Follicular carcinoma of the thyroid presenting as metastasis in the wall of an arachnoid cyst

The brain is an uncommon site for metastases of differentiated thyroid carcinoma with the most common location being cerebral hemispheres, followed by cerebellum and pituitary gland. Metastasis in the wall of an arachnoid cyst is exceedingly rare with single case report available in the published literature. Arachnoid cyst metastasis from an extraneuraxial malignancy has not been published until. We present a unique case of thyroid carcinoma metastasizing to the wall of an intracranial arachnoid cyst and the most interesting fact is that it was the first clinical manifestation of her malignancy.

Gene-edited and -engineered stem cell platform drives immunotherapy for brain metastatic melanomas

Oncolytic virus therapy has shown activity against primary melanomas; however, its efficacy in brain metastases remains challenging, mainly because of the delivery and immunosuppressive nature of tumors in the brain. To address this challenge, we first established PTEN-deficient melanoma brain metastasis mouse models and characterized them to be more immunosuppressive compared with primary melanoma, mimicking the clinical settings. Next, we developed an allogeneic twin stem cell (TSC) system composed of two tumor-targeting stem cell (SC) populations. One SC was loaded with oncolytic herpes simplex virus (oHSV), and the other SC was CRISPR-Cas9 gene-edited to knock out nectin 1 (N1) receptor (N1KO) to acquire resistance to oHSV and release immunomodulators, such as granulocyte-macrophage colony-stimulating factor (GM-CSF). Using mouse models of brain metastatic BRAFV600E/PTEN-/- and BRAFV600E/wt/PTEN-/- mutant melanomas, we show that locoregional delivery of TSCs releasing oHSV and GM-CSF (TSC-G) activated dendritic cell- and T cell-mediated immune responses. In addition, our strategy exhibited greater therapeutic efficacy when compared with the existing oncolytic viral therapeutic approaches. Moreover, the TSCs composed of SC-oHSV and SCN1KO-releasing GM-CSF and single-chain variable fragment anti-PD-1 (TSC-G/P) had therapeutic efficacy in both syngeneic and patient-derived humanized mouse models of leptomeningeal metastasis. Our findings provide a promising allogeneic SC-based immunotherapeutic strategy against melanomas in the CNS and a road map toward clinical translation.

Real-world analysis of clinicopathological characteristics, survival rates, and prognostic factors in patients with melanoma brain metastases in China

PURPOSE

We aimed to establish the clinicopathological characteristics and prognostic factors of patients with melanoma brain metastases (MBM) in the East Asian population.

METHODS

Overall survival (OS) and intracranial progression-free survival (PFS) were evaluated by Kaplan-Meier analysis. Cox regression analyses were used to determine prognostic factors associated with intracranial PFS and OS.

RESULTS

Between July 2007 and December 2019, 431 patients diagnosed with MBM were enrolled. Mucosal subtype (p = 0.013), LDH level (p = 0.014), the number of MBM ≥ 4 (p = 0.02), local treatment (p < 0.0001) and the use of PD-1 inhibitors (p < 0.0001) were independent prognostic factors for intracranial PFS. Mucosal subtype (p = 0.022), LDH level (p = 0.005), no extracranial metastasis (p = 0.01), concurrent liver metastasis (p = 0.004), local treatment (p = 0.001) and the use of PD-1 inhibitors (p < 0.0001) were independent prognostic factors for OS. Mucosal subtype brain metastases had a poor response to PD-1 inhibitors (p = 0.007), with a shorter intracranial PFS than other subtypes. In BRAF mutation patients with MBM, the first-line BRAF/MEK inhibitor therapy group had an advantage in OS compared to the first-line anti-PD-1 therapy group (p = 0.043).

CONCLUSION

Our findings depict clinical characteristics and prognostic factors of MBM in the East Asian population, suggesting the mucosal subtype as an adverse prognostic and predictive factor for patients with MBM. For BRAF mutation patients with MBM, first-line BRAF/MEK inhibitor therapy may bring a potential survival benefit compared to first-line anti-PD-1 therapy.

