Should cerebral metastases be treated by chemotherapy alone?

[Brain metastases and chemotherapy]

INTRODUCTION

The epidemiology of brain or central nervous system metastases is poorly documented. Retrospective studies based on autopsies that were aimed at investigating the incidence and prevalence of brain metastases have revealed the shortfalls in tumour registers. The exact role of cerebral metastases has not been addressed within the scope of cancer considered as a public health issue.

CURRENT KNOWLEDGE AND KEY POINTS

The prognosis of brain metastases should not be considered either on general or a priori basis as being poorer than that of other metastatic sites. Evaluation of the role of focal radiation therapy and chemotherapy is still in progress. Appropriate use of therapeutical strategies directed at brain tumors generally improves the condition of most patients. It also usually increases survival and enhances the quality of life.

FUTURE PROSPECTS AND PROJECTS

The role of chemotherapy in current therapeutical strategies has not yet been defined and should be investigated and developed.

Activity of combination chemotherapy in brain metastases from breast and lung adenocarcinoma

Brain metastases represent a common complication of breast and lung cancer, with an overall incidence exceeding 30-40% of cases. Results achieved with radiotherapy are disappointing, with a median survival of a few months, and no clear activity has been observed with chemotherapy. The aims of this study were to assess the activity and feasibility of a new chemotherapeutic approach according to the following schedule: lomustine, 80 mg/m2 day 1; carboplatin, 80 mg/m2 days 1, 8, 15, 22; vinorelbine, 20 mg/m2 days 1, 8, 15, 22; L-leucovorin 250 mg/m2 days 1, 8, 15, 22; and fluorouracil, 500 mg/m2 days 1, 8, 15, 22. Cycles were repeated every 6 weeks. Since January 1994, 28 patients have been enrolled and 26 are evaluable for response and side effects. Major patient characteristics were median age, 55 years (range 31-72); men/women 15/11; lung primary, 20; breast primary, 6; performance status Eastern Cooperative Oncology Group, 0-2. A total of 64 cycles were administered (median/patient, two cycles). Nine partial remissions have been observed (35%, 95% confidence interval 17-56%), 6 disease stabilizations, and 11 disease progressions. Median duration of response was 3 months, and median time to progression for the whole group was 3.7 months (range 1-7). Treatment was well tolerated. Mild or moderate side effects included neutropenia, thrombocytopenia, mucositis, and nausea/vomiting; grade III-IV toxicity included neutropenia and thrombocytopenia. In conclusion, our results indicate that the schedule proposed is feasible and effective in this subset of patients.

Management of metastatic brain tumors

BACKGROUND

Brain metastases are the most common neurological complication of systemic cancer. They represent a serious cause of morbidity and mortality and a significant challenge for neurosurgeons. They outnumber all other intracranial tumors combined and, with advances in technology and treatment of systemic cancer, are on the increase as cancer patients live longer.

METHODS

We have reviewed the major factors that influence the occurrences of metastases in the central nervous system: primary cancer, patient age and sex, clinical aspects of presentation, basic diagnostic modalities, diagnostic imaging (computed tomography and magnetic resonance imaging), and treatment considerations. In discussing these different aspects, we emphasize the efficacy of different treatment options, including recent information regarding multiple metastases that broadens the scope of surgical implications. The criteria we present are directed toward considerations made by general surgeons, as well as those made by neurosurgeons.

CONCLUSIONS

Although radiotherapy remains the main therapeutic modality, surgical excision has increasingly shown advantages in certain settings, as has stereotactic radiosurgery. Chemotherapy is less effective, but its advantages are reviewed, as are the implications of recurrent metastases.

Response of brain metastases from breast cancer to systemic chemotherapy

In a prospective, nonrandomized study, the response of brain metastases (BM) from breast cancer to a standard systemic chemotherapy regimen was measured by clinical follow-up and serial computed tomography (CT) scans. Treatment consisted of 4-week courses of cyclophosphamide, methotrexate, and 5-fluorouracil (CMF) in 20 patients or 3-week courses of cyclophosphamide, doxorubicin, and 5-fluorouracil (CAF) in 2 patients. Seven patients had previously received CMF or CAF as adjuvant treatment or for progressive systemic disease. Another seven patients had been previously treated for BM with the use of surgery and/or radiation therapy (RT). Based on the results of clinical follow-up and CT scan, a response that lasted at least 6 weeks was seen in 13 patients (59%; 95% confidence interval, 37% to 80%), including 4 of the 7 patients with recurrent BM. Objective tumor regression occurred after two courses of chemotherapy in 76% of the patients who could be examined and after six courses in 47%. The median duration of neurologic remission in the 13 patients was 30 weeks (range, 15 to 66 weeks). The median overall survival time was 25 weeks (range, 2 to 83 weeks). The response rate of systemic disease paralleled the neurologic response. When compared with a matched group of historical control subjects treated with RT alone, chemotherapy induced a higher rate of neurologic response and led to a longer survival time. These results warrant further studies on the use of chemotherapy in BM from breast cancer.