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Brain metastases

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Current Treatment Options in Oncology Aims and scope Submit manuscript

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Brain metastases are an increasingly common complication in patients with systemic cancer. The optimal treatment for each patient depends on careful evaluation of several factors: the location, size, and number of brain metastases; the patient's age, general condition, and neurologic status; and the extent of systemic cancer to name a few. For patients with a single brain metastasis and limited systemic disease, the standard treatment is surgical resection followed by whole brain radiation therapy. In patients with a small, single metastasis, stereotactic radiosurgery is probably comparable to surgery. Patients with several metastases (up to three) and controlled systemic disease can be treated with whole-brain radiation and stereotactic radiosurgery. Patients with multiple metastases (more than three) are generally treated with whole-brain radiation alone. Radiosurgery is effective in treating patients with a limited number of recurrent brain metastases and stable systemic diseases. Surgery may have a role in patients with a large symptomatic recurrent lesion producing mass effect. Reirradiation and chemotherapy may have a limited role in patients with multiple recurrent metastases.

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References and Recommended Reading

  1. Clouston PD, DeAngelis LM, Posner JB: The spectrum of neurological disease in patients with systemic cancer. Ann Neurol 1992, 31:268–273.

    Article  PubMed  CAS  Google Scholar 

  2. Patchell R: Brain metastases. Handbook of Neurology 1997, 25:135–149. This a good review of the management of brain metastases.

    Google Scholar 

  3. Wen PY, Loeffler JS: Management of brain metastases. Oncology 1999, 13:941–961. This is a recent overview of the management of brain metastases.

    PubMed  CAS  Google Scholar 

  4. Davey P: Brain metastases. Curr Probl Cancer 1999, 23:59–98.

    Article  PubMed  CAS  Google Scholar 

  5. Posner JB: Intracranial metastases. In Neurologic Complications of Cancer. Philadelphia: FA Davis; 1995:77–110.

    Google Scholar 

  6. Sawaya R, Bindal RK: Metastatic brain tumors. In Brain Tumors. Edited by Kaye AH, Laws ER. Edinburgh: Churchill Livingstone; 1995:923–946.

    Google Scholar 

  7. Graus F, Walker RW, Allen JC: Brain metastases in children. J Pediatr 1983, 103:558–561.

    Article  PubMed  CAS  Google Scholar 

  8. Johnson JD, Young B: Demographics of brain metastasis. Neurosurg Clin North Am 1996, 7:337–344.

    CAS  Google Scholar 

  9. Bouffet E, Doumi N, Thiesse P, et al.: Brain metastases in children with solid tumors. Cancer 1997, 79:403–410.

    Article  PubMed  CAS  Google Scholar 

  10. Delattre JY, Krol G, Thaler HT, Posner JB: Distribution of brain metastases. Arch Neurol 1988, 45:741–744.

    PubMed  CAS  Google Scholar 

  11. Patchell RA, Tibbs PA, Walsh JW, et al.: A randomized trial of surgery in the treatment of single metastases to the brain. N Engl J Med 1990, 322:494–500.

    Article  PubMed  CAS  Google Scholar 

  12. Schaefer PW, Budzik RF, Gonzalez RG: Imaging of cerebral metastases. Neurosurg Clin North Am 1996, 7:393–423. This is a good review of neuroimaging for brain metastases.

    CAS  Google Scholar 

  13. Kofman S, Garvin JS, Nagamani D, et al.: Treatment of cerebral metastases from breast cancer with prednisone. JAMA 1957, 163:1473–1476.

    CAS  Google Scholar 

  14. Galicich JH, French LA, Melby JC: Use of dexamethasone in the treatment of cerebral edema associated with brain tumors. Lancet 1961, 81:46–53.

    CAS  Google Scholar 

  15. Batchelor T, DeAngelis LM: Medical management of cerebral metastases. Neurosurg Clin North Am 1996, 7:435–446. This is a good overview of the medical management of patients with brain metastases.

    CAS  Google Scholar 

  16. Vecht CJ, Hovestadt A, Verbiest HBC, et al.: Dose-effect relationship of dexamethasone on Karnofsky performance in metastatic brain tumors: a randomized study of doses of 4, 8, and 16 milligrams per day. Neurology 1994, 44:675–680.

    PubMed  CAS  Google Scholar 

  17. Werk EE, Choi Y, Sholiton Z, et al.: Interference in the effect of dexamethasone by diphenylhydantoin. N Engl J Med 1969, 281:32–34.

    Article  PubMed  Google Scholar 

  18. Lawson LA, Blouin RA, Smith RB, et al.: Phenytoindexamethasone interaction: a previously unreported observation. Surg Neurol 1981, 16:23–24.

