Critical Care Medicine-Hematologic and Oncologic Disorders>>>>>Solid Tumors
Question 4#

A 57-year-old woman with history of breast cancer treated with L. mastectomy and chemotherapy and radiation presents with a 1- week history of headaches, gait instability, progressive confusion, and a new onset seizure. On physical examination she is somnolent and only opens her eyes in response to voice. She is only oriented to person (knows her own name) but is not oriented to place or date. She does not follow commands but does withdraw from painful stimuli. Emergent noncontrast head CT is performed, which reveals multiple masses with surrounding edema and no evidence of blood. 

What is the most appropriate intervention for this patient at this time?

A. Endotracheal intubation
B. IV dexamethasone therapy
C. Radiation therapy
D. Extra ventricular drain placement

Correct Answer is B

Comment:

Correct Answer: B

Brain metastases occur in up to 20% of the patients with cancer and indicate poor prognosis. Lung cancer, breast cancer, renal cell carcinoma, and melanoma are the most common types of cancer that metastasize to brain. Contrast-enhanced magnetic resonance imagining is the study of choice for diagnosing brain metastases. 

IV glucocorticoids are indicated in symptomatic patients with brain metastases and surrounding edema and can be symptomatically effective within hours of administration. 

The patient in the question is able to protect her airway, and therefore at this point there is no indication for endotracheal intubation (choice A is incorrect). Although radiation therapy may play a role in long-term management of brain metastases, there is no role for radiation therapy in acute management (choice C is incorrect). Although the patient does have evidence of increased intracranial pressure (headache, nausea/vomiting), conservative measures such as glucocorticoids should be attempted first. In comatose patients or those with severely increased intracranial pressure (TBI, obstructive hydrocephalus, intracranial hemorrhage), hyperventilation, hyperosmolar therapy with osmotic diuretics, and extra ventricular drainage of cerebrospinal fluid may be utilized to reduce intracranial pressure. 

References:

  1. Kaal EC, Vecht CJ. The management of brain edema in brain tumors. Curr Opin Oncol. 2004;16:593-600.
  2. Halfdanarson TR Hogan WJ Madsen BE. Emergencies in hematology and oncology. Mayo Clin Proc. 2017;92:609-641.
  3. Lin X, DeAngelis LM. Treatment of brain metastases. J Clin Oncol. 2015;33:3475-3484.