal tract more often metastasize to the posterior cranial fossa. In approximately 40-50% of cases, single (solitary) metastases are found, in 50-60% - multiple. Solitary metastases are typical for clear cell kidney cancer and gastrointestinal adenocarcinoma, multiple - for melanoma, lung and breast cancer. The main method for diagnosing metastatic brain tumors is MRI, which has the highest sensitivity and allows you to detect multiple metastases even in cases where CT only one lesion is visible.

The onset of neurological disorders can be different: a tumor-like variant, when general cerebral and focal symptoms increase over several days or weeks; apoplexy variant, simulating a stroke, when focal symptoms (aphasia, hemiparesis, focal epileptic seizures, etc.) occur acutely and, as a rule, are caused by hemorrhage into a metastasis or occlusion of a cerebral vessel by a metastatic embolus (this course is typical for metastases of chorionic carcinoma, melanoma , lung cancer); remitting variant, when general cerebral and focal symptoms have a wave-like course, reminiscent of a vascular or inflammatory process.

The clinical picture is often caused by a combination of focal and general cerebral symptoms and depends on the localization of metastases in the brain, their size and the severity of perifocal edema. 40-50% of patients experience headache, 20% have hemiparesis, 14% have impaired cognitive function and behavior, 12% have focal or generalized seizures, 7% have ataxia, 16% have other symptoms. In 3-7% of patients, an asymptomatic course is observed, especially characteristic of lung cancer, when metastases are detected only during a control CT or MRI examination. Perifocal edema often increases the volume of the brain much more than the metastatic tumor itself, and along with it leads to increased intracranial pressure, which is manifested by the following general cerebral symptoms: headache, often diffuse, aggravated by changes in the position of the head and torso and combined with dizziness; nausea and vomiting, which are not uncommon at the height of the headache and may be an early sign of metastatic brain damage; congestive optic discs during fundus examination (at the early stage of acute intracranial hypertension, this symptom may be absent). Along with these three main manifestations of intracranial hypertension, drowsiness, depressed consciousness, double vision, transient episodes of visual impairment, and persistent hiccups may be noted. A critical increase in intracranial pressure is indicated by Cushing's triad: an increase in systolic blood pressure, bradycardia and a decrease in breathing. Intracranial hypertension can lead to diffuse cerebral ischemia and entrapment or herniation of brain tissue into the notch of the tentorium cerebellum (transtentorial herniation), into the foramen magnum, or under the medullary falx. Most often this is the direct cause of death of patients.

Treatment of patients with brain metastases depends on the number and location of metastases, the nature and extent of the primary tumor. Maintenance therapy is carried out (corticosteroids, anticonvulsants, psychotropic drugs, etc.) and specific antitumor treatment - surgical, radiation, chemotherapy. Corticosteroids are prescribed to patients with clinical signs of intracranial hypertension, as well as when cerebral edema or displacement of its structures is detected on CT or MRI . Standard doses of dexamethasone are 4-6 mg every 6-8 hours. If effectiveness is insufficient, the dose is increased to an ultra-high dose, sometimes reaching 25 mg every 6 hours. Considering the high frequency of side effects, the dose of corticosteroids should be as minimal as possible, in addition, with For preventive purposes, it is necessary to use drugs that protect the gastric mucosa. Corticosteroids can control neurological symptoms from several weeks to several months; when prescribed, the median survival of patients with clinical manifestations of brain metastases who do not receive antitumor treatment increases from 1 to 2 months. Anticonvulsants are prescribed only for focal or generalized seizures. Surgical treatment is carried out mainly in patients with solitary brain metastases with a controlled primary lesion. More often, metastases located in areas of the brain that are relatively safe for neurosurgical intervention are operated on, for example, in the frontal lobe, cerebellum, and temporal lobe of the non-dominant hemisphere. After surgery, to suppress micrometastases, the entire brain is irradiated at a total dose of about 25-40 Gy. This combination treatment can increase the median survival of patients to 10-16 months, the 2-year survival rate of patients undergoing surgical treatment can reach 15-20%, the 5-year survival rate - 10%, and there are isolated cases of cure. For brain metastases, the size of which does not exceed 3-4 cm, the radiosurgical method is sometimes used (implantation of radioactive sources in the bed of the removed tumor).