    Article  PubMed  CAS  Google Scholar 

  19. Slivka A, Wen PY, Shea WM, Loeffler JS: Pneumocystis pneumonia during steroid taper in patients with primary brain tumors. Am J Med 1993, 94:216–219.

    Article  PubMed  CAS  Google Scholar 

  20. Cohen N, Strauss G, Lew R, et al.: Should prophylactic anticonvulsants be administered to patients with newly-diagnosed cerebral metastases? A retrospective analysis. J Clin Oncol 1988, 6:1621–1624.

    PubMed  CAS  Google Scholar 

  21. Glantz M, Cole B, Friedberg M, et al.: A randomized, blinded, placebo-controlled trial of divalproex sodium prophylaxis in adults with newly diagnosed brain tumors. Neurology 1996, 46:985–991.

    PubMed  CAS  Google Scholar 

  22. Weaver S, DeAngelis LM, Fulton D, et al.: A prospective randomized study of prophylactic anticonvulsants in patients with primary or metastatic brain tumors and without seizures. Ann Neurol 1997, 42:430.

    Google Scholar 

  23. Mamon H, Wen PY, Loeffler JS: Allergic skin reactions to anticonvulsant medications in patients receiving cranial radiation. Epilepsia 1999, 40:341–344.

    Article  PubMed  CAS  Google Scholar 

  24. Grossman SA, Sheidler VR, Gilbert MR : Decreased phenytoin levels in patients receiving chemotherapy. Am J Med 1989, 87:505–510.

    Article  PubMed  CAS  Google Scholar 

  25. Fetell MR, Grossman SA, Fisher JD, et al.: Preirradiation paclitaxel in glioblastoma multiforme: efficacy, pharmacology, and drug interactions. New Approaches to Brain Tumor Therapy Central Nervous System Consortium. J Clin Oncol 1997, 15:3121–3128.

    PubMed  CAS  Google Scholar 

  26. Glantz MJ, Cole BF, Forsyth PA, et al.: Practice parameter: anticonvulsant prophylaxis in patients with newly diagnosed brain tumors. Neurology 2000, 54:1886–1893. This practice parameter from the American Academy of Neurology reviews the available data concerning prophylactic anticonvulsants in brain tumor patients and includes a meta-analysis of the randomized studies on this subject. It recommends that patients with newly diagnosed brain tumors who have not had a seizure should not be routinely treated with prophylactic anticonvulsants.

    PubMed  CAS  Google Scholar 

  27. Lang FF, Sawaya R: Surgical treatment of metastatic brain tumors. Semin Surg Oncol 1998, 14:53–63.

    Article  PubMed  CAS  Google Scholar 

  28. Bindal RK, Sawaya R, Leavens ME, et al.: Surgical treatment of multiple brain metastases. J Neurosurg 1993, 79:210–216.

    PubMed  CAS  Google Scholar 

  29. Hernandez-Avila G, Black P McL, Loeffler JS, et al.: Is it worth operating on a patient with more than one intracranial metastasis [abstract]. Congress of Neurological Surgeons, 49th Annual Meeting,1999. Boston,

  30. Vecht CJ, Haaxma-Reiche EM, Noordijk GW, et al.: Treatment of single brain metastasis: radiotherapy alone or combined with neurosurgery? Ann Neurol 1993, 33:583–590.

    Article  PubMed  CAS  Google Scholar 

  31. Noordijk EM, Vecht CJ, Haaxma-Reiche H, et al.: The choice of treatment of single brain metastasis should be based on extracranial tumor activity and age. Int J Radiat Oncol Biol Phys 1994, 29:711–717.

    PubMed  CAS  Google Scholar 

  32. Mintz AP, Kestle J, Rathbone MP, et al.: A randomized trial to assess the efficacy of surgery in addition to radiotherapy in patients with a single brain metastasis. Cancer 1996, 78:1470–1476.

    Article  PubMed  CAS  Google Scholar 

  33. Sundaresan N, Sachdev V, DiGiacinto G: Re-operation for brain metastases. J Clin Oncol 1988, 6:1625–1629.

    PubMed  CAS  Google Scholar 

  34. Bindal RK, Sawaya R, Leavens ME, et al.: Re-operation for recurrent metastatic brain tumors. J Neurosurg 1995, 83:600–604.

    PubMed  CAS  Google Scholar 

  35. Arbit E, Wronski M, Burt M, Galicich JH: The treatment of patients with recurrent brain metastases. Cancer 1995, 76:765–773.

