Resectable brain metastases

Skull destruction from intracranial metastasis arising from pulmonary squamous cell carcinoma: a case report

Introduction

Squamous cell carcinoma of the lung represents 30% of all non-small cell lung carcinomas. It arises from dysplasia of squamous epithelium of the bronchi and is strongly associated with cigarette smoking. Squamous cell carcinoma of the lung is known to produce metastases in the brain parenchyma.

Case presentation

We present the case of an 80-year-old indigenous Australian man with an unusual presentation of metastatic carcinoma of the lung. The case demonstrated a squamous cell carcinoma of the lung with an intracranial metastatic lesion destroying the parietal bone and extending into the extracranial soft tissue. A visible deformity as a result of the metastasis was evident on physical examination and computed tomography demonstrated extensive bone destruction.

Conclusion

The authors were unable to find a case of this occurring from a squamous cell carcinoma of the lung anywhere in the world literature. The case report demonstrates an unusual disease presentation with a rare intracranial metastasis invading through the skull.

Current advances in understanding and managing secondary brain metastasis

Metastatic brain tumors are the number one cause of intracranial neoplasms in adults and are associated with higher morbidity and mortality. The frequency of metastatic brain tumors is increasing because of improved survival in cancer patients. The molecular mechanism of brain metastasis is complex and not completely known. Vasogenic edema produced by tumor-derived VEGF is responsible for clinical symptoms. Dexamethasone remains the mainstay of medical management with not completely known mechanisms of action. Surgery and radiation are the main treatment modalities for metastatic brain tumors. Systemic chemotherapy has a very limited role in treatment of these tumors. Leptomeningeal metastasis is associated with extremely poor outcome.

Brain metastases from colorectal cancer: the role of surgical resection in selected patients

AIM

Brain metastasis is infrequent in colorectal cancer patients, and the prognosis is poor. In this retrospective study survival and prognostic factors were determined in patients with brain metastasis from colorectal cancer.

METHOD

Between 1997 and 2006, 39 patients with brain metastasis from colorectal cancer who survived more than 1 month were identified. Data were collected with regard to patient characteristics, location and stage of the primary tumour, extent and location of metastatic disease, and treatment modalities used.

RESULTS

Most (79.5%) patients had pulmonary metastases before brain metastasis, and the brain was the site of solitary metastasis in only one patient. The most frequent symptom was weakness [18 (43.6%) patients]. Overall median survival was 5.0 months and the 1- and 2-year survival rates were 21.8 and 9.1%, respectively. Univariate analysis revealed uncontrolled extracranial metastases (P = 0.019), multiple brain lesions (P = 0.026), bilateral brain metastases (P = 0.032) and serum carcinoembryonic antigen levels greater than 5 ng/ml (P = 0.008) to be poor prognostic factors. The median survival after the diagnosis of brain metastasis was significantly longer in patients who underwent surgical resection (15.2 ± 8.0 months) than in those treated by other modalities (P = 0.001). Treatment modality was the only independent prognostic factor for overall survival in patients with brain metastases from colorectal cancers (P = 0.015).

CONCLUSION

Aggressive surgical resection in selected patients with brain metastases from colorectal cancer may prolong survival, even in the presence of extracranial metastatic lesions.

Therapeutic approaches for HER2-positive brain metastases: circumventing the blood-brain barrier

We aim to summarize data from studies of trastuzumab in patients with human epidermal growth factor receptor 2 (HER2)-positive metastatic breast cancer (MBC) and brain metastasis and to describe novel methods being developed to circumvent the blood-brain barrier (BBB). A literature search was conducted to obtain data on the clinical efficacy of trastuzumab and lapatinib in patients with HER2-positive MBC and brain metastasis, as well as the transport of therapeutic molecules across the BBB. Trastuzumab-based therapy is the standard of care for patients with HER2-positive MBC. Post hoc and retrospective analyses show that trastuzumab significantly prolongs overall survival when given after the diagnosis of central nervous system (CNS) metastasis; this is probably attributable to its control of extracranial disease, although trastuzumab may have a direct effect on CNS disease in patients with local or general perturbation of the BBB. In patients without a compromised BBB, trastuzumab is thought to have limited access to the brain, because of its relatively large molecular size. Several approaches are being developed to enhance the delivery of therapeutic agents to the brain. These include physical or pharmacologic disruption of the BBB, direct intracerebral drug delivery, drug manipulation, and coupling drugs to transport vectors. Available data suggest that trastuzumab extends survival in patients with HER2-positive MBC and brain metastasis. Novel methods for delivery of therapeutic agents into the brain could be used in the future to enhance access to the CNS by trastuzumab, thereby improving its efficacy in this setting.