Radiation therapy as an independent treatment method is indicated for multiple brain metastases and solitary inoperable metastases. The total radiation dose to the entire brain is 25-50 Gy over 2-4 weeks. The effectiveness of treatment of metastases largely depends on the radiosensitivity of the tumor (for breast and lung cancer it is usually higher than for melanoma or sarcomas). The median survival of patients ranges from 3 to 6 months; as a rule, after effective treatment, the cause of death of patients is the progression of the primary tumor, and not brain damage. If a relapse occurs after a standard course of radiation therapy, then repeated irradiation of the brain is ineffective.

Chemotherapy for brain metastases in most patients is ineffective and is advisable only in cases where the primary tumor is sensitive to the treatment and the antitumor drug is able to penetrate the blood-brain barrier (germ tumors, small cell lung cancer, chorionic carcinoma, lymphomas).

Tumors affecting the spinal cord

Metastatic tumors that cause compression of the spinal cord are most common (3-7.4%) in patients with breast, lung, and prostate cancer. The source of metastases can also be lymphomas, sarcomas, testicular tumors, kidney cancer, stomach cancer, intestinal cancer, and multiple myeloma. At autopsy, such metastases are found in 5-10% of cancer deaths.

The ways in which the spinal cord is damaged are different. Direct hematogenous metastasis to the spinal cord and spread along the cerebrospinal fluid pathways are rare. Intramedullary compression occurs only in 1-4% of cases, usually it is a solitary metastasis combined with metastatic lesions of the brain parenchyma. Typically, a tumor compressing the spinal cord grows from vertebrae affected by metastases or through the intervertebral foramina and is almost always located in the extradural space. Compression of the spinal cord may be a consequence of a fracture of a vertebra affected by metastasis. Tumors causing compression of the spinal cord are found in the thoracic spine in 59-78% of patients, in the lumbosacral spine in 16-33%, in the cervical spine in 4-15%, approx. The departmental ratio is 4:2:1. In 25-49% of patients, multiple lesions of the vertebrae occur. In some cases, spinal symptoms may be caused by vascular disorders of the ischemic type due to tumor compression of the radicular and anterior spinal arteries.

The first clinical manifestation of spinal cord compression in the prodromal phase in 70-97% of patients is back pain and/or radicular pain. Local back pain is usually dull, aching and localized within 1-2 segments. Radicular pain may be constant or occur with movement. The pain syndrome often intensifies with coughing, straining, turning the neck, or lying on the back, so many people sleep half-sitting. Further direct compression of the spinal cord usually manifests as weakness (74%) predominantly in the proximal legs and/or sensory disturbances in the form of paresthesia (53%) - abnormal sensations experienced without receiving external irritation (feelings of numbness, crawling, heat or cold, tingling , burning, etc.), sensory ataxia (4%), which occur weeks or months after the onset of pain. The patient begins to complain of difficulty getting up from a low chair, toilet, or walking up stairs. At this stage, neurological disorders, as a rule, increase quickly: paraplegia may develop within a few days. Pelvic disorders (52%) usually appear later, however, with compression of the conus medullaris (vertebral metastases TX-LI), urinary disorders may be the first and only symptom. If compression of the spinal cord is suspected, a CT or MRI of the spine and spinal cord should be immediately performed, according to indications - myelography, skeletal scanning, since early diagnosis and effective treatment improve the prognosis. Differential diagnosis of metastatic lesions of the spinal cord is carried out, first of all, with a herniated disc, epidural hematoma, abscess, circulatory disorders, primary tumor of the spine and spinal cord. Compression spinal cord requires urgent intervention. Treatment begins at the first sign of compression. Corticosteroids are prescribed, radiation and surgical treatment, chemotherapy and hormonal therapy are carried out.