    Article  PubMed  CAS  Google Scholar 

  36. Borgelt B, Gelber R, Kramer S, et al.: The palliation of brain metastases. Final results of the first two studies by the Radiation Therapy Oncology group. Int J Radiat Oncol Biol Phys 1980, 6:1–9.

    PubMed  CAS  Google Scholar 

  37. Berk L: An overview of radiotherapy trials for the treatment of brain metastases. Oncology 1995, 9:1205–1211.

    PubMed  CAS  Google Scholar 

  38. Vermeulen SS: Whole brain radiotherapy in the treatment of metastatic brain tumors. Semin Surg Oncol 1998, 14:64–69.

    Article  PubMed  CAS  Google Scholar 

  39. Coia LR, Hanks GE, Martz K, et al.: Practice patterns of palliative care for the United States 1984-1985. Int J Radiat Oncol Biol Phys 1993, 25:209–214.

    Google Scholar 

  40. Hazuka MB, Kinzie JJ: Brain metastases: results and effects of re-irradiation. Int J Radiat Oncol Biol Phys 1988, 15:433–437.

    Article  PubMed  CAS  Google Scholar 

  41. Wong WW, Schild SE, Sawyer TE, Shaw EG: Analysis of outcome in patients reirradiated for brain metastases. Int J Radiat Oncol Biol Phys 1996, 34:585–590.

    Article  PubMed  CAS  Google Scholar 

  42. Cooper JS, Steinfield A, Lerch IA: Cerebral metastases: value of re-irradiation in selected patients. Radiology 1990, 174:883–885.

    PubMed  CAS  Google Scholar 

  43. Posner JB: Side effects of radiation therapy. In Neurologic Complications of Cancer. Philadelphia: FA Davis; 1995:311–335.

    Google Scholar 

  44. DeAngelis L, Delattre J-Y, Posner JB: Radiation-induced dementia in patients cured of brain metastases. Neurology 1989, 39:789–796.

    PubMed  CAS  Google Scholar 

  45. Schultheiss TE, Kun LE, Ang KK, et al.: Radiation response of the central nervous system. Int J Radiat Oncol Biol Phys 1995, 31:1093–1112.

    Article  PubMed  CAS  Google Scholar 

  46. Patchell RA, Tibbs PA, Regine WF, et al.: Postoperative radiotherapy in the treatment of single brain metastases to the brain. JAMA 1998, 280:1485–1489.

    Article  PubMed  CAS  Google Scholar 

  47. Boyd TS, Mehta MP: Stereotactic radiosurgery for brain metastases. Oncology 1999, 13:1397–1409. This is a recent comprehensive review of radiosurgery for brain metastases.

    PubMed  CAS  Google Scholar 

  48. Auchter RM, Lamond JP, Alexander E III, et al.: A multiinstitutional outcome and prognostic factor analysis of radiosurgery for resectable single brain metastasis. Int J Radiat Oncol Biol Phys 1996, 35:27–35. This is an important multi-institutional retrospective analysis of the results of radiosurgery for single brain metastases showing that outcomes comparable to surgical resection can be achieved with radiosurgery.

    Article  PubMed  CAS  Google Scholar 

  49. Alexander E III, Moriarty TM, Davis RB, et al.: Stereotactic radiosurgery for the definitive, noninvasive treatment of brain metastases. J Natl Cancer Inst 1995, 87:34–49.

    Article  PubMed  Google Scholar 

  50. Becker G, Duffner F, Kortmann R, et al.: Radiosurgery for the treatment of brain metastases in renal cell carcinoma. Anticancer Res 1999, 19:1611–1617.

    PubMed  CAS  Google Scholar 

  51. Mori Y, Kondziolka D, Flickinger JC, et al.: Stereotactic radiosurgery for cerebral metastatic melanoma: factors affecting local disease control and survival. Int J Radiat Oncol Biol Phys 1998, 42:581–589.

    Article  PubMed  CAS  Google Scholar 

  52. Young RF: Radiosurgery for the treatment of brain metastases. Semin Surg Oncol 1998, 14:70–78.

    Article  PubMed  CAS  Google Scholar 

  53. Muacevic A, Kreth FW, Horstmann GA, et al.: Surgery and radiotherapy compared with gamma knife radiosurgery in the treatment of solitary cerebral metastases of small diameter. J Neurosurg 1999, 91:35–43.

    Article  PubMed  CAS  Google Scholar 

  54. Brandt RA, Cruz J, Scluajolitz J, et al.: Neurosurgical treatment of brain metastases: Microsurgery or radiosurgery [abstract]. Presented at the American Association of Neurological Surgeons Annual Meeting, 1996.