Prediction of outcomes for patients with brain parenchymal metastases from breast cancer (BC): a new BC-specific prognostic model and a nomogram

The purpose of this study is to validate the recently published Breast-Graded Prognostic Assessment (GPA) and propose a new prognostic model and nomogram for patients with brain parenchymal metastases (BM) from breast cancer (BC). We retrospectively investigated 171 consecutive patients who received a diagnosis of BM from BC during 2000-2008. We appraised the recently proposed Sperduto's BC-specific GPA in training cohort through Kaplan-Meier survival curve using log-rank test and area under the curve for the BC-GPA predicting overall survival at 1 year and developed a new nomogram to predict outcomes using multivariate Cox-regression analysis. By putting the Sperduto's Breast-GPA together with our nomogram, we developed a new prognostic model. We validated our new prognostic model with an independent external patient cohort from 2 institutes for the same period. On the basis of our Cox-regression analysis, therapeutic effect of trastuzumab and status of extracranial systemic disease control were incorporated into our new prognostic model in addition to Karnofsky performance status, age, and hormonal status. Our new prognostic model showed significant discrimination in median survival time, with 3.7 months for class I (n = 15), 7.8 months for class II (n = 82), 10.7 months for class III (n = 42), and 19.2 months for class IV (n = 32; P < .0001). The new prognostic model accurately predicted survival among patients with BC from BM in an external validation cohort (P < .0001). We propose a new prognostic model and a nomogram reflecting the different biological features of BC, including treatment effect and status of extracranial disease control, which was excellently validated in an independent external cohort.

Radiation therapy for cutaneous melanoma

Radiation therapy is used infrequently for cutaneous melanoma, despite research suggesting benefit in certain clinical scenarios. This review presents data forming the highest level of evidence supporting the use of radiation therapy. Retrospective and prospective studies demonstrate radiation therapy for primary tumors is associated with high control rates. Two randomized trials have found improvements in regional control with adjuvant radiotherapy to regional lymphatics. Retrospective and prospective studies demonstrate radiation therapy is associated with palliative response and metastatic tumor control. Optimal care of melanoma patients involves radiation therapy; awareness of this is incumbent of clinicians caring for patients with this disease.

Resection plus whole-brain irradiation versus resection plus whole-brain irradiation plus boost for the treatment of single brain metastasis

BACKGROUND

The optimal treatment for patients with a single brain metastasis is controversial. This study investigated the value of a radiation boost given in addition to neurosurgerical resection and whole-brain irradiation (WBI).

PATIENTS AND METHODS

In this retrospective study, outcome data of 105 patients with a single brain metastasis receiving metastatic surgery plus WBI (S + WBI) were compared to 90 patients receiving the same treatment plus a boost to the metastatic site (S + WBI + B). The outcomes that were compared included local control of the resected metastasis (LC) and overall survival (OS). In addition to the treatment regimen, eight potential prognostic factors were evaluated including age, gender, performance status, extent of metastatic resection, primary tumor type, extracerebral metastases, recursive partitioning analysis (RPA) class, and interval from first diagnosis of cancer to metastatic surgery.

