Guidelines for the Initial Management of Metastatic Brain Tumors: Role of Surgery, Radiosurgery, and Radiation Therapy

View More View Less
  • a From the Division of Neurosurgery, Lineberger Comprehensive Cancer Center, Department of Radiation Oncology, and Divison of Medical Oncology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, and the Department of Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, University of South Florida College of Medicine, Tampa, Florida.

Brain metastases are an increasingly important determinant of survival and quality of life in patients with cancer. Current approaches to the management of brain metastases are driven by prognostic factors, including the Karnofsky Performance Status, tumor histology, number of metastases, patient age, and status of systemic disease. Most brain metastases are treated with radiosurgery, computer-assisted surgery, or whole brain radiation therapy. Remarkable advances in computer-assisted neuronavigation have made neurosurgical removal of metastases safer, even in eloquent areas of the brain. Computerization also enhances the efficacy and safety of conformal radiosurgery planning using various modern stereotactic radiosurgery (SRS) technologies, including newer frameless-based systems. Controversial issues include whether to defer whole brain radiotherapy (WBRT) in patients undergoing SRS or image-guided surgery and when to use SRS “boost” in a patient undergoing WBRT. The determination of how best to apply these treatments for individual patients cannot be standardized to a single paradigm, but data from well-controlled studies help physicians make informed decisions about the benefits and risks of each approach.

Correspondence: Matthew G. Ewend, MD, Division of Neurological Surgery, Burnett-Womack 3013, University of North Carolina, Chapel Hill, NC 27599. E-mail: ewend@med.unc.edu

EDITORS

Steven Brem, MD, Department of Neuro-Oncology, H. Lee Moffitt Cancer Center & Research Institute, University of South Florida College of Medicine, Tampa, Florida

Disclosure: Steven Brem, MD, has disclosed that he has been involved in a research study with MGI.

CME AUTHOR

Désirée Lie, MD, MSEd, Clinical Professor, Family Medicine, University of California, Orange; Director, Division of Faculty Development, UCI Medical Center, Orange, California

Disclosure: Désirée Lie, MD, MSEd, has disclosed no relevant financial relationships.

  • 1.

    Nussbaum ES, Djalilian HR, Cho KH et al.. Brain metastases. Histology, multiplicity, surgery, and survival. Cancer 1996;78:17811788.

  • 2.

    Patchell RA, Tibbs PA, Regine WF et al.. Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial. JAMA 1998;280:14851489.

    • Search Google Scholar
    • Export Citation
  • 3.

    Patchell RA, Tibbs PA, Walsh JW et al.. A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990;322:494500.

    • Search Google Scholar
    • Export Citation
  • 4.

    Ewend MG, Brem S, Gilbert M et al.. Treatment of single brain metastasis with resection, intracavity carmustine polymer wafers, and radiation therapy is safe and provides excellent local control. Clin Cancer Res 2007;13:36373641.

    • Search Google Scholar
    • Export Citation
  • 5.

    Markesbery WR, Brooks WH, Gupta GD et al.. Treatment for patients with cerebral metastases. Arch Neurol 1978;35:754756.

  • 6.

    Soffietti R, Cornu P, Delattre JY et al.. EFNS Guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force. Eur J Neurol 2006;13:674681.

    • Search Google Scholar
    • Export Citation
  • 7.

    Glantz MJ, Cole BF, Forsyth PA et al.. Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Report of the Quality Standards Subcommittee of the American Academy of Neurology. Neurology 2000;54:18861893.

    • Search Google Scholar
    • Export Citation
  • 8.

    Ewend MG, Elbabaa S, Carey LA. Current treatment paradigms for the management of patients with brain metastases. Neurosurgery 2005;57(5 Suppl):S6677; discussion S1–4.

    • Search Google Scholar
    • Export Citation
  • 9.

    Davis PC, Hudgins PA, Peterman SB et al.. Diagnosis of cerebral metastases: double-dose delayed CT vs contrast-enhanced MR imaging. AJNR Am J Neuroradiol 1991;12:293300.

    • Search Google Scholar
    • Export Citation
  • 10.

    Sze G, Milano E, Johnson C et al.. Detection of brain metastases: comparison of contrast-enhanced MR with unenhanced MR and enhanced CT. AJNR Am J Neuroradiol 1990;11:785791.

    • Search Google Scholar
    • Export Citation
  • 11.

    Gaspar L, Scott C, Rotman M et al.. Recursive partitioning analysis (RPA) of prognostic factors in three Radiation Therapy Oncology Group (RTOG) brain metastases trials. Int J Radiat Oncol Biol Phys 1997;37:745751.

    • Search Google Scholar
    • Export Citation
  • 12.