Sector Irradiation vs. Whole Brain Irradiation After Resection of Singular Brain Metastasis-A Prospective Randomized Monocentric Trial

To minimize recurrence following resection of a cerebral metastasis, whole-brain irradiation therapy (WBRT) has been established as the adjuvant standard of care. With prolonged overall survival in cancer patients, deleterious effects of WBRT gain relevance. Sector irradiation (SR) aims to spare uninvolved brain tissue by applying the irradiation to the resection cavity and the tumor bed. 40 were randomized to receive either WBRT (n = 18) or SR (n = 22) following resection of a singular brain metastasis. Local tumor control was satisfactory in both groups. Recurrence was observed earlier in the SR (median 3 months, 1–6) than in the WBRT cohort (median 8 months, 7–9) (HR, 0.63; 95% CI, 0.03–10.62). Seventeen patients experienced a distant intracranial recurrence. Most relapses (n = 15) occurred in the SR cohort, whereas only two patients in the WBRT group had new distant tumor manifestation (HR, 6.59; 95% CI, 1.71–11.49; p = 0.002). Median overall survival (OS) was 15.5 months (range: 1–61) with longer OS in the SR group (16 months, 1–61) than in the WBRT group (13 months, 3–52), without statistical significance (HR, 0.55; 95% CI, 0.69–3.64). Concerning neurocognition, patients in the SR group improved in the follow-up assessments, while this was not observed in the WBRT group. There were positive signals in terms of QOL within the SR group, but no significant differences in the global QLQ and QLQ-C30 summary scores were found. Our results indicate comparable efficacy of SR in terms of local control, with better maintenance of neurocognitive function. Unsurprisingly, more distant intracranial relapses occurred.

Clinical Trial Registration:ClinicalTrials.gov, identifier NCT01667640.

Brain Metastasis of Follicular Thyroid Carcinoma in Pregnancy: A Case Report and Literature Review

Brain metastases (BMs) related to cancer are quite common and represent the most common brain cancer. We present a rare case of a 32-year-old female, 36 weeks pregnant, admitted to the emergency with complaints of severe headache, vomiting, and left hemiparesis associated with drowsiness. Cranial tomography showed an image suggestive of an expansive lesion in the right front-temporo-insular region with an important mass effect. The result of biopsy with immunohistochemistry was compatible with metastasis of follicular thyroid carcinoma (FTC). The knowledge of neurological characteristics in the clinical analysis of patients with thyroid carcinoma must be highly valued, both in the correct interpretation of the signs and in the early investigation through skull imaging exams.

Virtual biopsy using MRI radiomics for prediction of BRAF status in melanoma brain metastasis

Brain metastases are common in patients with advanced melanoma and constitute a major cause of morbidity and mortality. Between 40% and 60% of melanomas harbor BRAF mutations. Selective BRAF inhibitor therapy has yielded improvement in clinical outcome; however, genetic discordance between the primary lesion and the metastatic tumor has been shown to occur. Currently, the only way to characterize the genetic landscape of a brain metastasis is by tissue sampling, which carries risks and potential complications. The aim of this study was to investigate the use of radiomics analysis for non-invasive identification of BRAF mutation in patients with melanoma brain metastases, based on conventional magnetic resonance imaging (MRI) data. We applied a machine-learning method, based on MRI radiomics features for noninvasive characterization of the BRAF status of brain metastases from melanoma (BMM) and applied it to BMM patients from two tertiary neuro-oncological centers. All patients underwent surgical resection for BMM, and their BRAF mutation status was determined as part of their oncological work-up. Their routine preoperative MRI study was used for radiomics-based analysis in which 195 features were extracted and classified according to their BRAF status via a support vector machine. The BRAF status of 53 study patients, with 54 brain metastases (25 positive, 29 negative for BRAF mutation) was predicted with mean accuracy = 0.79 ± 0.13, mean precision = 0.77 ± 0.14, mean sensitivity = 0.72 ± 0.20, mean specificity = 0.83 ± 0.11 and with a 0.78 area under the receiver operating characteristic curve for positive BRAF mutation prediction. Radiomics-based noninvasive genetic characterization is feasible and should be further verified using large prospective cohorts.

Human melanoma brain metastases cell line MUG-Mel1, isolated clones and their detailed characterization

Melanoma is a leading cause of high mortality that frequently spreads to the brain and is associated with deterioration in quality and quantity of life. Treatment opportunities have been restricted until now and new therapy options are urgently required. Our focus was to reveal the potential heterogeneity of melanoma brain metastasis. We succeeded to establish a brain melanoma metastasis cell line, namely MUG-Mel1 and two resulting clones D5 and C8 by morphological variety, differences in lipidome, growth behavior, surface, and stem cell markers. Mutation analysis by next-generation sequencing, copy number profiling, and cytogenetics demonstrated the different genetic profile of MUG-Mel1 and clones. Tumorigenicity was unsuccessfully tested in various mouse systems and finally established in a zebra fish model. As innovative treatment option, with high potential to pass the blood-brain barrier a peptide isolated from lactoferricin was studied in potential toxicity. Brain metastases are a major clinical challenge, therefore the development of relevant in vitro and in vivo models derived from brain melanoma metastases provides valuable information about tumor biology and offers great potential to screen for new innovative therapies.

