Multidisciplinary patient-centered management of brain metastases and future directions

Palmer, Joshua D.; Trifiletti, Daniel M.; Gondi, Vinai; Chan, Michael D.; Minniti, Giuseppe; Rusthoven, Chad G.; Schild, Steven E.; Mishra, Mark V.; Bovi, Joseph; Williams, Nicole; Lustberg, Maryam B.; Brown, Paul D.; Rao, Ganesh; Roberge, David

doi:10.1093/noajnl/vdaa034

Cited by 33 publications

(35 citation statements)

References 138 publications

(151 reference statements)

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“…Although some retrospective series report radiological changes suggestive of radiation necrosis in more than 20% of patients treated with postoperative radiation, the 12-month estimated risk of symptomatic radiation necrosis is about 5–10% in the majority of studies. In a systematic review and meta-analysis on postoperative SRS following excision of brain metastases, Akanda et al [ 6 ] observed a similar incidence of less than 10% in 28 out of 36 studies using different imaging modalities. Although there is no head-to-head comparison of postoperative HSRT versus single-fraction SRS to the surgical bed, the relatively low risk of radiation necrosis after HSRT for volumes larger than 20–25 ml suggests that hypofractionation may represent a better approach for large cavities [ 19 , 24 , 31 , 32 ].…”

Section: Resultsmentioning

confidence: 99%

“…Postoperative whole brain radiation therapy (WBRT) has been traditionally employed in patients with resected brain metastases owing to its efficacy in reducing the risk of local recurrence in the surgical bed and the incidence of new distant metastases [ 1 ]. Stereotactic radiosurgery (SRS), which is the recommended treatment for patients with a limited number of brain metastases [ 2 , 3 ], has been increasingly employed to target the postoperative resection cavity as an alternative to WBRT [ 4 – 6 ]. Several retrospective series of stereotactic irradiation given as single fraction, referred to as SRS, or delivered in few fractions, typically named hypofractionated stereotactic radiotherapy (HSRT) or fractionated SRS, have shown local control rates from 70 to 90% at one year with low incidence of radiation-induced toxicity [ 4 , 5 ].…”

Section: Introductionmentioning

confidence: 99%

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Current status and recent advances in resection cavity irradiation of brain metastases

et al. 2021

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Despite complete surgical resection brain metastases are at significant risk of local recurrence without additional radiation therapy. Traditionally, the addition of postoperative whole brain radiotherapy (WBRT) has been considered the standard of care on the basis of randomized studies demonstrating its efficacy in reducing the risk of recurrence in the surgical bed as well as the incidence of new distant metastases. More recently, postoperative stereotactic radiosurgery (SRS) to the surgical bed has emerged as an effective and safe treatment option for resected brain metastases. Published randomized trials have demonstrated that postoperative SRS to the resection cavity provides superior local control compared to surgery alone, and significantly decreases the risk of neurocognitive decline compared to WBRT, without detrimental effects on survival. While studies support the use of postoperative SRS to the resection cavity as the standard of care after surgery, there are several issues that need to be investigated further with the aim of improving local control and reducing the risk of leptomeningeal disease and radiation necrosis, including the optimal dose prescription/fractionation, the timing of postoperative SRS treatment, and surgical cavity target delineation. We provide a clinical overview on current status and recent advances in resection cavity irradiation of brain metastases, focusing on relevant strategies that can improve local control and minimize the risk of radiation-induced toxicity.

