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Stereotactic Radiosurgery for Multiple Brain Metastases

Current Treatment Options in Neurology volume 21, Article number: 6 (2019) Cite this article

Abstract

Purpose of review

To give an overview on the current evidence for stereotactic radiosurgery of brain metastases with a special focus on multiple brain metastases.

Recent findings

While the use of stereotactic radiosurgery in patients with limited brain metastases has been clearly defined, its role in patients with multiple lesions (> 4) is still a matter of controversy. Whole-brain radiation therapy (WBRT) has been the standard treatment approach for patients with multiple brain lesions and is still the most commonly used treatment approach worldwide. Although distant brain failure is improved by WBRT, the overall survival is not readily impacted. As WBRT is associated with significant neurocognitive decline compared to stereotactic radiosurgery (SRS), SRS has been explored and increasingly utilized for selected patients with multiple brain metastases. Recent clinical data indicated the feasibility of stereotactic radiosurgery to multiple brain metastases with a similar survival in patients with more than 4 brain metastases versus patients with a maximum of 4 brain metastases. Also, neurocognitive function and quality of life was maintained after stereotactic radiosurgery which is essential in a palliative setting.

Summary

The application of stereotactic radiosurgery with Gamma Knife, Cyberknife, or LINAC-based equipment has emerged as an effective and widely available treatment option for patients with limited brain metastases. Although not formally proven in prospective studies, SRS may also be considered as a safe and effective treatment option in selected patients with multiple brain metastases. Especially in patients with a favorable prognosis, survival over several years is observed also in the setting of multiple BM. For these patients, avoidance of the neurocognitive damage of WBRT is desirable, and SRS is often a more appropriate treatment in the current multimodality treatment of BM in which systemic treatment is often the cornerstone of the treatment. For patients with an intermediate (3–12 months) and poor prognosis (< 3 months), the application of WBRT becomes more and more controversial, because of its acute side effects, such as hair loss and fatigue and, thereby, detrimental effect on quality of life. For these patients, best supportive care, primary systemic treatment, and even SRS may be preferred over WBRT on an individualized patient basis.

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Affiliations

  1. Department of Radiation Oncology, University Hospital of Zurich, University of Zurich, Raemistrasse 100, 8091, Zurich, Switzerland

    Johannes Kraft MD, Matthias Guckenberger MD & Nicolaus Andratschke MD

  2. Erasmus MC Rotterdam/Holland Proton Therapy Center Delft, MAASTRO Clinic Maastricht, Maastricht, The Netherlands

    Jaap Zindler MD

  3. Radiation Oncology Unit, UPMC Hillman Cancer Center, San Pietro Hospital, Rome, Italy

    Giuseppe Minniti MD

  4. IRCCS Neuromed, Pozzilli, IS, Italy

    Giuseppe Minniti MD

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  5. Nicolaus Andratschke MD
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Correspondence to Johannes Kraft MD.

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Conflict of Interest

Johannes Kraft and Matthias Guckenberger each declare no potential conflicts of interest. Nicolaus Andratschke reports grants from Brainlab AG, outside the submitted work. Giuseppe Minniti reports personal fees from BrainLAb, outside the submitted work. Jaap Zindler has no personal conflicts of interest—MAASTRO Clinic has a research agreement with Varian Medical Systems Palo Alto USA.

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Kraft, J., Zindler, J., Minniti, G. et al. Stereotactic Radiosurgery for Multiple Brain Metastases. Curr Treat Options Neurol 21, 6 (2019). https://doi.org/10.1007/s11940-019-0548-3

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  • DOI: https://doi.org/10.1007/s11940-019-0548-3

Keywords

  • Brain metastases
  • Multiple brain metastases
  • Stereotactic radiosurgery