Management of brain metastases in lung cancer: evolving roles for radiation and systemic treatment in the era of targeted and immune therapies

Abstract

Brain metastases are a common occurrence in both non-small cell and small cell lung cancer with the potential to affect quality of life and prognosis. Due to concerns about the accessibility of the central nervous system by systemic chemotherapy agents, the management of brain metastases has historically relied on local therapies including surgery and radiation. However, novel targeted and immune therapies that improve overall outcomes in lung cancer have demonstrated effective intracranial activity. As a result, the management of brain metastases in lung cancer has evolved, with both local and systemic therapies now playing an important role. Factors such as tumor histology (non-small versus small cell), oncogenic driver mutations, and symptom burden from intracranial disease impact treatment decisions. Here, we review the current management of brain metastases in lung cancer, highlighting the roles of stereotactic radiosurgery and novel systemic therapies as well as the ongoing questions that remain under investigation.

Parotid metastases from primary lung cancer: Case series and systematic review of the features

“…In other words, patients with lung cancer parotid metastasis seem to show a greater tendency of brain metastasis. Previous studies concluded that WBRT ( 60 , 61 ), stereotactic radiosurgery (SRS) ( 62 , 63 ), and prophylactic cranial irradiation (PCI) ( 62 , 64 , 65 ) can improve the prognosis of these patients and bring survival benefits. Therefore, for patients for whom brain metastasis already appears, WBRT or SRS should be performed as soon as possible.…”

“…Therefore, for patients for whom brain metastasis already appears, WBRT or SRS should be performed as soon as possible. More importantly, for patients who have not yet developed brain metastasis, PCI should be applied in time ( 62 ). Furthermore, several studies ( 66 , 67 ) have shown that parotidectomy seems to have no improvement in the prognosis of metastatic parotid tumors.…”

Five-Year Sustained Complete Remission With Minimal Adverse Effects Following Radiosurgery for 2-cm Brain Metastasis With Deep Eloquent Location From Lung Adenocarcinoma Despite Low Marginal Dose and High 12 Gy Volume

“…Single-fraction (sf) SRS (sfSRS) is widely utilized for BM ≤3 cm in diameter from LAC and other primaries [1][2][3]7,9]. Generally, a prescription dose (PD) of 24 Gy is expected to provide one-year LTC probability of 95% for ≤20-mm BM, while 18 Gy is expected to provide one-year LTC probability of >85% for ≤20 mm and 75% for ≤30 mm [10].…”

“…Stereotactic radiosurgery (SRS) is an important local treatment option, especially for limited BM cases [ 1 ]. In addition to the sophistication of the radiotherapy armamentarium, the ongoing progress of anti-cancer medications based on the integration of molecular diagnosis has enhanced systemic control and prognosis of LAC-BM cases [ 2 , 3 ]. According to the recently updated scores for estimating the prognosis of LAC-BM cases, i.e.…”

“…Symptomatic BM as the first clinical manifestation of lung cancer, not otherwise specified, poses a therapeutic challenge in determining the optimal sequence of further evaluation and treatment [ 5 , 6 ]. In such clinical scenarios, long-term local tumor control (LTC) and safety are unprecedentedly expected for SRS, considering the potential long-term survival period [ 2 , 4 , 7 , 8 ].…”