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Section: Resultsmentioning

confidence: 99%

Section: Introductionmentioning

confidence: 99%

Current status and recent advances in resection cavity irradiation of brain metastases

et al. 2021

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“…We excluded patients if either occipital metastasis had a diameter under 1 cm at presentation to assess tumors for which surgery would be considered a treatment option. [ 7 ] Following radiological review, 18 patients were included for analysis.…”

Section: Methodsmentioning

confidence: 99%

Bilateral occipital metastases: Visual deficits and management considerations

Zaki

Gupta

Hauser

et al. 2020

Surgical Neurology International

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Background: Metastases to the bilateral occipital lobes pose a difficult clinical scenario due to risk of debilitating visual loss. We sought to characterize clinical outcomes following different treatment modalities to help guide management in this challenging situation. Methods: We retrospectively reviewed brain metastases patients treated at a single institution between 2008 and 2017 and assessed visual symptoms before and after treatment, the tumor and peritumoral edema volumes before treatment, and clinical outcomes including mortality. Results: Eighteen patients with metastases affecting both occipital lobes were identified. Lung cancer represented the most common primary (n = 10). Visual deficits were present in 12 patients at the time of diagnosis of bilateral occipital metastases (67%). Patients received radiotherapy (n = 5) or combined surgical resection and radiotherapy (n = 13). Among symptomatic patients, two received radiation and 10 received combined surgery and radiation. Nine patients had improved visual symptoms after treatment with no new visual deficits reported as a result of treatment. Among asymptomatic patients, three were treated with radiation alone and three with resection and radiation. Three of these patients developed new visual symptoms following treatment, including one patient with Balint’s syndrome. Conclusion: Patients with symptomatic bilateral occipital lobe metastases may experience visual improvement following intervention, especially if symptoms stem from compression or edema. Those without visual symptoms are at risk of developing new visual deficits during treatment, which should be included in the decision-making process and when counseling patients. Visual deficits improved after surgery in the majority of patients, with no cases of immediate visual deterioration.

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“…Fractionated SRS is typically delivered to 25-30 Gy over 3-5 fractions and is considered for lesions close to critical structures, such as the brainstem or the optic apparatus. Some centers utilize the concept of low overall intracranial disease burden based on total volume of all brain metastases (<15-30 cc) to select patients to be treated with SRS; however, this parameter has not been defined adequately and requires prospective validation [4].…”

Section: Modern Role For Stereotactic Radiosurgerymentioning

confidence: 99%

“…The role of systemic therapy in the treatment of BM is evolving. Previously, its role was restricted due to variable CNS penetration of the blood-brain barrier (BBB) and limited activity [4]. Targeted therapies with greater CNS penetration and improved efficacy have emerged in parallel with the identification of driver mutations, which have led to advances in drug discovery and development [5].…”

Section: Introductionmentioning

confidence: 99%

Integration of Systemic Therapy and Stereotactic Radiosurgery for Brain Metastases

Tonse

Tom

Mehta

et al. 2021

Cancers

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Brain metastasis (BM) represents a common complication of cancer, and in the modern era requires multi-modal management approaches and multi-disciplinary care. Traditionally, due to the limited efficacy of cytotoxic chemotherapy, treatment strategies are focused on local treatments alone, such as whole-brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and resection. However, the increased availability of molecular-based therapies with central nervous system (CNS) penetration now permits the individualized selection of tailored systemic therapies to be used alongside local treatments. Moreover, the introduction of immune checkpoint inhibitors (ICIs), with demonstrated CNS activity has further revolutionized the management of BM patients. The rapid introduction of these cancer therapeutics into clinical practice, however, has led to a significant dearth in the published literature about the optimal timing, sequencing, and combination of these systemic therapies along with SRS. This manuscript reviews the impact of tumor biology and molecular profiles on the management paradigm for BM patients and critically analyzes the current landscape of SRS, with a specific focus on integration with systemic therapy. We also discuss emerging treatment strategies combining SRS and ICIs, the impact of timing and the sequencing of these therapies around SRS, the effect of corticosteroids, and review post-treatment imaging findings, including pseudo-progression and radiation necrosis.

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Multidisciplinary patient-centered management of brain metastases and future directions

Cited by 33 publications

References 138 publications

Current status and recent advances in resection cavity irradiation of brain metastases

Current status and recent advances in resection cavity irradiation of brain metastases

Bilateral occipital metastases: Visual deficits and management considerations

Integration of Systemic Therapy and Stereotactic Radiosurgery for Brain Metastases

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