Multidisciplinary patient-centered management of brain metastases and future directions

Abstract

The incidence of brain metastasis is increasing as improvements in systemic therapy lead to increased survival. This provides new and challenging clinical decisions for patients who are trying to balance the risk of recurrence or progression with treatment-related side effects, and it requires appropriate management strategies from multidisciplinary teams. Improvements in prognostic assessment and systemic therapy with increasing activity in the brain allow for individualized care to better guide the use of local therapies and/or systemic therapy. Here, we review the current landscape of brain-directed therapy for the treatment of brain metastasis in the context of recent improved systemic treatment options. We also discuss emerging treatment strategies including targeted therapies for patients with actionable mutations, immunotherapy, modern whole-brain radiation therapy, radiosurgery, surgery, and clinical trials.

Keywords: brain metastasis; radiosurgery; surgery; systemic therapy; treatment overview.

Figure 1.

Modern precision management of patients with brain metastases based on expert consensus. *Is meant to reference the lower right box & close observation q6-8 week MRI

Figure 2.

An example of a patient treated using single-isocenter multitarget radiosurgery for 30 brain lesions. The total volume of brain tumor (GTV total) is 4.7 cc. A 2–3 mm planning target volume (PTV) was used with 24 Gy prescribed to the PTV total and 27 Gy to the gross tumor volume total in 3 fractions. Treatment delivered with 5 volumetric modulated arc therapy arcs.

Figure 3.

(A) Sagittal MRI demonstrating the anatomy of the medial temporal lobe structures: the amygdala (red), hippocampus (green), parahippocampal cortex (purple), perirhinal cortex (yellow), and the entorhinal cortex (orange). (B) Coronal MRI demonstrating the fornix (light blue), hypothalamus (light pink), and mammary bodies (dark blue).

Figure 4.

Postoperative cavity radiosurgery contouring guidelines. The complete contouring guideline may be found in the supplementary material and is also found along with the CTSU website materials for the Alliance trial A071801.