Corticosteroids relieve pain in 85% of patients; if necessary, high and ultra-high doses are used, for example, the dose of dexamethasone can reach 100 mg/day. Patients in whom spinal cord compression is confirmed by MRI or CT, but there are no neurological symptoms, are prescribed standard doses of dexamethasone (16 mg / day), adjusting them depending on the course of the disease. Radiation therapy is indicated for tumors that are sensitive to radiation (for example, lymph nodes). -ma), multiple metastatic lesions of the vertebrae, absence or slight severity of neurological disorders, uncontrolled progression of the primary tumor. After radiation therapy, pain decreases in 70% of patients, and motor activity improves in 45-60%. The irradiation zone (total dose of about 30 Gy) includes the site of compression of the spinal cord and two vertebrae above and below this level. Surgical treatment is carried out in cases where the patient’s life expectancy exceeds 2 months. Indications for surgery are compression of the spinal cord by a bone fragment, metastases of tumors that are insensitive to radiation therapy (for example, kidney cancer), compression in an area previously irradiated, and progression of neurological disorders during irradiation. Laminectomy or anterior decompression is performed. The latter has clear advantages and involves resection of the vertebral body along with the tumor and subsequent fixation of the spine. After laminectomy, local irradiation is usually performed. Combined treatment improves the condition in 30-50% of patients; in approximately 40%, neurological disorders persist and in 20% continue to increase. Early treatment is important - in the first 7-14 days of spinal cord compression.

Chemotherapy and hormonal therapy are indicated in cases where there is a high chance of rapid development of their effect (for lymphomas, germ cell tumors, prostate and breast cancer, myeloma). Despite the treatment, 7-16% of patients experience repeated episodes of metastatic compression of the spinal cord brain

Meningeal carcinomatosis

Meningeal carcinomatosis is found in approximately 5% of patients with malignant tumors. The cause may be lymphoma, acute leukemia, small cell lung cancer, breast cancer, stomach cancer, ovarian cancer, melanoma. Clinical manifestations include general cerebral symptoms in the form of diffuse or local headache (especially in the morning or in a certain position), nausea, vomiting , memory impairment, confusion, seizures; stiffness and soreness of the neck muscles; damage to the cranial nerves, mainly oculomotor; involvement of the spinal roots with the development of pain, paresthesia, weakness in the limbs; unreasonable constipation, urinary retention or incontinence (retention may be an early sign of carcinomatosis). About a third of patients with metastatic lesions of the meninges also have intracerebral metastases. Diagnosis of meningeal carcinomatosis is difficult, since the above symptoms are nonspecific. The diagnosis is usually considered proven when malignant cells are detected in the cerebrospinal fluid, but in some cases they are detected only through repeated cytological studies or autopsy. Before lumbar puncture, it is necessary to do an MRI or CT scan of the brain and spinal cord with contrast; the accumulation of contrast in the subarachnoid cisterns of the base of the brain is of diagnostic importance; it is possible to detect tumor nodules on the roots of the cauda equina. A number of clinics conduct a study of cerebrospinal fluid for the presence of tumor markers.

Currently, treatment of meningeal carcinomatosis involves local irradiation of the lesions (eg, cauda equina) in combination with frequent intrathecal administration of methotrexate, cytarabine, and their combinations. Improvement is observed in approximately 80% of patients with lymphomas and leukemia, 50% with breast cancer, 30% with lung cancer, 20% with melanoma. Survival of such patients increases to an average of 4-6 months compared to 1-2 months for those who do not respond to therapy. Without treatment, worsening neurological disorders and death of the patient within a few weeks are inevitable.

Metastatic and compressive lesions of cranial and peripheral nerves

Damage to cranial and peripheral nerves in patients with malignant tumors is usually associated with two reasons:

compression by the tumor or its metastases. The main clinical symptom is local (at the site of compression) or distant (in the area of innervation of the affected nerve) pain, usually preceding other neurological disorders by weeks or months;
spread of the tumor process through the perineural or endoneural spaces. Such metastatic or carcinomatous infiltration occurs in malignant tumors of the head and neck, prostate and breast cancer, melanoma and is characterized by the simultaneous development of pain and neurological disorders.

Differential diagnosis of metastatic lesions of cranial and peripheral nerves is carried out, first of all, with iatrogenic neuropathies caused by radiation or chemotherapy, and paraneoplastic syndromes. Distinctive signs of metastatic lesions are pain, asymmetric, often unilateral, neurological disorders. We should not forget about other causes of neuro- and plexopathy: herniated disc, hematoma, abscess, etc.

