The role of tumor size in the radiosurgical management of patients with ambiguous brain metastases

Current strategies in the surgical management of cerebral metastases: an evidence-based review

Metastatic tumours are the most common form of cerebral neoplasm, occurring in up to 40% of patients with systemic cancer. Although the presence of metastatic disease portends limited survival, aggressive management of cerebral metastases is vital to preventing death from neurological causes and prolonging functional independence. Due to advancement in neurosurgical techniques and the advent of stereotactic radiosurgery as a non-operative alternative, current decision making for selecting the appropriate local treatment often results in clinical equipoise. In addition, the traditional blanket application of whole brain radiation has come under scrutiny as new evidence regarding the deleterious neurocognitive effects of ionizing radiation emerges. The completion of a series of randomized studies comparing the efficacy of surgery, radiosurgery, whole brain radiotherapy and various combined approaches for cerebral metastases in recent years has shed important light on addressing some of these issues. The focus of this review is to summarize the key findings and outline a practical approach for the management of cerebral metastases.

[Brain metastasis from breast cancer: who?, when? and special considerations about the role of technology in neurosurgery]

Questions about both the place and the role of surgery on brain metastasis from breast cancer are arising more and more frequently in practice due to the increase of brain metastasis in patients suffering from a form of cancer recognized as one of the most recurrent cancers in adults but also one of the most sensitive to general treatments of the systemic disease. With improvements in anaesthesia, in surgical instruments, and in global care, neurosurgery has taken advantage of new techniques such as pre- and even per-operative imagery and also neuronavigation. These techniques enable radical and effective surgical intervention with a high level of safety for the patient, making neurosurgery perfectly competitive with other therapeutic modalities, particularly on functional grounds. As for symptomatic treatments or other anti-metastasis treatments, most situations allow a reflection on the global therapeutic strategy which can be adapted to individual cases depending on the patient's general prognosis. In developing this global therapeutic strategy, surgical treatment is still as relevant as ever.

Management of brain metastases: the indispensable role of surgery

Brain metastases are the most common neurological complication of systemic cancer and carry a very poor prognosis. The management of patients with brain metastases has become more important recently because of the increased incidence of these tumors and the prolonged patient survival times that have accompanied increased control of systemic cancer. In this article, we review the current perspectives on surgical treatment of brain metastases in terms of patient selection criteria, intraoperative adjuncts, whole-brain radiation therapy (WBRT) as a postoperative adjuvant, reoperation for tumor recurrence, and resection of multiple and single metastases. Achieving the best outcome in treatment of brain metastasis requires the judicious and complementary use of surgical resection along with modalities such as whole-brain radiation therapy and stereotactic radiosurgery.

Usefulness of contrast-enhanced T1-weighted sampling perfection with application-optimized contrasts by using different flip angle evolutions in detection of small brain metastasis at 3T MR imaging: comparison with magnetization-prepared rapid acquisition of gradient echo imaging

BACKGROUND AND PURPOSE

Early accurate diagnosis of brain metastases is crucial for a patient's prognosis. This study aimed to compare the conspicuity and detectability of small brain metastases between contrast-enhanced 3D fast spin-echo (sampling perfection with application-optimized contrasts by using different flip angle evolutions [SPACE]) and 3D gradient-echo (GE) T1-weighted (magnetization-prepared rapid acquisition of GE [MPRAGE]) images at 3T.

MATERIALS AND METHODS

Sixty-nine consecutive patients with suspected brain metastases were evaluated prospectively by using SPACE and MPRAGE on a 3T MR imaging system. After careful evaluation by 2 experienced neuroradiologists, 92 lesions from 16 patients were selected as brain metastases. We compared the shorter diameter, contrast rate (CR), and contrast-to-noise ratio (CNR) of each lesion. Diagnostic ability was compared by using receiver operating characteristic (ROC) analysis. Ten radiologists (5 neuroradiologists and 5 residents) participated in the reading.