RESULTS

The LC rates at 1 year, 2 years, and 3 years were 38%, 20%, and 9%, respectively, after S + WBI, and 67%, 51%, and 33%, respectively, after S + WBI + B (p = 0.002). The OS rates at 1 year, 2 years, and 3 years were 52%, 25%, and 19%, respectively, after S + WBI, and 60%, 40%, and 26%, respectively, after S + WBI + B (p = 0.11). On multivariate analyses, improved LC was significantly associated with OP + WBI + B (p = 0.006) and total resection of the metastasis (p = 0.014). Improved OS was significantly associated with age ≤ 60 years (p = 0.028), Karnofsky Performance Score > 70 (p = 0.015), breast cancer (p = 0.041), RPA class 1 (p = 0.012), and almost with the absence of extracerebral metastases (p = 0.05).

CONCLUSION

A boost in addition to WBI significantly improved LC but not OS following resection of a single brain metastasis.

[Radiotherapy of singular brain metastases]

Single cerebral metastases in malignant disease pose a particular therapeutic challenge. The options consist of surgical resection, stereotactic radiation, and total brain irradiation. No significant therapeutic advantage for any of these methods has as yet been demonstrated in the literature. We present the case of a young patient with a single brain metastasis of a sigmoidal carcinoma, in stable general condition. We present our therapeutic regimen and discuss the various pros and cons of the different therapies.

Treatment of brain metastases in patients with HER2+ breast cancer

Brain metastases are a frequent complication of cancer. However, effective treatments are available. This article aims to review clinical aspects of patients with brain metastases discussing the various treatment options for such patients. It will address the importance and significance of brain metastases in patients with breast cancer and, finally, review the problem of brain metastasis associated with human epidermal growth factor receptor 2-positive (HER2+) breast cancer. With ever-improving survival rates of patients with cancer, there is a greater likelihood that many will develop brain metastases. Treatments such as whole brain or stereotactic radiotherapy and surgery have been shown to be effective against brain metastases. In HER2+ breast cancer, trastuzumab has been shown to be very effective, although it cannot cross the blood-brain barrier. If patients with breast cancer who are being treated with trastuzumab and are responding systemically, develop brain metastases, then patient prognosis does need to be taken into account; however, maintaining treatment with trastuzumab while using available therapies to treat intracranial lesions should be considered as an option.

Brain metastases: current management and new developments

PURPOSE OF REVIEW

To review the state-of-the-art and new developments in the management of patients with brain metastases.

RECENT FINDINGS

Treatment decisions are based on prognostic factors to maximize neurologic function and survival, while avoiding unnecessary therapies. Whole-brain radiotherapy (WBRT) is the treatment of choice for patients with unfavorable prognostic factors. Stereotactic radiosurgery (SRS) or surgery is indicated for patients with favorable prognostic factors and limited brain disease. In single brain metastasis, the addition of either stereotactic radiosurgery or surgery to WBRT improves survival. The omission of WBRT after surgery or radiosurgery results in a worse local and distant control, though it does not affect survival. The incidence of neurocognitive deficits in long-term survivors after WBRT remains to be defined. New approaches to avoid cognitive deficits following WBRT are being investigated. The role of chemotherapy is limited. Molecularly targeted therapies are increasingly employed. Prophylaxis with WBRT is the standard in small-cell lung cancer.

SUMMARY

Many questions need future trials: the usefulness of new radiosensitizers; the role of local treatments after surgery; and the impact of molecularly targeted therapies on subgroups of patients with specific molecular profiles. Quality of life and cognitive functions are recognized as major endpoints in clinical trials.

A matched-pair analysis comparing whole-brain radiotherapy plus stereotactic radiosurgery versus surgery plus whole-brain radiotherapy and a boost to the metastatic site for one or two brain metastases

PURPOSE

To compare the results of whole-brain radiotherapy plus stereotactic radiosurgery (WBRT+SRS) with those of surgery plus whole-brain radiotherapy and a boost to the metastatic site (OP+WBRT+boost) for patients with one or two brain metastases.

METHODS AND MATERIALS

Survival, intracerebral control, and local control of the treated metastases were retrospectively evaluated. To reduce the risk of selection bias, a matched-pair analysis was performed. The outcomes of 47 patients who received WBRT+SRS were compared with those of a second cohort of 47 patients who recieved OP+WBRT+boost. The two treatment groups were matched for the following potential prognostic factors: WBRT schedule, age, gender, performance status, tumor type, number of brain metastases, extracerebral metastases, recursive partitioning analysis class, and interval from tumor diagnosis to WBRT.

