Neurologists offering a diagnosis to patients often receive a response of relief, "Thank goodness. I thought I had a brain tumor." Unfortunately, at times the patient actually does have a brain tumor or some other neurological malignancy. In fact, the practicing neurologist must consider neoplasm in the differential diagnosis of a very large variety of neurological presentations, even though cancer may not ultimately prove to be the culprit. Thus, neuro-oncology, although not part of the 3-year Continuum core curriculum, is, nonetheless, a vitally important subject for clinical neurologists.
Faculty chair David Schiff, MD, has recognized the fact that metastatic disease to the nervous system is far more frequently encountered by the general neurologist than are primary tumors. He has accordingly chosen to emphasize that problem in this issue of Continuum. First, Stuart Burri, MD, and Anthony Asher, MD, FACS, discuss the most frequently encountered neurological manifestation of cancer, brain metastases. They provide a thorough, lucid discussion of diagnosis and management, emphasizing evidence-based decision making. Dr Schiff, himself, then focuses on spinal metastases, including detailed discussion of the diagnosis and management of cord compression, one of the true neurological emergencies. Leptomeningeal metastasis, a less frequent and often enigmatic condition, is ably reviewed by Jan Drappatz, MD, and Tracy Batchelor, MD, MPH, who also address the unusual peripheral nerve metastases.
Fascination with the immunologically mediated paraneoplastic syndromes has increased in recent years as the numbers of recognized conditions continue to mount. While their actual incidence is relatively rare, these paraneoplastic conditions are often considered in the differential diagnosis of a wide variety of neurological conditions. Furthermore, study of the paraneoplastic disorders offers insight into the biology of the nervous system and its component parts. Luis Bataller, MD, PhD, and Josep Dalmau, MD, PhD, provide a clear and comprehensive discussion of this subject.
Although the therapy for neurological malignancy remains generally disappointing, slow but steady progress continues. With increasing treatment options, inevitably more iatrogenic complications arise. Neurologists must understand the currently available therapies for a variety of types of neurological cancer and must also be aware of their potential adverse effects on the nervous system. Radiation therapy has been a mainstay in the treatment of neurological malignancy, and Martin Taphoorn, MD, and Jacoline Bromberg, MD, offer a thorough discussion of both its beneficial and deleterious effects. In addition to dealing with neoplasia in the nervous system, neurologists are often consulted by their medical or oncological colleagues who confront patients with neurological symptoms and signs. While some of these patients are suffering the consequences of their underlying malignancy, many others are experiencing the neurotoxicity that is associated with a wide variety of chemotherapeutic agents. Pamela New, MD, skillfully guides the reader through the sometimes bewildering garden of antineoplastic agents, pointing out the neurotoxic land mines that litter the terrain. With her help, you will be far better equipped to diagnose and manage these treatment complications.
Questions that teach are invaluable educational tools. Marc Chamberlain, MD, in his excellent patient management problem, and Joanne Lynn, MD, and Steven Lewis, MD, who developed the multiple-choice questions, help cap your learning experience in this issue of Continuum.
I greatly appreciate the efforts of Dr Schiff, who has been an outstanding organizer and an efficient and responsive leader for this important issue on neuro-oncology. He assembled a gifted group of specialists who met his and our standards for clarity and thoroughness. Their diligence will reward you with greatly enhanced practical knowledge of this critical field.
Aaron E. Miller, MD