RESULTS

The mean diameter was significantly larger by using SPACE than MPRAGE (mean, 4.5 +/- 3.7 versus 4.3 +/- 3.7 mm, P = .0014). The CR and CNR of SPACE (mean, 57.3 +/- 47.4%, 3.0 +/- 1.9, respectively) were significantly higher than those of MPRAGE (mean, 37.9 +/- 41.2%, 2.6 +/- 2.2; P < .0001, P = .04). The mean area under the ROC curve was significantly larger with SPACE than with MPRAGE (neuroradiologists, 0.99 versus 0.88, P = .013; residents, 0.99 versus 0.78, P = .0001).

CONCLUSIONS

Lesion detectability was significantly higher on SPACE than on MPRAGE, irrespective of the experience of the reader in neuroradiology. SPACE should be a promising diagnostic technique for assessing brain metastases.

Outcome After Radiosurgery for Brain Metastases in Patients With Low Karnofsky Performance Scale (KPS) Scores

PURPOSE

The objective of this retrospective study was evaluation of the outcome after stereotactic radiosurgery (SRS) in patients with intracranial metastases and poor performance status.

METHODS AND MATERIALS

Forty consecutive patients with metastatic brain tumors and Karnofsky performance scale (KPS) scores < or =50 (mean, 43 +/- 8; median, 40) treated with SRS were analyzed. Poor performance status was caused by presence of intracranial metastases in 28 cases (70%) and resulted from uncontrolled extracerebral disease in 12 (30%).

RESULTS

Survival after SRS varied from 3 days to 11.5 months (mean, 3.8 +/- 2.9 months; median, 3.3 months). Survival probability constituted 0.50 +/- 0.07 at 3 months and 0.20 +/- 0.05 at 6 months posttreatment. Cause of low KPS score (p = 0.0173) and presence of distant metastases beside the brain (p = 0.0308) showed statistically significant associations with overall survival in multivariate Cox proportional hazards regression analysis. Median survival was 6.0 months if low KPS score was caused by cerebral disease and distant metastases in regions beyond the brain were absent, 3.3 months if low KPS score was caused by cerebral disease and distant metastases in regions beyond the brain were present, and 1.0 month if poor performance status resulted from extracerebral disease.

CONCLUSIONS

Identification of the cause of low KPS score (cerebral vs. extracerebral) in patients with metastatic brain tumor(s) may be important for prediction of the outcome after radiosurgical treatment. If poor patient performance status without surgical indications is caused by intracranial tumor(s), SRS may be a reasonable treatment option.

Radiobiology of brain metastasis: applications in stereotactic radiosurgery

Stereotactic radiosurgery is a neurosurgical modality in which a target lesion can be irradiated while sparing normal brain tissue. In some respects, brain metastasis is well suited for radiosurgery, as metastatic lesions tend to be small and well circumscribed and displace (but do not infiltrate) normal brain tissue, facilitating the delivery of radiation. Advances in stereotactic radiosurgical planning, such as blocking patterns and beam shaping, have allowed further targeting of discrete lesions while minimizing the effect of radiation toxicity on the central nervous system. In this paper the authors review the radiobiology of brain metastases and stereotactic radiosurgical approaches that can be used to treat these tumors safely.

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.

Contrast-enhanced FLAIR imaging in combination with pre- and postcontrast magnetization transfer T1-weighted imaging: Usefulness in the evaluation of brain metastases

PURPOSE

To assess whether the use of postcontrast fluid-attenuated inversion recovery (FLAIR) imaging in combination with pre- and postcontrast magnetization transfer (MT) T1-weighted imaging (T1WI) can increase diagnostic confidence in the evaluation of brain metastases.

MATERIALS AND METHODS

Brain MR images from 41 patients with suspected brain metastases were reviewed. Two radiologists viewed pre- and postcontrast MT-T1W images for the presence of metastatic tumors and rated the possible enhanced lesions using a five-point confidence scale (session 1). The postcontrast FLAIR images were then viewed together with pre- and postcontrast MT-T1W images, and the presence of metastasis was rated again (session 2).