RESULTS

The 1-year survival rates were 65% after WBRT+SRS and 63% after OP+WBRT+boost (p = 0.19). The 1-year intracerebral control rates were 70% and 78% (p = 0.39), respectively. The 1-year local control rates were 84% and 83% (p = 0.87), respectively. On multivariate analyses, improved survival was significantly associated with better performance status (p = 0.009), no extracerebral metastases (p = 0.004), recursive partitioning analysis Class 1 (p = 0.004), and interval from tumor diagnosis to WBRT (p = 0.001). Intracerebral control was not significantly associated with any of the potential prognostic factors. Improved local control was significantly associated with no extracerebral metastases (p = 0.037).

CONCLUSIONS

Treatment outcomes were not significantly different after WBRT+SRS compared with OP+WBRT+boost. However, WBRT+SRS is less invasive than OP+WBRT+boost and may be preferable for patients with one or two brain metastases. The results should be confirmed by randomized trials.

Non-small cell lung cancer and silent brain metastasis. Survival and prognostic factors

The detection of silent brain metastasis is becoming increasingly common in patients with non-small cell lung cancer (NSCLC). The aim of this study was to evaluate clinical course, prognostic significance, and treatment efficacy in patients with asymptomatic brain metastasis. A retrospective study of patients with cytologically and histologically diagnosed NSCLC and brain metastasis detected by cranial computed tomography or magnetic resonance imaging was performed. We compared 12 neurologically asymptomatic patients to 69 symptomatic patients and analyzed overall survival, clinical course, and prognostic factors (age, sex, performance status, histologic type, TNM stage, number and size of brain metastases, clinical neurologic status, and treatment of primary tumor and brain metastasis). The strongest favorable prognostic factor was active treatment of both the primary tumor (surgery, chemotherapy and/or thoracic radiotherapy) and brain metastasis (neurosurgery and/or whole brain radiotherapy). Neurologically asymptomatic patients had significantly longer survival times than did symptomatic patients (median survival of 7.5 and 4 months, respectively). Control of clinical neurologic status during follow-up was achieved in a greater proportion of asymptomatic patients (80%) than symptomatic patients (40%). We conclude that it is important to detect brain metastasis in patients with NSCLC before neurologic signs or symptoms develop, as early detection improves prognosis and provides patients with the opportunity of receiving timely and more effective treatment.

[Current management of brain metastases]

INTRODUCTION

Cerebral metastases occur in 15 to 20% of cancers and their incidence is increasing. The majority occur at an advanced stage of the disease, but metastasis may be the inaugural sign of cancer. The aim of treatments, which are often palliative, is to preserve the neurological status of the patient with the best quality of life.

STATE OF ART

Corticosteroids are widely used for symptomatic palliation, requiring close monitoring and regular dose adaptation. Antiepileptic drugs should be given only for patients who have had a seizure. In case of multiple cerebral metastases occurring at an advanced stage of the disease, whole brain radiation is the most effective therapy for rapid symptom control. However, radiotherapy moderately improves overall survival, which often depends on the progression of disseminated systemic disease. On the contrary, surgery is indicated in case of a solitary metastasis, particularly when the patient is young (less than 65 years), with good general status (Karnofsky greater than 70), and when the systemic disease is under control. Radiosurgery offers an attractive alternative for these patients with good prognostic factors and a small number of cerebral metastases (< or = 4).

PERSPECTIVES

Chemotherapy, considered in the past as not effective, is taking on a more important place in patients with multiple nonthreatening metastases from chemosensitive cancers (breast, testes...). Radiosurgery and whole brain radiotherapy are complementary techniques. Their respective role in the management of multiple metastases (< 4) remains to be further investigated.

CONCLUSIONS

Therapeutic options are increasingly effective to improve the functional prognosis of patients with cerebral metastases. Ideally, a multidisciplinary assessment offers the best choice of therapeutic modalities.