    Vecht CJ, Haaxma-Reiche H, Noordijk EM et al.. Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol 1993;33:583590.

    • Search Google Scholar
    • Export Citation
  • 13.

    Thomas AJ, Rock JP, Johnson CC et al.. Survival of patients with synchronous brain metastases: an epidemiological study in south-eastern Michigan. J Neurosurg 2000;93:927931.

    • Search Google Scholar
    • Export Citation
  • 14.

    Burt M, Wronski M, Arbit E et al.. Resection of brain metastases from non-small-cell lung carcinoma. Results of therapy. J Thorac Cardiovasc Surg 1992;103:399410; discussion 410–411.

    • Search Google Scholar
    • Export Citation
  • 15.

    Bindal RK, Sawaya R, Leavens ME et al.. Surgical treatment of multiple brain metastases. J Neurosurg 1993;79:210216.

  • 16.

    Norris LK, Grossman SA, Olivi A. Neoplastic meningitis following surgical resection of isolated cerebellar metastasis: a potentially preventable complication. J Neurooncol 1997;32:215223.

    • Search Google Scholar
    • Export Citation
  • 17.

    Mintz AH, Kestle J, Rathbone MP et al.. A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with a single cerebral metastasis. Cancer 1996;78:14701476.

    • Search Google Scholar
    • Export Citation
  • 18.

    Rogers LR, Rock JP, Sills AK et al.. Results of a phase II trial of the GliaSite radiation therapy system for the treatment of newly diagnosed, resected single brain metastases. J Neurosurg 2006;105:375384.

    • Search Google Scholar
    • Export Citation
  • 19.

    Chang SD, Main W, Martin DP et al.. An analysis of the accuracy of the CyberKnife: a robotic frameless stereotactic radiosurgical system. Neurosurgery 2003;52:140146; discussion 146–147.

    • Search Google Scholar
    • Export Citation
  • 20.

    Mehta MP, Tsao MN, Whelan TJ et al.. The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases. Int J Radiat Oncol Biol Phys 2005;63:3746.

    • Search Google Scholar
    • Export Citation
  • 21.

    Kondziolka D, Patel A, Lunsford LD et al.. Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases. Int J Radiat Oncol Biol Phys 1999;45:427434.

    • Search Google Scholar
    • Export Citation
  • 22.

    Amendola BE, Wolf AL, Coy SR et al.. Brain metastases in renal cell carcinoma: management with gamma knife radiosurgery. Cancer J 2000;6:372376.

  • 23.

    Manon R, O'Neill A, Knisely J et al.. Phase II trial of radiosurgery for one to three newly diagnosed brain metastases from renal cell carcinoma, melanoma, and sarcoma: an Eastern Cooperative Oncology Group study (E 6397). J Clin Oncol 2005;23:88708876.

    • Search Google Scholar
    • Export Citation
  • 24.

    Aoyama H, Shirato H, Tago M et al.. Stereotactic radiosurgery plus whole-brain radiation therapy vs stereotactic radiosurgery alone for treatment of brain metastases: a randomized controlled trial. JAMA 2006;295:24832491.

    • Search Google Scholar
    • Export Citation
  • 25.

    Patchell RA, Tibbs PA, Regine WF et al.. Letter to the editor. JAMA 1998;281:1696.

  • 26.

    Shaw EG, Gaspar LE, Gibbs FA et al.. Multiple brain metastases. American College of Radiology. ACR Appropriateness Criteria. Radiology 2000;215:11211128.

    • Search Google Scholar
    • Export Citation
  • 27.

    DeAngelis LM, Delattre JY, Posner JB. Radiation-induced dementia in patients cured of brain metastases. Neurology 1989;39:789796.

  • 28.

    Aoyama H, Tago M, Kato N et al.. Neurocognitive function of patients with brain metastasis who received either whole brain radiotherapy plus stereotactic radiosurgery or radiosurgery alone. Int J Radiat Oncol Biol Phys 2007;68:13881395.

    • Search Google Scholar
    • Export Citation
  • 29.

    Bendell JC, Domchek SM, Burstein HJ et al.. Central nervous system metastases in women who receive trastuzumab-based therapy for metastatic breast carcinoma. Cancer 2003;97:29722977.

    • Search Google Scholar
    • Export Citation
  • 30.

    Lin N, Carey L, Liu M et al.. Phase 2 trial of lapatinib for brain metastases in patients with HER2-positive breast cancer. J Clin Oncol 2008;26:19931999.

    • Search Google Scholar
    • Export Citation
All Time Past Year Past 30 Days
Abstract Views 0 0 0
Full Text Views 1653 562 59
PDF Downloads 1528 580 51
EPUB Downloads 0 0 0