RESULTS

A total of 240 possible enhanced lesions were detected in session 1. Judging by follow-up MR examinations, 196 were considered to be nonmetastatic findings and 44 were determined to be metastasis. In session 2 the confidence rating for nonmetastasis increased significantly in the subset of nonmetastatic findings (P < 0.001), and the confidence rating for metastasis increased significantly in the subset of metastases (P < 0.05).

CONCLUSION

The addition of postcontrast FLAIR imaging to pre- and postcontrast MT-T1WI improves diagnostic confidence in evaluation of brain metastases.

Functional Magnetic Resonance Imaging Is More Reliable than Somatosensory Evoked Potential or Mapping for the Detection of the Primary Motor Cortex in Proximity to a Tumor

The accurate localization of the primary motor cortex (M1) is critical for the preservation of motor function during resection of brain tumors in and around the M1. The goal of the present study was to determine which technique provided the most accurate localization of M1. The accuracy of preoperative functional magnetic resonance imaging (fMRI), intraoperative somatosensory evoked potential (SEP) and cortical mapping for the localization of M1 was determined in 17 patients with brain tumors in and around the M1. Because localization of the M1 is typically symmetrical in the cerebral hemispheres, the M1 on the affected side was localized by determination of the M1 location on the unaffected side using fMRI with patient hand clenching. The location of M1 was successfully determined by SEP in 5 of 11 cases. In the remainder of cases, the sulcus at which phase reversal occurred during SEP was shifted 1 or 2 gyri rostral to the central sulcus. The location of M1 was successfully determined by brain mapping in 9 of 15 cases. In the remainder of cases, stimulation failed to elicit a motor response. Finally, the location of M1 was successfully determined by fMRI in 16 of 17 cases. These data indicate that fMRI was more reliable than SEP or brain mapping for the detection of M1 in proximity to a tumor.

Optimizing therapy for patients with brain metastases

Brain metastases from systemic cancers are the most common malignant brain tumors encountered. Although prognosis remains poor, it is possible to stratify patients according to risk. Furthermore, an aggressive therapeutic approach for good-risk patients that includes a combination of either surgery or stereotactic radiosurgery (SRS) and whole brain radiation therapy (WBRT) can improve survival and decrease the risk of central nervous system progression.

Nonsmall cell lung cancer presenting with synchronous solitary brain metastasis

BACKGROUND

Solitary brain metastases occur in about 50% of patients with brain metastases from nonsmall cell lung cancer (NSCLC). The standard of care is surgical resection of solitary brain metastases, or stereotactic radiosurgery (SRS) plus whole brain radiation therapy (WBRT). However, the optimal treatment for the primary site of newly diagnosed NSCLC with a solitary brain metastasis is not well defined. The goal was to distinguish which patients might benefit from aggressive treatment of their lung primary in patients whose solitary brain metastasis was treated with surgery or SRS.

METHODS

The cases of 84 newly diagnosed NSCLC patients presenting with a solitary brain metastasis and treated from December 1993 through June 2004 were retrospectively reviewed at The University of Texas M. D. Anderson Cancer Center. All patients had undergone either craniotomy (n = 53) or SRS (n = 31) for management of the solitary brain metastasis. Forty-four patients received treatment of their primary lung cancer using thoracic radiation therapy (median dose 45 Gy; n = 8), chemotherapy (n = 23), or both (n = 13).

RESULTS

The median Karnofsky performance status score was 80 (range, 60-100). Excluding the presence of the brain metastasis, 12 patients had AJCC Stage I primary cancer, 27 had Stage II disease, and 45 had Stage III disease. The median follow-up was 9.7 months (range, 1-86 months). The 1-, 2-, 3-, and 5-year overall survival rates from time of lung cancer diagnosis were 49.8%, 16.3%, 12.7%, and 7.6%, respectively. The median survival times for patients by thoracic stage (I, II, and III) were 25.6, 9.5, and 9.9 months, respectively (P = .006).