Current therapeutic options for breast cancer central nervous system metastases

OPINION STATEMENT

Breast cancer metastases to the central nervous system (CNS) has devastating consequences for the individual. As treatment options for metastatic breast cancer expand and as quality of life and overall survival improve, researchers are targeting potential treatments for this sanctuary site. Attention is now being focused on defining the phenotype of breast cancer that has a propensity to metastasize to the CNS. Specific therapies that penetrate the blood brain barrier as well as adjuvant therapies that decrease recurrence in the CNS are currently being investigated. We will review current approaches to the diagnosis, evaluation, and treatment of CNS metastases in breast cancer patients.

[Silent brain metastasis in the initial staging of lung cancer: evaluation by computed tomography and magnetic resonance imaging]

OBJECTIVE

Brain metastases are common in patients with lung cancer and influence both prognosis and treatment decisions. The aim of this study was to evaluate the incidence of silent brain metastasis during the initial staging of lung cancer using cranial computed tomography (CT) and magnetic resonance imaging (MRI).

PATIENTS AND METHODS

We performed a retrospective analysis of lung cancer patients with no neurologic signs or symptoms who were evaluated by cranial CT, MRI, or both at the time of diagnosis. Results were checked using data obtained during systematic monitoring of progression. The incidence of brain metastasis was analyzed by sex, age, histology, and TNM stage.

RESULTS

Silent brain metastasis was detected in 8.3% of the 169 patients with lung cancer. The detection rate was 7.9% in the cranial CT group and 11.3% in the cranial MRI group. The percentage of false positives and false negatives was 0% and 1.9%, respectively. Cranial MRI performed better than CT in detecting multiple brain metastases (72.8% vs 50%) and metastases smaller than 1 cm (36.3% vs 16.7%). The incidence of brain metastasis was lower in patients aged over 70 years and higher in patients with adenocarcinoma (20% compared to 5.3% to 5.9% for other histologic subtypes, P=.01). No association was found with TNM stage.

CONCLUSIONS

The incidence of silent brain metastasis is high in patients under 70 years of age, particularly in patients with adenocarcinomas, even in initial stages. This should be taken into consideration when planning staging procedures. Cranial MRI seems to be more accurate than cranial CT for detecting multiple metastases and small metastases.

A boost in addition to whole-brain radiotherapy improves patient outcome after resection of 1 or 2 brain metastases in recursive partitioning analysis class 1 and 2 patients

BACKGROUND

The current study was conducted to compare 2 treatment regimens including surgical resection and whole-brain radiotherapy (WBRT) for patients with 1 to 2 brain metastases.

METHODS

A total of 201 patients with recursive partitioning analysis (RPA) class 1 to 2 disease with 1 to 2 resectable brain metastases were analyzed retrospectively. Patients underwent either resection of the metastases plus WBRT with 10 fractions of 3 grays (Gy) each or 20 fractions of 2 Gy each (99 patients; Group A) or the same treatment plus a WBRT boost to the metastatic site (10 fractions of 3 Gy each plus 5 fractions of 3 Gy each or 20 fractions of 2 Gy each plus 5 fractions of 2 Gy each) (102 patients; Group B). Eight other potential prognostic factors were evaluated with regard to overall survival (OS), brain control (BC), and local control of resected metastases (LC): age, gender, Karnofsky performance status, extent of surgical resection, tumor type, extracranial metastases, RPA class, and interval from tumor diagnosis to WBRT.

RESULTS

Group B patients had better 1-year OS (66% vs 41%; P < .001). On multivariate analysis of OS, treatment regimen (relative risk [RR] of 1.94; P < .001), extent of surgical resection (RR of 1.80; P = .001), and interval from tumor diagnosis to WBRT (RR of 1.62; P = .010) were found to be statistically significant. On multivariate analysis of BC, treatment regimen (RR of 2.15; P = .002), extent of surgical resection (RR of 2.78; P < .001), and interval from tumor diagnosis to WBRT (RR of 1.52; P = .034) were found to be statistically significant. On multivariate analysis of LC, treatment regimen (RR of 2.31; P = .002) and extent of surgical resection (RR of 3.79; P < .001) were found to be statistically significant. On RPA class subgroup analyses, outcome was found to be significantly better with a WBRT boost in both RPA class 1 and class 2 patients. A WBRT boost resulted in better outcome after both complete and incomplete surgical resection. However, the results concerning BC and LC were not found to be statistically significant if surgical resection was incomplete.

