Practice parameters for the management of single brain metastasis

Double Trouble: A Case Report on the Surgical Management of Dual Intracranial Metastases

Intracranial metastasis disease (IMD) has proven to be a frequent secondary occurrence, usually for primary cancers such as lung, breast, and melanoma, which have a high possibility of metastasizing to the brain. Due to the reasons listed above, treatment and early diagnosis are incredibly challenging. In the past decade, medicine has developed much better imaging solutions and radiological and surgical approaches, increasing the postoperative survival prognosis and achieving more time-efficient results. It is still exceptionally difficult to be able to prevent what type of metastasis a patient might develop other than by using the tumor type or subtype. We present a case of a 51-year-old female patient entering the Neurosurgical Clinic at the University Hospital "St. Ivan Rilski" for operative treatment of a second metastatic lesion located on the left parietal lobe in January 2024. She had previously had an operative resection of an initial lesion located on the left temporal lobe in December 2023. Her medical history began in 2015 when her first diagnosis was a breast carcinoma, followed by operative treatment and radio-, chemo-, and targeted therapy. In 2020, due to metastases located in the bones, she had to undergo another treatment with chemotherapy as well as have a total hysterectomy done as a result of another metastasis. The patient did not provide any family history, nor did she confirm any past or current allergies to foods, drugs, etc. Under general inhalation anesthesia, the patient was placed in a park bench position to the right and had a Mayfield head holder applied. Through a left parietal craniotomy and neuronavigation, a tumor formation was revealed with the characteristic of a secondary lesion. A gross total resection was achieved through a microsurgical technique. Postoperatively, there were no further complications observed in the patient, and she was discharged on day five from the hospital with relief of her symptoms.

Treatment for Brain Metastases: ASCO-SNO-ASTRO Guideline

PURPOSE

To provide guidance to clinicians regarding therapy for patients with brain metastases from solid tumors.

METHODS

ASCO convened an Expert Panel and conducted a systematic review of the literature.

RESULTS

Thirty-two randomized trials published in 2008 or later met eligibility criteria and form the primary evidentiary base.

RECOMMENDATIONS

Surgery is a reasonable option for patients with brain metastases. Patients with large tumors with mass effect are more likely to benefit than those with multiple brain metastases and/or uncontrolled systemic disease. Patients with symptomatic brain metastases should receive local therapy regardless of the systemic therapy used. For patients with asymptomatic brain metastases, local therapy should not be deferred unless deferral is specifically recommended in this guideline. The decision to defer local therapy should be based on a multidisciplinary discussion of the potential benefits and harms that the patient may experience. Several regimens were recommended for non-small-cell lung cancer, breast cancer, and melanoma. For patients with asymptomatic brain metastases and no systemic therapy options, stereotactic radiosurgery (SRS) alone should be offered to patients with one to four unresected brain metastases, excluding small-cell lung carcinoma. SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases. SRS, whole brain radiation therapy, or their combination are reasonable options for other patients. Memantine and hippocampal avoidance should be offered to patients who receive whole brain radiation therapy and have no hippocampal lesions and 4 months or more expected survival. Patients with asymptomatic brain metastases with either Karnofsky Performance Status ≤ 50 or Karnofsky Performance Status < 70 with no systemic therapy options do not derive benefit from radiation therapy.Additional information is available at www.asco.org/neurooncology-guidelines.

The 100 Most Cited Papers About Brain Metastases

BACKGROUND

A vast amount of articles centered on brain metastases have been published.

OBJECTIVE

To present the 100 most-cited articles dedicated to brain metastasis and to accomplish a broad literature review.

METHODS

In December 2019, we performed a title-focused search using the Thomson Reuters Web of Science database to identify the most cited articles centered on brain metastatic disease. Our search query term was based on using the following algorithm: "brain metastases" OR "brain metastasis" OR "brain metastatic disease" OR "cerebral metastases" OR "cerebral metastasis" OR "cerebral metastatic disease." Afterward, we reviewed the results to certify that they were relevant to the purposes of our research protocol. The 100 most cited papers were chosen and further analyzed.

RESULTS

Our search resulted in 11,579 articles, published from 1975 until the completion of our survey. The most cited article, by Patchell et al., was published in 1990, with 1862 citations, and an average of 62.07 citations per year, whereas the last in our list, by Gaspar et al., was published in 2010, with 195 total citations, and an average of 19.50 citations per year. Countries with the highest-cited articles included the United States (75 records), followed by Canada (16 records).