CONCLUSIONS

By applying American Joint Committee on Cancer staging to only the primary site, the thoracic Stage I patients in our study with solitary brain metastases had a more favorable outcome than would be expected and was comparable to Stage I NSCLC without brain metastases. Aggressive treatment to the lung may be justified for newly diagnosed thoracic Stage I NSCLC patients with a solitary brain metastasis, but not for locally advanced NSCLC patients with a solitary brain metastasis.

Long-term survivors after gamma knife radiosurgery for brain metastases

BACKGROUND

Stereotactic radiosurgery, with or without whole-brain radiation therapy, has become a valued management choice for patients with brain metastases, although their median survival remains limited. In patients who receive successful extracranial cancer care, patients who have controlled intracranial disease are living longer. The authors evaluated all brain metastasis in patients who lived for > or = 4 years after radiosurgery to determine clinical and treatment patterns potentially responsible for their outcome.

METHODS

Six hundred seventy-seven patients with brain metastases underwent 781 radiosurgery procedures between 1988 and 2000. Data from the entire series were reviewed; and, if patients had > or = 4 years of survival, then they were evaluated for information on brain and extracranial treatment, symptoms, imaging responses, need for further care, and management morbidity. These long-term survivors were compared with a cohort who lived for < 3 months after radiosurgery (n = 100 patients).

RESULTS

Forty-four patients (6.5%) survived for > 4 years after radiosurgery (mean, 69 mos with 16 patients still alive). The mean age at radiosurgery was 53 years (maximum age, 72 yrs), and the median Karnofsky performance score (KPS) was 90. The lung (n = 15 patients), breast (n = 9 patients), kidney (n = 7 patients), and skin (melanoma; n = 6 patients) were the most frequent primary sites. Two or more organ sites outside the brain were involved in 18 patients (41%), the primary tumor plus lymph nodes were involved in 10 patients (23%), only the primary tumor was involved in 9 patients (20%), and only brain disease was involved in 7 patients (16%), indicating that extended survival was possible even in patients with multiorgan disease. Serial imaging of 133 tumors showed that 99 tumors were smaller (74%), 22 tumors were unchanged (17%), and 12 tumors were larger (9%). Four patients had a permanent neurologic deficit after brain tumor management, and six patients underwent a resection after radiosurgery. Compared with the patients who had limited survival (< 3 mos), long-term survivors had a higher initial KPS (P = 0.01), fewer brain metastases (P = 0.04), and less extracranial disease (P < 0.00005).

CONCLUSIONS

Although the expected survival of patients with brain metastases may be limited, selected patients with effective intracranial and extracranial care for malignant disease can have prolonged, good-quality survival. The extent of extracranial disease at the time of radiosurgery was predictive of outcome, but this does not necessarily mean that patients cannot live for years if treatment is effective.

The American Society for Therapeutic Radiology and Oncology (ASTRO) evidence-based review of the role of radiosurgery for brain metastases

PURPOSE

To systematically review the evidence for the use of stereotactic radiosurgery in adult patients with brain metastases.

METHODS

Key clinical questions to be addressed in this evidence-based review were identified. Outcomes considered were overall survival, quality of life or symptom control, brain tumor control or response and toxicity. MEDLINE (1990-2004 June Week 2), CANCERLIT (1990-2003), CINAHL (1990-2004 June Week 2), EMBASE (1990-2004 Week 25), and the Cochrane library (2004 issue 2) databases were searched using OVID. In addition, the Physician Data Query clinical trials database, the proceedings of the American Society of Clinical Oncology (ASCO) (1997-2004), ASTRO (1997-2004), and the European Society of Therapeutic Radiology and Oncology (ESTRO) (1997-2003) were searched. Data from the literature search were reviewed and tabulated. This process included an assessment of the level of evidence.