CONCLUSIONS

After surgical resection of 1 to 2 brain metastases, a boost of 10 to 15 Gy in addition to WBRT was found to improve outcome. After incomplete surgical resection, further dose escalation to the metastatic site may be considered.

Temozolomide and radiation in low-grade and anaplastic gliomas: temoradiation

Recently completed trials suggest the addition of nitrosourea-based chemotherapy to radiotherapy increases the progression-free but not overall survival of grade II and III gliomas. Temozolomide has proven benefit in grade II/III gliomas progressive following standard therapy and when added to radiation for glioblastoma. Newly launched and planned phase III trials will explore whether the addition of temozolomide to radiotherapy improves overall survival in grade II/III as well as the prognostic and predictive value of 1p/19q analyses and MGMT promotor methylation status. Additionally, they will measure cognition and quality of life to determine if improvements in time to progression translate into better functional status and patient satisfaction.

Stereotactic radiosurgery alone versus resection plus whole-brain radiotherapy for 1 or 2 brain metastases in recursive partitioning analysis class 1 and 2 patients

BACKGROUND

The objective of this study was to compare stereotactic radiosurgery (SRS) alone with resection plus whole-brain radiotherapy (WBRT) for the treatment of patients in recursive partitioning analysis (RPA) class 1 and 2 who had 1 or 2 brain metastases.

METHODS

Two hundred six patients in RPA class 1 and 2 who had 1 or 2 brain metastases were analyzed retrospectively. Patients in Group A (n = 94) received from 18 grays (Gy) to 25 Gy SRS, and patients in Group B (n = 112) underwent resection of their metastases and received 10 x 3 Gy/20 x 2 Gy WBRT. Eight other potential prognostic factors were evaluated regarding overall survival (OS), brain control (BC), and local control (LC) of treated metastases: age, sex, performance status, tumor type, number of brain metastases, extracranial metastases, RPA class, and interval from tumor diagnosis to treatment of brain metastases.

RESULTS

A comparison of the 2 treatment groups did not reveal significantly different OS (P = .19), BC (P = .52), or LC (P = .25). In RPA subgroup analyses, outcome also did not differ significantly for either RPA class of patients (P values from .21 to .83). On multivariate analysis, improved OS was associated with age < or =60 years (relative risk [RR], 1.75; P = .002), better performance status (RR, 1.67; P = .015), no extracranial metastases (RR, 2.84; P < .001), interval from tumor diagnosis to treatment >12 months (RR, 1.70; P = .003), and RPA class 1 (RR, 1.51; P = .016). Improved BC was associated with a single metastasis (RR, 1.54; P = .034) and an interval from tumor diagnosis to treatment >12 months (RR, 1.58; P = .019), and improved LC was associated with an interval from tumor diagnosis to treatment >12 months (RR, 1.59; P = .047).

CONCLUSIONS

SRS alone appeared to be as effective as resection plus WBRT in the treatment of 1 or 2 brain metastases for patients in RPA class 1 and 2. Patient outcomes were associated with age, Karnofsky performance status, number of brain metastases, extracranial metastases, RPA class, and interval from tumor diagnosis to treatment.

Surgical management of brain metastases

Metastatic brain tumors continue to increase in incidence as patients with cancer live longer. The options for management continue to evolve as well, with advances in radiation-based treatment, chemotherapy, and surgery. Although metastatic brain tumors are frequently treated without surgical intervention, there continues to be a significant role for surgery in caring for patients with these lesions. Study data have proven that surgery has a positive effect on survival and quality of life in properly selected patients. Those with a suitable age, functional status, systemic disease control, and several metastases may be suitable for surgical treatment. Advances in preoperative imaging and planning as well as intraoperative surgical adjuncts have lowered the morbidity associated with resection. With proper patient selection and operative and postoperative management, resection continues to play a significant and evolving role in the care of patients with metastatic brain tumor.