Outcomes of Metastatic Brain Lesions Treated with Radioactive Cs-131 Seeds after Surgery: Experience from One Institution

Introduction

Brain metastases are common in patients with advanced systemic cancer and often recur despite treatment with surgical resection and radiotherapy. Whole brain radiation therapy (WBRT) and stereotactic radiosurgery (SRS) have significantly improved local control rates but are limited by complications including neurocognitive deficits and radiation necrosis. These risks can be higher in the re-irradiation setting. Brachytherapy may be an alternative method of additional targeted adjuvant radiotherapy with acceptable rates of toxicity.

Methods

A retrospective chart review of all patients undergoing resection for metastatic brain lesions and permanent low-dose rate Cs-131 brachytherapy was performed for one institution over a 10-year period. All patients had previous radiation therapy already and, after surgery, were followed with imaging every three months. Patient demographics, disease characteristics, intracranial disease, peri- and post-operative complications, and outcomes were recorded. The primary outcome of interest was local tumor recurrence at the site of brachytherapy while secondary outcomes included distant disease progression (within the brain) and complications such as radiation necrosis.

Results

During the study period, nine cases of individual patients met inclusion criteria. The median preoperative lesion diameter was 3 cm (0.8–4.1). The median overall survival after surgery and brachytherapy was 10.3 months, after excluding two patients who were lost to follow-up. Six of nine patients had no local recurrence, while three patients had development or progression of distant lesions. No patients experienced acute or delayed complications.

Conclusion

Cs-131 brachytherapy is a promising alternative method for controlling brain metastases after previous radiation interventions and surgical resection. In this case series, there were no incidences of local tumor recurrence or complications such as radiation necrosis.

The significance of BRAF V600E mutation status discordance between primary cutaneous melanoma and brain metastases: The implications for BRAF inhibitor therapy

To compare BRAF V600E status of primary melanoma and brain metastases to assess for discordance by cross-sectional study, and to evaluate clinical implications on BRAF inhibitor therapy.Brain metastases are common in patients with advanced melanoma. Between 40% and 60% of melanomas demonstrate BRAF mutations, BRAF V600E being most common. Selective BRAF inhibitor therapy has shown improvement in outcome in patients with melanoma. It has been demonstrated that not all metastatic lesions carry the same BRAF mutation status as the primary, but the frequency in which discordance occurs remains unclear. Establishing this may have implications in the use of BRAF inhibitors in patients with melanoma brain metastases.Patients who underwent metastectomy for melanoma brain metastases were identified using our local histopathology database. A review of histology of the primary lesion and the metastasis was performed for each patient, assessing for BRAF mutation status discordance.Fourty-two patients who underwent a brain metastectomy following excision of a melanoma primary were identified over a 7-year period. Median survival was 9 months. The median Breslow thickness for the primary lesion was 3.4 mm. Six patients (14%) had discrepancy between the BRAF status of a melanoma primary and metastatic lesion. Of these 6 patients, 3 had a BRAF mutation positive primary with a BRAF mutation negative metastatic lesion, while the other 3 had a BRAF mutation negative primary with BRAF mutation positive metastasis.There is an important discordance rate in the BRAF mutation status of melanoma primaries versus brain metastases.

The Hidden Morbidity of Cancer: Burden in Caregivers of Patients with Brain Metastases

Caregiving is a highly individualized experience. Although numerous articles have been published on caregiver burden from a variety of diagnoses and conditions, this article presents the unique features of caregiving in patients with brain metastases. Improved long-term survival, concerns about disease recurrence or progression, the cancer experience (initial diagnosis, treatment, survivorship, recurrence, progression, and end of life), and the increasing complexity of cancer treatments add to the demands placed on the caregivers of patients with brain metastases. Health care professionals must identify caregiver burden and administer the appropriate interventions, which must be as unique and individualized as the caregivers' experiences.