RESULTS

For patients with newly diagnosed brain metastases, managed with whole-brain radiotherapy alone vs. whole-brain radiotherapy and radiosurgery boost, there were three randomized controlled trials, zero prospective studies, and seven retrospective series (which satisfied inclusion criteria). For patients with up to three (<4 cm) newly diagnosed brain metastases (and in one study up to four brain metastases), radiosurgery boost with whole-brain radiotherapy significantly improves local brain control rates as compared with whole-brain radiotherapy alone (Level I-III evidence). In one large randomized trial, survival benefit with whole-brain radiotherapy was observed in patients with single brain metastasis. In this trial, an overall increased ability to taper down on steroid dose and an improvement in Karnofsky performance status was seen in patients who were treated with radiosurgery boost as compared with patients treated with whole-brain radiotherapy alone. However, Level I evidence regarding overall quality of life outcomes using a validated instrument has not been reported. All randomized trials showed improved local control with the addition of radiosurgery to whole-brain radiotherapy. For patients with multiple brain metastases, there is no overall survival benefit with the use of radiosurgery boost to whole-brain radiotherapy (Level I-III evidence). Radiosurgery boost is associated with a small risk of early or late toxicity. In patients treated with radiosurgery alone (withholding whole-brain radiotherapy) as initial treatment, there were 2 randomized trials, 2 prospective cohort studies, and 16 retrospective series. There is Level I to Level III evidence that the use of radiosurgery alone does not alter survival as compared to the use of whole-brain radiotherapy. However, there is Level I to Level III evidence that omission of whole-brain radiotherapy results in poorer intracranial disease control, both local and distant (defined as remaining brain, outside the radiosurgery field). Quality of life outcomes have not been adequately reported. Radiosurgery is associated with a small risk of early or late toxicity. Radiosurgery as salvage for patients with brain metastases was reported in zero randomized trials, one prospective study, and seven retrospective series.

CONCLUSIONS

Based on Level I-III evidence, for selected patients with small (up to 4 cm) brain metastases (up to three in number and four in one randomized trial), the addition of radiosurgery boost to whole-brain radiotherapy improves brain control as compared with whole-brain radiotherapy alone. In patients with a single brain metastasis, radiosurgery boost with whole-brain radiotherapy improves survival. There is a small risk of toxicity associated with radiosurgery boost as compared with whole-brain radiotherapy alone. In selected patients treated with radiosurgery alone for newly diagnosed brain metastases, overall survival is not altered. However, local and distant brain control is significantly poorer with omission of upfront whole-brain radiotherapy (Level I-III evidence). Whether neurocognition or quality of life outcomes are different between initial radiosurgery alone vs. whole-brain radiotherapy (with or without radiosurgery boost) is unknown, because this has not been adequately tested. There was no statistically significant difference in overall toxicity between those treated with radiosurgery alone vs. whole-brain radiotherapy and radiosurgery boost based on an interim report from one randomized study. There is insufficient evidence as to the clinical benefit/risks radiosurgery used in the setting of recurrent or progressive brain metastases, although radiographic responses are well-documented.

Brain metastasis of unknown primary: A diagnostic and therapeutic dilemma

The diagnosis of a brain metastasis is usually made during the routine follow up examinations of patients with known cancer, who are under the care of oncology departments. The involvement of the neurosurgeon depends on the philosophy and referral patterns of each oncology group. Patients with brain metastases of unknown primary (BMUP) are much more likely to seek the help of a neurosurgeon or a neurologist before contacting an oncologist, because the presenting clinical features originate from the brain. BMUPs are almost equal in numbers to brain primaries and differ from regular cerebral metastases regarding their site of origin, which will remain unknown in about 50% despite vigorous investigation. The clinical picture is similar to that of primary brain tumours but they seem to show different areas of predilection in the brain parenchyma. By reviewing the literature we are presenting the epidemiology, clinical presentation, diagnostic workup and treatment plan for this group of patients.

Selective excision of metastatic brain tumors originating in the motor cortex with preservation of function

PURPOSE

Brain metastases are common in patients with cancer and can cause considerable morbidity or death. Metastasis in eloquent areas of the brain, particularly the primary motor cortex, may present significant treatment challenges.

PATIENTS AND METHODS

Seventeen consecutive patients with metastasis within the primary motor cortex underwent selective microsurgical tumor resection. Operative, hospital, neuroimaging, and follow-up information was reviewed.