Stereotactic radiosurgery in the management of brain metastasis

Metastatic disease to the brain occurs in a significant percentage of patients with cancer and can limit survival and worsen quality of life. Glucocorticoids and whole-brain radiation therapy (WBRT) have been the mainstay of intracranial treatments, while craniotomy for tumor resection has been the standard local therapy. In the last few years however, stereotactic radiosurgery (SRS) has emerged as an alternative form of local therapy. Studies completed over the past decade have helped to define the role of SRS. The authors review the evolution of the techniques used and the indications for SRS use to treat brain metastases. Stereotactic radiosurgery, compared with craniotomy, is a powerful local treatment modality especially useful for small, multiple, and deep metastases, and it is usually combined with WBRT for better regional control.

Update in the treatment of brain metastases from lung cancer

Brain metastases from lung cancer represent a prevalent and challenging clinical dilemma. The brain is an extremely common site of failure for non-small-cell lung cancer and small-cell lung cancer, often as a solitary site of disease. Despite steady research developments during recent years, survival rates remain poor. Some research suggests that the outcomes and characteristics of brain metastases that result from lung cancer primary sites are perhaps different than those from other primary sites. Clinical treatment strategies should therefore be adjusted accordingly. This article reviews the clinical characteristics, prognostic factors, and treatment strategies of brain metastases from lung cancer with a particular emphasis on recent research developments in the field.

La radiothérapie des métastases cérébrales

Brain metastases are an important cause of mortality and morbidity. The prognosis is poor with a median survival of less than one year in the majority of cases. From this review, whole-brain irradiation clearly appears as the standard treatment. However, its role could be discussed according to newer treatment modalities, radiosurgery or new chemotherapies. Post irradiation neurocognitive status remains insufficiently known.

RPA classification has prognostic significance for surgically resected single brain metastasis

PURPOSE

To retrospectively evaluate prognostic factors that correlate with overall survival among patients with a surgically resected single brain metastasis.

METHODS AND MATERIALS

An Institutional Review Board-approved database of the Cleveland Clinic Brain Tumor Institute was queried for patients with a single brain metastasis treated by surgical resection between February 1984 and January 2004. The primary endpoint was overall survival from the date of surgery by the Kaplan-Meier method.

RESULTS

A total of 271 patients were included. Statistically significant variables for improved survival on multivariate analysis included age <65 years, lack of extracranial metastases, control of primary tumor, histology (non-small-cell lung carcinoma), and use of stereotactic radiosurgery. The median survival for all patients was 10.2 months. Survival of patients in recursive partitioning analysis (RPA) class 1 was better (21.4 months) than those in RPA class 2 (9.0 months, p < 0.001), RPA class 3 (8.9 months, p = 0.15), or the combined group of RPA classes 2 and 3 (9.0 months, p < 0.001). Patients had a median survival of 10.6 months after documented gross total resection and 8.7 months after subtotal resection, which approached statistical significance (p = 0.07). Those who were treated with stereotactic radiosurgery had a median survival of 17.1 months, which was greater than patients who were not treated with stereotactic radiosurgery (8.9 months, p = 0.006).

CONCLUSIONS

This analysis supports the prognostic significance of the RPA classification in patients with a single brain metastasis who undergo surgical resection and adjuvant therapy. RPA class 1 patients have a very favorable prognosis with a median survival of 21.4 months.

Therapeutic management of metastatic brain tumors

Whole brain radiation therapy (WBRT) for patients with brain metastases provides increased local control, locoregional control, and median survival over supportive care or steroids alone. In addition, effective palliative relief is realized in the majority of patients. Despite this, median survival with WBRT alone remains fixed at a relatively unfortunate 4-6 months as demonstrated in prospective randomized controlled trials. Key issues in the therapeutic management of brain metastases include techniques to optimize the multimodal application of WBRT in conjunction with surgery, radiosurgery, chemotherapy, and radiosensitizers. Efforts to incorporate these approaches to improve survival are currently under active investigation.