What is the prognosis for a patient with at least 19 brain lesions if they do not receive treatment?

Prognosis for Untreated Multiple Brain Lesions

Without treatment, a patient with 19 brain lesions faces an extremely poor prognosis with high mortality, likely surviving less than one year with progressive neurological deterioration.

Natural History of Untreated Brain Lesions

• Brain lesions, particularly multiple lesions, represent a significant threat to life and neurological function, with glioblastoma being the most lethal brain tumor type, showing only one-third of patients surviving for 1 year and fewer than 5% living beyond 5 years 1
• The presence of multiple lesions (19 in this case) significantly worsens the prognosis compared to single lesions, as the cumulative mass effect and edema from multiple lesions increases intracranial pressure more rapidly 1
• High-grade astrocytomas diffusely infiltrate surrounding tissues and frequently cross the midline to involve the contralateral brain, causing progressive neurological deterioration 1

Expected Symptoms and Disease Progression

• Initial symptoms may include headaches, seizures, and focal neurologic deficits related to the size and location of the tumors and associated peritumoral edema 1
• As the disease progresses without treatment, patients will experience:
  • Worsening neurological deficits corresponding to the locations of the lesions 1
  • Increased intracranial pressure leading to symptoms such as severe headache, nausea, vomiting, and altered mental status 1
  • Progressive deterioration in functional status and Karnofsky Performance Status (KPS) 1
  • Development of obstructive hydrocephalus if lesions block cerebrospinal fluid pathways 1

Timeframe for Disease Progression

• Deterioration can occur rapidly, with studies showing that in patients with brain lesions, deterioration occurred within 24 hours in 71% of cases 1
• For high-grade lesions such as glioblastoma, median survival without treatment is typically 3-6 months 1
• For metastatic brain lesions, survival without treatment varies by primary cancer type but generally ranges from 1-3 months 1

Factors Affecting Prognosis

• The number of lesions (19) is a significant negative prognostic factor, as multiple lesions create cumulative mass effect and edema 1
• Location of lesions affects prognosis - lesions in critical areas such as the brainstem carry worse prognosis 1
• Histological type of the lesions (if known) would significantly impact prognosis - glioblastomas have worse outcomes than lower-grade tumors 1
• Patient age, performance status, and presence of neurologic deficits are important prognostic factors 1

Potential Complications

• Increased risk of seizures, which may be difficult to control without proper treatment 1
• Progressive neurological deterioration leading to loss of independence in activities of daily living 1
• Increased intracranial pressure can lead to brain herniation, which is often fatal 1
• Risk of intracranial hemorrhage within the lesions, which can cause sudden deterioration 1, 2

Important Considerations

• Even with treatment, the prognosis for multiple brain lesions is generally poor, but treatment can significantly extend survival time and improve quality of life compared to no treatment 1
• The decision to forgo treatment should be made with full understanding of the likely rapid progression and poor outcome 1
• Palliative care should be considered early in the disease course to manage symptoms and improve quality of life during the remaining time 1