Neurosurgery consult

[smm07]

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All,
I have been in fellowship for 6 months now, and I still do not know how to respond when neurosurgery asks if surgery is indicated for a patient with brain mets. Typically the scenario plays out as such:

1) Patient admitted with a new symptomatic brain mets (in most cases of known disease. ie: already with biopsy proven lung or breast cancer)
2) Neurosurgery says no emergent surgery indicated.
3) Neurosurgery then consults me (medical oncology fellow) to ask if urgent surgery is indicated

What is appropriate for a medical doctor to tell a surgeon? I can comment on prognosis. I can discuss chemotherapy options after stabilization of symptomatic met. What else is my role in the multidisciplinary approach? I honestly don't know what to tell these surgeons. I'd like to hear others' perspectives.

 

[QuizzicalApe]

I wouldn't even know how to respond to a surgeon asking me if emergent surgery is indicated.

I guess I'd have them clarify. Is that question coming from a recognition that the masses are technically operable but they don't know if you'd rather treat them medically or with radiation due to perceived futility of surgery?

Still, though, I'd expect them to have an opinion

 

[gutonc]

Here's the best part of finishing up fellowship and getting a real job...you'll never get asked this again once you finish.

Comment on median survival, current PS and symptoms. Even better if you can get your Rad Onc folks on board with you.

It also really depends on the situation:
- Bx proven cancer w/ multiple brain mets? Unless they're about to herniate from edema, surgery probably isn't indicated
- New diagnosis admitted for sxs related to brain met(s)...we need tissue anyway, take that s*** out.

In the end, your attending needs to sack up and decide what's most appropriate. Hopefully s/he has the patient's best interest at heart.

Once you're out in the real world, the neurosurgeons will be begging to take these folks to the OR. Your job at that point is to prevent them from taking the hospice-bound folks and thanking them for helping to care for your patients.