Updates in the management of brain metastases

Abstract

The clinical management/understanding of brain metastases (BM) has changed substantially in the last 5 years, with key advances and clinical trials highlighted in this review. Several of these changes stem from improvements in systemic therapy, which have led to better systemic control and longer overall patient survival, associated with increased time at risk for developing BM. Development of systemic therapies capable of preventing BM and controlling both intracranial and extracranial disease once BM are diagnosed is paramount. The increase in use of stereotactic radiosurgery alone for many patients with multiple BM is an outgrowth of the desire to employ treatments focused on local control while minimizing cognitive effects associated with whole brain radiotherapy. Complications from BM and their treatment must be considered in comprehensive patient management, especially with greater awareness that the majority of patients do not die from their BM. Being aware of significant heterogeneity in prognosis and therapeutic options for patients with BM is crucial for appropriate management, with greater attention to developing individual patient treatment plans based on predicted outcomes; in this context, recent prognostic models of survival have been extensively revised to incorporate molecular markers unique to different primary cancers.

Keywords: brain metastases; chemotherapy; stereotactic radiosurgery; surgery; whole brain radiation.

Fig. 1.

Diagnosis-specific graded prognostic assessment worksheet to estimate survival from newly diagnosed brain metastases.* Abbreviations: GPA, Graded Prognostic Assessment; KPS, Karnofsky performance status; ECM, extracranial metastases; LumA, luminal A; LumB, luminal B; GI, gastrointestinal. Breast cancer subtype definitions: Basal: triple negative. LumA: estrogen receptor (ER)/progesterone receptor (PR) positive, (HER2) negative. LumB: triple positive. HER2: ER/PR negative, HER2 positive. *Figure reprinted with permission. ©2012 American Society of Clinical Oncology. All rights reserved. Sperduto PW et al: Summary report on the graded prognostic assessment: an accurate and facile diagnosis-specific tool to estimate survival for patients with brain metastases. Journal of Clinical Oncology, 30(4):419–425.