RESULTS

There were 10 women and seven men (mean age, 54.3 years) who underwent 17 operations for symptomatic brain metastases. Motor cortex was identified and tumor (mean volume, 10.2 cm(3)) was completely resected in all patients. Three patients had transient or reversible complications. Karnofsky performance scores improved in 16 of 17 patients at 4 weeks postoperatively, with a mean improvement of 1.8 grades compared with preoperative scores (P < .05). Overall survival of 16 patients with distant follow-up (> 6 months or until death) averaged 10.6 +/- 4.4 months, with nine of 16 (56%) assessable patients surviving 1 year or longer. Survival of these 16 patients, by recursive partitioning analysis (RPA), was 11.2, 13.3, and 6.7 months for RPA classes I, II, and III, respectively. The cause of death in 14 of 15 patients who have died was progressive systemic disease; in one patient it was a combination of systemic and distant CNS disease progression. There were no local CNS recurrences.

CONCLUSION

Complete microsurgical resection of metastatic tumors in the primary motor cortex is feasible and efficacious, results in a sustained improvement in performance outcomes, and permits satisfactory long-term survival.

Resection of brain metastases previously treated with stereotactic radiosurgery

Object. To date, no report has been published on outcomes of patients undergoing resection for brain metastases who were previously treated with stereotactic radiosurgery (SRS). Consequently, the authors reviewed their institutional experience with this clinical scenario to assess the efficacy of surgical intervention.

Methods. Sixty-one patients (each harboring three or fewer brain lesions), who were treated at a single institution between June 1993 and August 2002 were identified. Patient charts and their neuroimaging and pathological reports were retrospectively reviewed to determine overall survival rates, surgical complications, and recurrence rates.

A univariate analysis revealed that patient preoperative recursive partitioning analysis (RPA) classification, primary disease status, preoperative Karnofsky Performance Scale score, type of focal treatment undergone for nonindex lesions, and major postoperative surgical complications were factors that significantly affected survival (p ≤ 0.05). In contrast, only the RPA class and focal (conventional surgery or SRS) treatment of nonindex lesions significantly (or nearly significantly) affected survival in the multivariate analysis. Major neurological complications occurred in only 2% of patients. The median time to distant recurrence after resection was 8.4 months; that to local recurrence was not reached. The overall median survival time was 11.1 months, with 25% of patients surviving 2 or more years. Conventional surgery facilitated tapering of steroid administration.

Conclusions. The complication, morbidity, survival, and recurrence rates are consistent with those seen after conventional surgery for recurrent brain metastases. Our results indicate that in selected patients with a favorable RPA class in whom nonindex lesions are treated with focal modalities, surgery can provide long-term control of SRS-treated lesions and positively affect overall survival.

Stereotactic radiosurgical treatment in 103 patients for 153 cerebral melanoma metastases

PURPOSE

To report on the outcome of patients with melanoma brain metastases treated with stereotactic radiosurgery (SRS).

PATIENTS AND METHODS

One hundred three patients with 153 intracranial melanoma metastases consecutively underwent Linac-based SRS between November 1991 and October 2001. The Kaplan-Meier method, univariate comparisons with log-rank test, and multivariate analyses with classification and regression tree models were performed. Calculations were based on last imaging date rather than the date of the last visit.

