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The Treatment of Brain Metastases

Summary:Brain metastases are common in patients with systemic cancer, and their incidence is increasing. Most brain metastases become overtly symptomatic and if left untreated lead to an inexorable neurologic deterioration and death. The most common symptoms are headache, limb paresis, behavioral and cognitive changes, and seizures. Most early symptoms are due to peritumoral edema and as such can be ameliorated with glucocorticosteroids. Timely diagnosis and vigorous treatment of cerebral metastases, although rarely curative, may lead to a remission of symptoms, enhance quality of life, and prolong survival. The treatment of choice for the single or multiple solitary brain metastases in the absence of active systemic cancer is surgical resection. Patients with unresectable multiple cerebral metastases or those with progressive systemic disease are best treated with whole-brain radiotherapy. Radiosurgery is emanating as a promising modality for the treatment of a single lesion or for up to four cerebral lesions, or for lesions at relapse, with a tumor control rate of >90%. At recurrence, treatment options are generally limited. Those patients with a single recurrent lesion and systemic disease under check can derive significant benefit from reoperation to result in a median survival similar to that after surgery for the original metastasis. Treatment with a radiation boost with stereotactic radiation is gaining momentum in this setting. The overall prognosis for patients with cerebral metastases is dismal, and the treatment is primarily palliative. The best subgroup of patients, those who are candidates for surgical resection, have an expected median survival of 9 months, with 1-, 2-, 3-, and 5-year survival rates of 40%, 16%, 11%, and 6%, respectively.