Single Institutional Experience of Stereotactic Radiosurgery Alone for First Brain Metastatic Event and Salvage of Second Brain Metastatic Event in a Community Setting with Review of the Literature

PURPOSE

To document survival for patients treated with stereotactic radiosurgery (SRS) alone for brain metastases either at initial presentation or for salvage in conjunction with other known prognostic factors in a single institutional community setting with comparison to current literature.

METHODS

All patients treated for brain metastases with SRS between October 2006 and October 2013 were reviewed. We identified 91 patients treated with SRS alone for first brain metastatic event (FBME) and 87 patients treated with SRS for second brain metastatic event (SBME). We excluded the 14 patients treated with SRS for both FBME and SBME to satisfy the independence assumption for comparison of groups. Patient demographics, including age, gender, primary cancer type, presence of extracranial metastases, number of brain metastases, initial site of metastases (brain vs. other), recursive partitioning analysis (RPA), and Karnofsky Performance status (KPS) were documented.

RESULTS

There were no significant differences in overall survival for patients treated with SRS for FBME compared with SBME (log-rank p = 0.9347). Univariate and multivariable Cox regression modeling revealed KPS (p = 0.0003) and RPA (p = 0.0143) were the only independent prognostic factors for survival. Specifically, patients with RPA 1 had a 61% decreased risk of death compared to those with RPA 3. Patients with RPA 2 had a 33% decreased risk of death compared to those with RPA 3. The 1-year survival rate was 36.5% for patients with RPA1, 33.3% for those with RPA 2, and 17.1% for those with RPA 3. Patients with KPS 90-100 had a 62% decreased risk of death compared to those with KPS < 70. The 1-year survival rate for patients KPS 90-100, 70-80, and <70 were 60.7, 24.6, and 16.7%, respectively.

CONCLUSION

No difference in survival was noted for FBME and SBME with performance status, the single most important prognostic factor following SRS. Aggressive treatment should be considered for patients with good performance status regardless if presenting with FBME or SBME. Our results are consistent with single, multi-institutional, and randomized trials after literature review.

Management of neuro-oncologic emergencies

Patients with brain tumors and systemic malignancies are subject to diverse neurologic complications that require urgent evaluation and treatment. These neurologic conditions are commonly due to the tumor's direct effects on the nervous system, such as cerebral edema, increased intracranial pressure, seizures, spinal cord compression, and leptomeningeal metastases. In addition, neurologic complications can develop as a result of thrombocytopenia, coagulopathy, hyperviscosity syndromes, infection, immune-related disorders, and adverse effects of treatment. Patients may present with typical disease syndromes. However, it is not uncommon for patients to have more subtle, nonlocalizing manifestations, such as alteration of mental status, that could be attributed to other systemic, nonneurologic complications. Furthermore, neurologic complications are at times the initial manifestations of an undiagnosed malignancy. Therefore a high index of suspicion is essential for rapid assessment and management. Timely intervention may prolong survival and improve quality of life. In this chapter, we will discuss the common neuro-oncologic emergencies, including epidemiology, pathophysiology, clinical presentation, diagnosis, and treatment.

The effect of whole-brain radiation (WBI) and Karnofsky performance status (KPS) on survival of patients receiving stereotactic radiosurgery (SRS) for second brain metastatic event

OBJECTIVE

The objective of the present study is to analyze prognostic factors affecting survival of patients receiving stereotactic radiosurgery (SRS) for second brain metastatic event (SBME) following initial treatment with whole brain irradiation (WBI), surgical resection, or previous SRS.

METHODS

The 88 patients treated with SRS for SBME at Philadelphia CyberKnife between January 2006 and October 2013 were included in the study group. Cox proportional-hazards regression was used to identify prognostic factors that significantly impacted survival from the time of SRS for SBME. Independent variables considered in survival analysis included primary disease, first brain metastatic event (FBME) treatment type, age, gender, number of brain metastases at SBME, Karnofsky performance status (KPS), recursive partitioning analysis (RPA), and presence of extracranial metastasis.

RESULTS

The median survival for all patients was 7.31 months. Log-rank comparison of Kaplan-Meier survival curves revealed significant impact by Karnofsky performance status (p = 0.003), RPA class (p = 0.008), age (p = 0.014), and FBME treatment type (p = 0.010). Median survival was longer for patients who had not previously received WBI (14.7 months). Median survival was further increased in patients who had not received previous WBI and demonstrated KPS scores of 70-100 (19.5 months). Patients who received WBI prior to SBME treatment experienced a pronounced decrement in median survival (5.7 months), yet patients in this group who demonstrated strong KPS scores (80-100) experienced significantly increased survival (15.5 months).