To relieve pain, various means are used, from anticonvulsants (carbamazepine, gabapentin) to narcotic analgesics (morphine, fentanyl). The main methods of treatment are radiation and chemotherapy. Surgical interventions are performed as indicated (for example, removal of a tumor at the apex of the lung). Cranial nerves can be damaged anywhere from the level of the nucleus to the root or trunk of the nerve. The cause is predominantly head and neck tumors, lymphoma, metastases of a malignant tumor in the brain, its membranes and skull bones. The abducens and facial nerves, as well as the caudal group, are most often affected. Thus, paresis of the facial nerve occurs in 5-25% of patients with malignant tumors located in the parotid region. Brachial plexus plexopathy in most cases has a compressive nature and is associated with tumor metastases (breast cancer, lymphoma, sarcoma, melanoma, etc.) to regional (axillary, supraclavicular, subclavian and cervical) lymph nodes, collarbone, 1st and 2nd ribs, as well as with a primary or metastatic tumor of the apex of the lung (Pancoast syndrome). Carcinomatous infiltration of the plexus is also possible. The main clinical manifestation is severe pain in the shoulder girdle, radiating to the elbow, along the inner edge of the forearm, to the IV-V fingers, subsequently objective sensory and motor disturbances, atrophy of the muscles of the hand and Horner's syndrome (narrowing of the palpebral fissure, enophthalmos, miosis) occur. on the losing side. The lower part of the plexus (CVII-CVIII-TI) is predominantly affected. When diagnosing plexopathy, it is advisable to perform an X-ray or CT scan of the chest and cervical spine, and ultrasound of the regional lymph nodes.

The lumbosacral plexus can be affected anywhere with local spread of a pelvic or abdominal tumor. Thus, the femoral nerve is compressed in the area of the femoral canal by metastasis in the lymph node, the sciatic nerve is affected by a tumor spreading into the sciatic notch, the sacral plexus is affected by metastases to the sacrum or by a soft tissue tumor located in front of the sacrum. Clinical manifestations of lumbosacral plexopathy are also different: weakness of the muscles of the pelvic girdle and lower extremities, impaired sensitivity and loss of reflexes from the legs, usually occurring against the background of pain in the lower back, buttock, and hip joint, radiating to the leg. In some cases, the function of the femoral nerve suffers predominantly with the development of weakness in the extensors of the leg, in others - the obturator nerve with weakness of the adductor muscles or the lateral cutaneous nerve of the thigh with paresthesia in the innervated area. When diagnosing, CT, MRI and ultrasound of the abdominal cavity, pelvis and regional lymph nodes should be performed, and if necessary, a biopsy should be performed.

According to the most conservative estimates, 8 - 10% of patients with malignant tumors develop symptomatic brain tumors (BM). Among malignant tumors, melanoma and small cell lung cancer have the highest metastatic potential, in which brain metastases develop by the second year of observation in 80% of patients with a disseminated process. At the same time, melanoma metastases have a worse prognosis for tumor control and survival. According to autopsy data, it was found that 25 - 40% of cancer patients have GBM that was not diagnosed during their lifetime. 60% of all metastatic tumors are diagnosed in patients aged 50–70 years, which coincides with the peak incidence of malignant neoplasms.

The vast majority of GBM is caused by hematogenous spread of tumor cells from the primary site (about 20% of cardiac output enters the brain vessels, explaining the fact that lung tumors most often metastasize to the brain). GBM manifests itself either as a solitary focus or has a multiple nature. Metastases can be localized in various anatomical intracranial formations: in the parenchyma, in the dura or pia mater, in the subarachnoid space and ventricles of the brain (in the brain, metastases are mainly localized at the border between the gray and white matter, as well as at the junction of the middle and posterior cerebral basins). cerebral arteries). Supratentorial metastases account for 80 - 85%, in the cerebellum - 10 - 15%, in the brain stem - 3 - 5%, in the meninges - 1 - 2% (this distribution probably depends on the blood supply to the brain: cerebral blood flow washes mainly the hemispheres, then the cerebellum and brain stem). It is extremely rare that metastases are found in the choroid plexus, pineal gland, pituitary gland, and optic nerve. A separate problem is meningeal carcinomatosis, when metastases develop in the meninges, are detected during routine or flow-through examination of the cerebrospinal fluid and metastasize within the central nervous system.

read also the article: Metastatic lesion of the meninges(to the site)

GBMs are most often found in patients with cancer of the lung, breast, sigmoid colon, kidney, prostate, lymphoma, and melanoma. In most patients with GBM, neurological symptoms gradually progress. In only 5–10% of patients, neurological symptoms occur acutely (“stroke-like” onset). This is associated with hemorrhage into the tumor or cerebral stroke due to embolism or compressive occlusion of blood vessels, which is especially common in metastases of melanoma, chorionic carcinoma and kidney cancer.

