Management of Brain Metastasis: Past Lessons, Modern Management, and Future Considerations

Abstract

Brain metastasis is a major challenge for patients, physicians, and the broader health care system, with approximately 170,000 new cases per year. After a diagnosis of brain metastasis, patients have a poor prognosis, but modern management has made significant advances in the past two decades to improve palliative efficacy and patient survival through a multidisciplinary approach. A number of factors must be taken into consideration in the treatment approach, including the number of intracranial lesions, the control of extracranial disease, and the patient's overall health, while weighing the benefits of treatment against the toxicities, both acute and chronic. With quality of life as an emphasis, emerging concepts for modern management of brain metastasis have sought to minimize long-term toxicities. The economic impact of such strategies for patients and the health care system has been demonstrated in some studies, but has not been a consistent area of focus. Each of these strategies, as well as novel therapeutics, has embraced the concept of personalized treatment. This review will discuss the current knowledge of modern multidisciplinary management of brain metastasis and look forward to emerging concepts.

Future perspectives in melanoma research. Meeting report from the “Melanoma Bridge. Napoli, December 2nd-4th 2012”

“…Fortunately, questions about the risks and biology of brain metastases (e.g., molecular pathogenesis, tumor-host relationships, site of primary and its environmental and genetic features) have started to see answers, and much new information is expected from collaborative networks that have been developed to answer these and other questions about biology and management of brain metastases. In 296 patients with resected brain met(s) BRAF and NRAS status was determined, and they were evaluated between Jan 2005-Dec 2011 (before BRAFi, MEKi therapies) [85]. In terms of difference in median age, BRAF wild-type (WT) patients were 66 years, while BRAF (all comers) and NRAS mutated patients were mid-50s.…”

Influence on morbidity and mortality of neoadjuvant radiation and chemotherapy among cranial malignancy patients in the postoperative setting

“…Primary tumor pathology typically determines chemosensitivity and which regimens are prescribed [13]. Different regimens tend to have variable toxicity and penetration of the blood-brain barrier [12,20,24]. Furthermore, different etiologies will have varying effects on compromising the blood-brain barrier and therefore increasing the permeability of the metastatic lesion to chemotherapy [5].…”

“…Over 50% of cranial tumors are extracranial in origin and brain metastases occur in 10-40% of adults with metastatic forms of cancer [9,12]. Approximately 170,000 metastatic brain tumors are diagnosed every year in the USA.…”

“…Neoadjuvant chemotherapy is often indicated in chemosensitive disease [12]. Chemotherapy may be primarily focused on the cranial tumor or the extracranial disease.…”

Evaluating the impact of hippocampal sparing during whole brain radiotherapy on neurocognitive functions: A preliminary report of a prospective phase II study

“…Traditionally, WBRT has long been a practical and effective therapeutic modality for various settings of management in radiation oncology. [2,3] For example, the indications for WBRT include brain metastasis/metastases, the setting of prophylactic cranial irradiation (PCI) used for patients with limited-stage small cell lung cancer, and even some cases of extensive-stage small cell lung cancer. [4] The rationale for WBRT is mainly based on the fact that it can target both microscopic and gross intracranial diseases.…”