From the Guidelines
Brain metastasis treatment should prioritize a combination of surgery, radiation therapy, and systemic therapy based on the primary cancer type, number and location of metastases, and patient's overall health, with the goal of improving morbidity, mortality, and quality of life. For patients with a favorable prognosis for survival and a single brain metastasis, treatment options include surgery with postoperative radiation, stereotactic radiosurgery (SRS) alone, whole-brain radiotherapy (WBRT) plus memantine (WB-M) and hippocampal avoidance (HA; 6 SRS), hypofractionated stereotactic radiotherapy, and discussion of systemic therapy in select patients with asymptomatic CNS metastases depending on metastasis size, resectability, and symptoms 1. Some key considerations in the management of brain metastases include:
- The number and location of metastases, with single or limited metastases often treated with surgical resection or SRS, and multiple metastases treated with WBRT alone or in combination with SRS
- The primary cancer type, with different cancers having different propensities for brain metastasis and responding differently to various treatments
- The patient's overall health and performance status, with patients having a better prognosis and more treatment options if they are in good health and have a high performance status
- The use of systemic therapy, including chemotherapy, targeted therapy, and immunotherapy, which can be effective in treating brain metastases in certain cases
- The management of symptoms and side effects, including cerebral edema, seizures, and cognitive decline, which can significantly impact the patient's quality of life. Newer approaches, such as hippocampal-sparing radiation techniques and blood-brain barrier penetrating drugs, are being developed to reduce cognitive side effects and improve treatment outcomes 1. Prognosis varies widely based on factors like primary cancer type, number of metastases, patient's functional status, and response to treatment, with median survival ranging from months to years depending on these factors 1. In general, the treatment of brain metastases requires a multidisciplinary approach, with close collaboration between neurosurgeons, radiation oncologists, medical oncologists, and other healthcare professionals to provide the best possible outcomes for patients.
From the Research
Brain Metastasis Overview
- Brain metastases (BMs) are the most frequent event during the course of Non-Small Cell Lung Cancer (NSCLC) disease 2
- Recent advancements in diagnostic and therapeutic procedures have increased the incidence and earlier diagnosis of BMs, with a need to optimize prognosis through tailored treatment solutions 2
Treatment Options
- Radiation therapy (RT) is a cornerstone of BMs management, either alone or combined with surgery and systemic therapies 2
- Stereotactic radiosurgery (SRS) is an effective treatment for patients with multiple brain metastases, improving outcomes and reducing toxicity compared to whole-brain radiation therapy (WBRT) 3
- Whole-brain radiation therapy with simultaneous integrated boost (WBRT+SIB) may have better intracranial local control than SRS in NSCLC-BM patients, especially in the context of systemic drug therapy 4
Challenges and Opportunities
- The use of ionizing radiation remains vital in the management of metastatic brain disease, but carries risks and toxicity, such as radionecrosis 5
- The combination of stereotactic radiotherapy and systemic treatments, such as chemotherapy, tyrosine kinase inhibitors (TKIs), and immunotherapy, is a subject of ongoing investigation 5
- There is a need for more data on patient-relevant outcomes, such as quality of life, functional status, and cognitive effects, in the context of radiation therapy for brain metastases 6
Radiation Therapy
- The combination of SRS plus WBRT compared with SRS alone or WBRT alone showed no statistically significant difference in overall survival or death due to brain metastases 6
- Radiation therapy after surgery did not improve overall survival compared with surgery alone 6
- WBRT plus systemic therapy was associated with increased risks for vomiting compared with WBRT alone 6