CONCLUSIONS

The outcomes of SRS for SBME are most favorable for patients who have not received previous WBI or who have maintained higher performance status despite previous WBI.

Treatment patterns and outcomes in BRAF V600E-mutant melanoma patients with brain metastases receiving vemurafenib in the real-world setting

Brain metastases are a common and serious complication among patients with metastatic melanoma. The selective BRAF inhibitor vemurafenib has demonstrated clinical efficacy in patients with BRAF V600E-mutant melanoma brain metastases (MBM). We examined the real-world application and clinical outcomes of vemurafenib in this patient population. Demographic, treatment patterns, response, and survival data were collected from medical charts. Clinical data on 283 patients with active BRAF V600E-mutant MBM treated with vemurafenib were provided by 70 US oncologists. Mean age was 57.2 years, 60.8% were male, 67.5% had ECOG performance status of 0–1, and 43.1% used corticosteroids at vemurafenib initiation. Median follow-up was 5.7 months. Following vemurafenib initiation, 48.1% of patients experienced intracranial response and 45.6% experienced extracranial response. The Kaplan–Meier estimate for overall survival was 59% at 12 months. Multivariate analyses showed associations between intracranial response and both corticosteroid use and vemurafenib as initial therapy after MBM diagnosis. Larger size (5–10 mm vs. <5 mm) and number of brain metastases (≥5 vs. <2) and progressive extracranial disease at treatment initiation were associated with decreased intracranial response and increased risk of disease progression. Multiple extracranial sites (2 vs. <2) and the absence of local treatments were also associated with increased risk of progression. Increased risk of death was associated with ≥2 extracranial disease sites, progressive extracranial disease, and ≥5 brain metastases. Subgroups of MBM patients may derive more benefit with vemurafenib, warranting prospective investigation.

Clinicopathological characteristics at primary melanoma diagnosis as risk factors for brain metastasis

To better identify melanoma patients who are, at the time of primary melanoma diagnosis, at high risk of developing brain metastases, primary melanoma characteristics were examined as risk factors for brain metastasis development. In a study of two patient cohorts, clinicopathological characteristics prospectively collected at primary cutaneous melanoma diagnosis for patients with/without brain metastasis were assessed in univariate and multivariate analyses using data from two prospectively collected databases: the Melanoma Cooperative Group (MCG) (1972-1982) and the Interdisciplinary Melanoma Cooperative Group (IMCG) (2002-2009). Candidate risk factors were evaluated in association with time to brain metastasis using either the log-rank test or Cox proportional hazards regression analysis with/without considering competing risks. Out of 2341 total patients included in the study, 222 (9.5%) developed brain metastases (median follow-up: 98 months). The median time to brain metastases was 30.5 months and the median survival time after brain metastases was 4 months. Increased hazard ratios (HRs) for brain metastasis were found among thicker (logarithmic value in mm) (MCG: HR=1.97, P<0.0001; IMCG: HR=1.31, P=0.018), ulcerated (MCG: HR=1.93, P=0.01; IMCG: HR=3.14, P<0.0001), and advanced-stage (MCG: HR=2.08, P=0.008; IMCG: HR=2.56, P=0.0002) primary melanomas on the basis of multivariate Cox regression analysis assuming the presence of competing risks. Primary cutaneous melanoma thickness, ulceration, and stage were identified and validated as risk factors associated with time to melanoma brain metastasis.

The role of cancer stem cells and miRNAs in defining the complexities of brain metastasis

Researchers and clinicians have been challenged with the development of therapies for the treatment of cancer patients whose tumors metastasized to the brain. Among the most lethal weapons known today, current management of brain metastases involves multiple therapeutic modalities that provide little, if any, for improving the quality of life and overall survival. Recently the role of cancer stem cells (CSCs) in the development of cancer has been studied extensively, and thus its role in the prognosis, diagnosis, and treatment is now being investigated even in the realm of brain metastasis (BM). Recognizing the molecular make-up of CSCs as well as understanding the role of these cells in resistance to treatment modalities is expected to benefit cancer patients. Additionally, past decade has witnessed an increase in awareness and understanding of the role of microRNAs (miRNAs) in various cancer types, and the deregulation miRNAs are critically important for the regulation of genes during the development and progression of human malignancies. The role miRNAs in BM is being investigated, and has also shown tremendous promise for future research. In this review, we discuss the problem and lethality of brain metastases and the current state of management, and further provide insight into novel avenues that are worth considering including the biological complexities of CSCs and miRNAs for designing novel therapies.