RESULTS

Median age was 51 years (range, 18-93 years). Median Karnofsky performance status was 90. Sixty-one patients (59%) had single brain metastasis at presentation. Treatment sequence was SRS alone (61 patients), SRS + whole-brain radiotherapy (WBRT) (12 patients), and salvage SRS after WBRT (30 patients). The median tumor volume was 1.9 cm(3) (range, 0.06-22.3 cm(3)). The median SRS minimum peripheral dose and isodose was 18 Gy (range, 10-24 Gy) and 85% (range, 60%-100%), respectively. The median follow-up was 6 months for all patients and 13 months (range, 2-46 months) for patients alive at the time of analysis. The 1-year local control (LC) for all patients treated with SRS was 49%. Among the patients treated with initial SRS alone, the 1-year LC was better for patients with tumors < or =2 cm(3) than with tumors >2 cm(3): 75.2% vs. 42.3% (p < 0.05). The 1-year distant brain metastasis-free survival incidence was 14.7% for the 73 patients receiving either initial SRS alone or SRS +WBRT. The initial number of brain lesions (single vs. multiple) was the only factor with a significant effect on distant brain metastasis-free survival at 1 year: 23.5% for single metastases and 0% for multiple lesions (p < 0.05). The 1-year overall survival was 25.2%. Stratification by Score Index for Radiosurgery (SIR) revealed a significant effect on survival, which was 29% at 1 year for SIR >6 and 10% for SIR <==6 (relative hazard ratio, 2.1; p < 0.05) in classification and regression-tree multivariate analysis involving age, Karnofsky performance status, primary tumor control, tumor volume, SRS dose, SIR (>6 vs. < or =6), and systemic disease status.

CONCLUSIONS

Initial SRS alone was an effective treatment modality for smaller cerebral melanoma metastases, achieving a 75% incidence of 1-year LC for < or =2 cm(3) single brain metastases and should be considered in patients with SIR >6. The role of WBRT in melanoma brain metastases cannot be addressed, owing to retrospective bias toward administering this treatment to patients with more aggressive disease. A prospective study is needed to assess the role of WBRT in patients with melanoma brain metastasis.

Brain metastases

Despite advances in the treatment of cancer, brain metastases appear to be increasing in frequency and are associated with a poor prognosis. Type of tumor, age, performance status, and extent of systemic disease are important prognostic factors that should be taken into consideration when making treatment decisions. Patients with a good performance status and controlled systemic disease may benefit from aggressive focal therapies (surgery or radiosurgery). Whole brain radiotherapy seems to increase local control but is associated with the risk of delayed cognitive deterioration in long-term survivors. In spite of this, whole brain radiotherapy remains the standard of care for those patients with poorer prognosis and for the treatment of recurrence after focal therapy. Chemotherapy has a limited role in the treatment of brain metastases but should be considered in selected patient populations.

Diagnosis and management of central nervous system metastases from breast cancer

The brain, cranial nerves, leptomeninges, spinal cord, and eye compose the central nervous system (CNS) and are at risk for the development of metastases from breast cancer. Such metastases are diagnosed on the basis of clinical suspicion and substantiated by neuroimaging, resection when indicated, and sampling of cerebrospinal fluid when leptomeningeal metastasis (LM) is suspected. Treatment is aimed at palliation of symptoms and preservation of neurologic function. Historically, conventional radiation therapy has been the mainstay of palliative treatment for brain, cranial nerve, spinal cord, and ocular metastases. However, additional treatment options for brain metastases have been brought about by technological advances in surgery to resect brain metastases, and stereotactic radiosurgery (SRS) to focally irradiate metastases, both of which have been substantiated by data from randomized trials. Ongoing research is aimed at refining criteria to select which patients with brain metastases should undergo surgery and SRS and how these focal therapies should be optimally integrated with whole-brain radiotherapy. Therapy for LM must carefully balance the potential risks and perceived benefits associated with CNS-directed therapies. Despite advances in neuroimaging, surgery, and radiation therapy, novel treatments are needed to improve the effectiveness of treatments for CNS metastases, especially LM, while reducing attendant neurotoxicity.

Surgical resection of metastatic intraventricular tumors

The ventricle is a rare site of brain metastases. Renal cell carcinoma has a higher propensity to metastasize to the ventricle compared with more common metastatic tumors (e.g., lung cancer). The trigone is the predominant location for intraventricular metastases, presumably because of the high concentration of choroid plexus in this region. Surgical resection is an important component of the management of these lesions, particularly if there is only a single intraventricular lesion. Despite the deep location of these tumors within the ventricle, survival in patients undergoing surgery for them is comparable to that in patients receiving surgery for intraparenchymal metastases.