read also the article “Metastases of lung cancer to the brain - the role of the neurosurgical stage of treatment” Aleshin V.A., Karakhan V.B., Bekyashev A.Kh., Belov D.M.; FSBI "RONC named after. N.N. Blokhin" of the Ministry of Health of Russia (magazine "Tumors of the Head and Neck" No. 2, 2016) [read]

Headache is the leading symptom in half of the patients and is most typical for multiple MGs and MGs of the posterior cranial fossa. Papilledema is combined with headache in 1/4 of cases. In 40% of patients, already at the onset of the disease there are mild focal neurological symptoms, which subsequently progress. Partial and generalized seizures are relatively rare (about 10% of cases) the first symptom of GBM. Mental disorders and cognitive impairment occur in 75% of patients, especially in patients with multiple GBM and/or increased intracranial pressure. Among the complications that develop in the presence of GBM, there is also the syndrome of inadequate secretion of antidiuretic hormone. When the disease is asymptomatic, difficulties arise in the diagnosis and treatment of GBM.

Please note! Most often (up to 80%) GBM are detected after the identification of the primary lesion (metachronous diagnosis) or simultaneously with the identification of the primary tumor (synchronous diagnosis). In 15% of cases, GBM are detected before the primary lesion is detected, and in 5% of patients, GBM remain the only sign of the disease with an unidentified primary focus.

The diagnosis is confirmed by magnetic resonance imaging (MRI), and the standard for imaging brain metastases is a study with gadolinium contrast enhancement only. Computed tomography (CT) is necessary either when bone structures are affected (including for subsequent 3D planning of stereolithographic models for large lesions), or in cases where MRI is not possible (in this case, contrast-enhanced CT is used to search for intracranial metastases). CT perfusion in cancer patients is used in the differential diagnosis of ischemic changes in the brain, lymphomas, meningiomas, hemangioblastomas and some other processes that have specific hemodynamic properties that can be differentiated using CT perfusion.

GBMs usually develop as well-demarcated, round nodules. Activated microglial cells - tissue macrophages, form a clear boundary in the form of a shaft between the tumor and the brain substance. The GBM is often surrounded by an area of edema as a result of disruption of the tumor's blood-brain barrier (BBM). Proteins penetrate from the tumor tissue into the surrounding brain matter and increase its water content. Edema is promoted by increased vascular permeability as a result of the action of VEGF (vascular endothelial growth factor - vascular endothelial growth factor)

Please note! Peripheral location in the brain, spherical shape, ring-shaped enhancement with marked peritumoral edema, or a round enhancing structure with central necrosis on MRI, and multifoci are suggestive of GBM. However, these signs are not pathognomonic even in patients with a history of malignant tumor.

Neuroimaging of MGM on RADIOPAEDIA.org

read also the article “Radiation diagnostics of brain neurometastases” by E.M. Zakharova, E.V. Tsapurina, State Educational Institution of Higher Professional Education "Nizhny Novgorod State Medical Academy" (magazine "Medical Almanac" No. 1 (14), March, 2011) [read]

Differential diagnosis is carried out with primary brain tumors (especially malignant gliomas and lymphomas) and conditions that are not neoplastic: abscesses, infections, hemorrhages, demyelination (clarification of the diagnosis is possible only after histological analysis of removed tissues). The basis of the differential diagnosis is anamnesis (for example, a single space-occupying lesion in the brain in a patient with a history of cancer is a metastasis in 95% of cases, and a primary neoplasm in only 5% of cases) and an MRI picture.

A study of cerebrospinal fluid is carried out if signs of meningeal carcinomatosis are detected (with neuroimaging and clinically). Carcinomatous meningitis in patients with breast cancer and breast cancer occurs more often than in patients with primary tumors of other locations.

If the primary lesion is not identified, CT of the chest, abdomen, pelvis (or MR diffusion of the whole body or whole body) is performed; colonoscopy, gastroscopy; blood test for tumor markers.

The goal of treatment for GBM is to prevent the patient's death from intracranial progression of the disease, reduce neurological symptoms or prevent its occurrence while maintaining the patient's quality of life for as long as possible. Treatment algorithms for patients with GBM:

It is recommended to observe the following frequency and methods of observation after treatment for GBM: in the first 1 - 2 years, a physical examination and collection of complaints are recommended to be carried out every 3 months, for a period of 3 - 5 years - once every 6 months. In patients at high risk of relapse, the interval between examinations can be shortened. Scope of examination: medical history and physical examination, MRI of the brain with intravenous contrast every 3 months. Examination for the presence of extracranial metastases is carried out in accordance with the primary focus - the source of the GBM.