CONCLUSIONS

We discovered the top 100 most-cited articles centered on brain metastasis, all of which show a potentially increased level of interest, because they are meaningful scientific reports. In addition, we reviewed the historical development and advances in brain metastasis research and relevant points of interest, alongside the relevant contributions of different authors, fields of special interest, and countries. Many of the most cited articles were written by authors whose specialty was not neurosurgery or by neurosurgeons who were supported by colleagues from other medical fields. As a consequence, many of these articles were not published in neurosurgery-dedicated journals.

A Practical Methodological Approach Towards Identifying Core Competencies in Medical Education Based on Literature Trends: A Feasibility Study Based on Vestibular Schwannoma Science

BACKGROUND

Competency-based medical education (CBME) is gaining momentum in postgraduate residency and fellowship training. While randomized trials, consensus statements, and practice guidelines can help delineate some of the core competencies for CBME, they are not applicable to all clinical scenarios.

OBJECTIVE

To propose and assess the feasibility of a practical methodology for addressing this issue using radiosurgery for vestibular schwannoma (VS) science as an example.

METHODS

The Web of Science electronic database was searched using relevant terms. A 3-step review of titles and abstracts was used. Studies were classified independently and in duplicate as either efficacy or effectiveness analyses. Cohen's kappa score was used to assess inter-rater agreement.

RESULTS

Overall, 1818 surgical and 943 radiosurgical publications were identified. The number of effectiveness studies surpassed that of efficacy studies in the late 1980s for surgical studies, and in the early-to-mid 1990s among radiosurgical studies. The publication rate was higher for radiosurgery in the mid 1990s, but it paralleled that of surgical studies beyond the early 2000s. Variations in this overall trend corresponded to the emergence of studies that assessed the role of endoscopy and the utility of dose reduction in radiosurgery.

CONCLUSION

We have confirmed the feasibility and accuracy of this objective methodological approach. By understanding how the peer-reviewed literature reflects actual practice interests, educators can tailor curricula to ensure that trainees remain current. While further validation studies are needed, this methodology can serve as a supplemental strategy for identifying additional core competencies in CBME.

Palliative care in lung cancer: ACCP evidence-based clinical practice guidelines (2nd edition)

GOALS/OBJECTIVES: To review the scientific evidence on symptoms and specific complications that are associated with lung cancer, and the methods available to palliate those symptoms and complications.

METHODS

MEDLINE literature review (through March 2006) for all studies published in the English language, including case series and case reports, since 1966 using the following medical subject heading terms: bone metastases; brain metastases; cough; dyspnea; electrocautery; hemoptysis; interventional bronchoscopy; laser; pain management; pleural effusions; spinal cord metastases; superior vena cava syndrome; and tracheoesophageal fistula.

RESULTS

Pulmonary symptoms that may require palliation in patients who have lung cancer include those caused by the primary cancer itself (dyspnea, wheezing, cough, hemoptysis, chest pain), or locoregional metastases within the thorax (superior vena cava syndrome, tracheoesophageal fistula, pleural effusions, ribs, and pleura). Respiratory symptoms can also result from complications of lung cancer treatment or from comorbid conditions. Constitutional symptoms are common and require attention and care. Symptoms referable to distant extrathoracic metastases to bone, brain, spinal cord, and liver pose additional problems that require a specific response for optimal symptom control. There are excellent scientific data regarding the management of many of these issues, with lesser evidence from case series or expert opinion on other aspects of providing palliative care for lung cancer patients.

CONCLUSIONS

Palliation of symptoms and complications in lung cancer patients is possible, and physicians who provide such care must be knowledgeable about these issues.

History of the AANS/CNS joint section on tumors and preface to the 20th anniversary Journal of Neuro-Oncology Special Issue

The Joint Section on Tumors of the American Association of Neurological Surgeons (AANS) and the Congress of Neurological Surgeons (CNS) was formed in 1984, at the suggestion of Dr. Edward R. Laws, Jr. and with Dr. Mark Rosenblum as the first Section Chair. The Joint Section on Tumors is the first professional organization devoted to the study and treatment of brain tumors. Its initial goals were to 'assist in the education of neurosurgeons in neuro-oncology and to serve as a resource [to the AANS and CNS] and other national groups on the clinical treatment of and research into nervous system tumors'. During its 20-year history, the Section has facilitated both open and invited talks at the neurosurgical national meetings, conducted its own Satellite Symposia, and instituted multiple awards and grants. Members have conducted research surveys and national practice pattern studies, and have collected and disseminated information on clinical protocols, research funding opportunities, and fellowships in neurosurgical oncology. Guidelines for brain tumor treatment and for neuro-oncology fellowships for surgeons have been written by Section committees. Studies presented orally at Section meetings, 1999-2002, had a remarkably high rate of full publication compared to other meetings - 73% actuarial at 4 years after presentation. Finally, nationwide in-hospital mortality rates for craniotomy for malignant glioma have fallen from 8 to 2% during the Section's existence. These data suggest that the Section's goals of educating all surgeons in neurosurgical oncology are being successfully met. A bibliography of secondary sources on the history of brain tumor surgery is appended.