Challenging the current paradigm of melanoma progression: brain metastasis as isolated first visceral site

Melanoma brain metastasis that develops as the isolated first visceral site challenges the current paradigm of tumor progression in which brain metastasis is regarded as the final stage. Here we test the hypothesis that melanoma patients who develop brain metastasis as the isolated first visceral site have distinct clinicopathological features at the time of primary melanoma diagnosis. Cutaneous melanoma patients enrolled in 2 prospectively collected databases were studied (Cohort 1: 1972-1982, Cohort 2: 2002-2009). Patients who developed brain metastasis as isolated first visceral site were compared with (1) all other patients, (2) patients who developed visceral metastasis: extracranial only or extracranial and brain, and (3) patients who progressed to other isolated visceral sites first. Two hundred seven of 2280 (9.1%) patients developed brain metastasis (median follow-up, 5.2 y). Seventy-four of 207 (35.7%) brain metastasis patients progressed to brain metastasis as the isolated first visceral site. These patients presented with primaries that were thinner and had no mitosis compared with all other visceral metastasis patients (Fisher's combined P = .02, .05, respectively), and there was a significant difference in American Joint Committee on Cancer stage distribution at initial melanoma diagnosis (combined P = .02). Post-visceral metastasis survival, however, was shorter in patients with brain metastasis as isolated first visceral site than in patients with visceral metastasis: extracranial and brain (combined P = .03). Brain metastasis as isolated first visceral site is a distinct clinicopathological entity. Studies are needed to better understand the biological factors driving this phenotype at the time of primary melanoma diagnosis and to determine its clinical implications.

Phase I clinical trial outcomes in 93 patients with brain metastases: the MD anderson cancer center experience

PURPOSE

Patients with brain metastases are often excluded from clinical trials, but it is unclear whether they pose an enhanced risk.

EXPERIMENTAL DESIGN

We reviewed the records of 1,181 consecutive patients, with and without brain metastases, treated in our Phase I Clinical Trials Program.

RESULTS

Ninety-three patients had brain metastases at the time of referral. Their median age was 54 years; median follow-up, 8 months. The rates of stable disease ≥ 4 months, partial response, and complete response combined in patients with and without brain metastases were 17% and 27%, respectively (P = 0.03). Although the median survival of patients with brain metastases was shorter than that of patients without brain metastases (7.5 vs. 10.3 months; P = 0.002), in multivariate analysis, the presence of brain metastases was not an independent factor predicting survival. There was no difference in time-to-treatment failure (1.74 vs. 1.84 months, respectively; P = 0.61) or in grade 3 and 4 toxicity rates (including neurologic; 12% vs. 10%, respectively; P = 0.77) between patients with and without brain metastases.

CONCLUSIONS

The rates of survival and response of patients with brain metastases were lower than those for other patients in the phase I setting, but the presence of brain metastases was not an independent prognostic factor predicting survival, indicating that other covariates that coexist with brain metastases were more significant. Time-to-treatment failure for patients with brain metastases was not decreased, nor was the incidence of serious adverse effects (including neurologic toxicity) increased, suggesting that these patients should be eligible for early clinical trials.

Therapy and prophylaxis of brain metastases

Metastases of various tumors to the brain account for the majority of brain cancers, and are associated with a poor prognosis. The most common primary sites are lung, breast, skin, kidney and colon; 10-40% of cancer patients develop brain metastases during the course of the disease. The incidence of brain metastasis appears to be rising; reasons may include better therapies for the systemic disease with longer survival of cancer patients but lower efficiency against brain metastases. In this article, we will discuss the conventional treatment with surgery, radiosurgery, radiotherapy and chemotherapy, but also new directions in the management of solid brain metastases. While general therapeutic nihilism should be avoided, it is important to recognize that the number of brain metastases, the extent of the systemic disease and also the tumor type have to be taken into account when choosing individual treatment regimens. Finally, special emphasis will be put on established and future approaches to prevent the disease. We thus aim to provide a framework for treating patients with different presentations of brain metastases, and to highlight important avenues for research.