PLEASE NOTE

Clinical diagnostic data do not always make it possible to reliably distinguish primary and secondary malignant neoplasms (MNT) of the brain: metastasis is often represented by a single focus (up to 50% of cases) without specific signs in radiological diagnostics. However, morphological examination of surgical material, as a rule, allows one to determine the secondary nature of the tumor, especially if it is of epithelial origin. At the same time, differentiation of the primary localization of carcinoma can cause significant difficulties. Thus, often metastatic tumors can differ from the primary lesion in histological pattern, blurring the boundaries between different types of adenocarcinomas, urothelial and squamous cell carcinomas and presenting an invasive solid growth of atypical epithelial cells without specific signs. In such cases, it is also necessary to take into account the possibility that the tumor belongs to melanoma, mesothelioma and other types of cancer. At the same time, in metastases, foci of keratinization that are not characteristic of the primary tumor can sometimes occur. The most common and convenient method for determining the source of cancer is the immunohistochemical (IHC) method. Demyashkin G.A. et al. (2018) developed an algorithm for differential diagnostic immunophenotyping of brain cancer with data, incl. to verify the primary tumor focus in case of verification of brain cancer as “metastasis (mts)” (see algorithm diagram below).

article “Immunophenotypic characteristics of brain metastases” Demyashkin G.A., Shalamova E.A., Nikitin P.V., Bogomolov S.N.; Federal State Budgetary Institution “9th Treatment and Diagnostic Center” of the Ministry of Defense of the Russian Federation, Moscow; Federal State Autonomous Educational Institution of Higher Education “First Moscow State Medical University named after. THEM. Sechenov" Ministry of Health of the Russian Federation, Moscow; FGAU "National Medical Research Center for Neurosurgery named after. acad. N.N. Burdenko" Ministry of Health of the Russian Federation, Moscow (magazine "Neurology, neuropsychiatry, psychosomatics" No. 4, 2018) [read]

Literature:

article “Tumor metastases in the brain” by E. A. Melnikova, Moscow Medical Academy named after. THEM. Sechenov (magazine “Neurosurgery” No. 3, 2005) [read];

article “Treatment of patients with metastatic brain lesions” by A.V. Golanov, S.M. Banov, S.R. Ilyalov, E.R. Vetlova, A.V. Smolin, A.Kh. Bekyashev, M.B. Dolgushin, D.R. Naskhletashvili, A.V. Nazarenko, S.V. Medvedev; 1 Federal State Institution “Research Institute of Neurosurgery named after. acad. N.N. Burdenko", Gamma Knife Center, Federal State Institution "Main Military Clinical Hospital named after. N.N. Burdenko" of the Russian Ministry of Defense, Federal State Budgetary Institution "Russian Oncological Research Center named after. N.N. Blokhin" Moscow, Russia (magazine "Questions of Neurosurgery" No. 4, 2016) [read];

clinical recommendations “Treatment of patients with metastatic brain lesions” Association of Neurosurgeons of Russia; 2015 [read], 2016 [read];

project “Clinical guidelines for the diagnosis and treatment of patients with metastatic brain tumors” Association of Oncologists of Russia, Moscow 2014 [read];

article (literature review) “Surgical treatment of tumor metastases in the brain” E.V. Gormolysova, S.V. Chernov, A.B. Dmitriev, A.V. Kalinovsky, D.A. Rzaev; Federal State Budgetary Institution "Federal Center of Neurosurgery", Novosibirsk (journal "Neurosurgery" No. 4, 2014) [read];

article “Modern approaches to radiation treatment of metastatic brain lesions” Golanov A.V., Banov S.M., Ilyalov S.R., Vetlova E.R., Kostyuchenko V.V. (magazine “Malignant Tumors”, No. 3 (10), 2014) [read];

dissertation “Stereotactic radiosurgery of intracerebral cancer metastases using a gamma knife device” S.R., Russian Academy of Medical Sciences Scientific Research Institute of Neurosurgery named after Acad. N.N. Burdenko, Moscow, 2008 [read]