Management of brain metastases

Patients with brain metastases have a generally poor outcome with a median survival after diagnosis of approximately 4 months. Management of brain metastases involves symptomatic treatment and definitive therapy, with the goal of stabilizing and improving neurologic function and survival. Traditional and novel therapies, including whole-brain radiation therapy (WBRT), surgery, radiosurgery, radiosensitizers, and chemotherapy are reviewed. The results of important clinical trials are discussed. In addition, current controversies in the management of brain metastases, such as the choice of surgery or radiosurgery for resectable lesions and the possible avoidance of (WBRT), are highlighted.

Whole brain radiation therapy with or without stereotactic radiosurgery boost for patients with one to three brain metastases: phase III results of the RTOG 9508 randomised trial

BACKGROUND

Brain metastases occur in up to 40% of all patients with systemic cancer. We aimed to assess whether stereotactic radiosurgery provided any therapeutic benefit in a randomised multi-institutional trial directed by the Radiation Therapy Oncology Group (RTOG).

METHODS

Patients with one to three newly diagnosed brain metastases were randomly allocated either whole brain radiation therapy (WBRT) or WBRT followed by stereotactic radiosurgery boost. Patients were stratified by number of metastases and status of extracranial disease. Primary outcome was survival; secondary outcomes were tumour response and local rates, overall intracranial recurrence rates, cause of death, and performance measurements.

FINDINGS

From January, 1996, to June, 2001, we enrolled 333 patients from 55 participating RTOG institutions--167 were assigned WBRT and stereotactic radiosurgery and 164 were allocated WBRT alone. Univariate analysis showed that there was a survival advantage in the WBRT and stereotactic radiosurgery group for patients with a single brain metastasis (median survival time 6.5 vs 4.9 months, p=0.0393). Patients in the stereotactic surgery group were more likely to have a stable or improved Karnofsky Performance Status (KPS) score at 6 months' follow-up than were patients allocated WBRT alone (43% vs 27%, respectively; p=0.03). By multivariate analysis, survival improved in patients with an RPA class 1 (p<0.0001) or a favourable histological status (p=0.0121).

INTERPRETATION

WBRT and stereotactic boost treatment improved functional autonomy (KPS) for all patients and survival for patients with a single unresectable brain metastasis. WBRT and stereotactic radiosurgery should, therefore, be standard treatment for patients with a single unresectable brain metastasis and considered for patients with two or three brain metastases.

Lung cancer. Palliative care

The majority of patients who acquire lung cancer will have troublesome symptoms at some time during the course of their disease. Some of the symptoms are common to many types of cancers, while others are more often encountered with lung cancer than other primary sites. The most common symptoms are pain, dyspnea, and cough. This document will address the management of these symptoms, and it will also address the palliation of specific problems that are commonly seen in lung cancer: metastases to the brain, spinal cord, and bones; hemoptysis; tracheoesophageal fistula; and obstruction of the superior vena cava.

Moving targets and ghosts of the past: outcome measurement in brain tumour therapy

Evaluation of novel therapies for brain tumours should logically consider quality and quantity of patient survival as primary endpoints. The urgency of the problem, however, frequently leads investigators to use surrogate endpoints and historical controls in order to more rapidly evaluate outcome. To examine the impact of the use of surrogate endpoints and historical controls on the evaluation of innovative brain tumour therapy, selective literature review of three content areas (intraarterial chemotherapy for malignant glioma, interstitial brachytherapy for malignant glioma and stereotactic radiosurgery for cerebral metastasis and malignant glioma) was carried out. The impact of surrogate outcome measures and use of historical controls was assessed by comparing the results of trials using these methods and randomised clinical trials. In the evaluation of both intraarterial chemotherapy and interstitial brachytherapy, promising results in early phase trials were not confirmed in randomised clinical trials. This result can be explained by selection bias and predicted by the use of controls carefully selected from large treatment data bases. In the evaluation of stereotactic radiosurgery, early phase trials are promising, but randomised clinical trials have not yet been done. Prior experience suggests that the early promising results with stereotactic radiosurgery should be subjected to randomised clinical trial validation before being considered proven. Careful selection of controls for early phase trials is necessary if erroneous conclusions are to be avoided.