  55. Kondziolka D, Patel A, Lunsford LD, et al.: Stereotactic radiosurgery plus whole brain radiotherapy versus radiotherapy alone for patients with multiple brain metastases [in process citation]. Int J Radiat Oncol Biol Phys 1999, 45:427–434. This is an important study comparing WBRT to WBRT and radiosurgery for patients with two to four brain metastases. The study was stopped at interim analysis because of the significantly better tumor control seen in the group receiving combination therapy.

    Article  PubMed  CAS  Google Scholar 

  56. Flickinger JC, Kondziolka D, Lunsford LD, et al.: A multi-institutional experience with stereotactic radiosurgery for solitary brain metastasis. Int J Radiat Oncol Biol Phys 1994, 28:797–802.

    PubMed  CAS  Google Scholar 

  57. Grob JJ, Regis J, Laurans R, et al.: Radiosurgery without whole brain radiotherapy in melanoma brain metastases. Club de Cancerologie Cutanee. Eur J Cancer 1998, 34:1187–1192.

    Article  PubMed  CAS  Google Scholar 

  58. Sneed PK, Lamborn KR, Forstner JM, et al.: Radiosurgery for brain metastases: is whole brain radiotherapy necessary. Int J Radiat Oncol Biol Phys 1999, 43:549–558.

    Article  PubMed  CAS  Google Scholar 

  59. Pirrzkall A, Debus J, Lohr F, et al.: Radiosurgery alone or in combination with whole-brain radiotherapy for brain metastases. J Clin Oncol 1998, 16:3563–3569.

    Google Scholar 

  60. Shirato H, Takamura A, Tomita M, et al.: Stereotactic irradiation without whole brain irradiation for single brain metastases. Int J Radiat Oncol Biol Phys 1997, 37:385–391.

    Article  PubMed  CAS  Google Scholar 

  61. Mehta M, Noyes W, Craig B, et al.: A cost-effectiveness and cost-utility analysis of radiosurgery vs. resection for single-brain metastases. Int J Radiat Oncol Biol Phys 1997, 39:445–454.

    Article  PubMed  CAS  Google Scholar 

  62. Bernstein M, Cabantog A, Laperriere N, et al.: Brachytherapy for recurrent single brain metastases. Can J Neurol Sci 1995, 22:13–16.

    PubMed  CAS  Google Scholar 

  63. Schulder M, Black PM, Shrieve DC, et al.: Permanent low-activity iodine-125 implants for cerebral metastases. J Neurooncol 1997, 33:213–221.

    Article  PubMed  CAS  Google Scholar 

  64. McDermott MW, Cosgrove GR, Larson DA, et al.: Interstitial brachytherapy for intracranial metastases. Neurosurg Clin North Am 1996, 7:485–495.

    CAS  Google Scholar 

  65. Lesser GJ: Chemotherapy of cerebral metastases from solid tumors. Neurosurg Clin North Am 1996, 7:7527–7536.

    Google Scholar 

  66. Buckner JC: The role of chemotherapy in the treatment of patients with brain metastases from solid tumors. Cancer Metastasis Rev 1991, 10:335–341.

    Article  PubMed  CAS  Google Scholar 

  67. Rosner D, Nemoto T, Lane WW: Chemotherapy induces regression of brain metastases in breast carcinoma. Cancer 1986, 58:832–839.

    Article  PubMed  CAS  Google Scholar 

  68. Kristensen CA, Kristjansen PEG, Hansen HH: Systemic chemotherapy of brain metastases from small-cell lung cancer: a review. J Clin Oncol 1992, 10:1498–1502.

    PubMed  CAS  Google Scholar 

  69. Rustin GJ, Newlands ES, Begent RH, et al.: Weekly alternating etoposide, methotrexate, and actinomycin/vincristine and cyclophosphamide chemotherapy for the treatment of CNS metastases of choriocarcinoma. J Clin Oncol 1989, 7:900–903.

    PubMed  CAS  Google Scholar 

  70. Cormio G, Gabriele A, Maneo A, et al.: Complete remission of brain metastases from ovarian carcinoma with carboplatin. Eur J Obstet Gynecol Reprod Biol 1998, 78:91–93.

    Article  PubMed  CAS  Google Scholar 

  71. Franciosi V, Cocconi G, Michiara M, et al.: Front-line chemotherapy with cisplatin and etoposide for patients with brain metastases from breast carcinoma, non-small cell lung carcinoma, or malignant melanoma: a prospective study. Cancer 1999, 85:1599–1605.

    Article  PubMed  CAS  Google Scholar 

  72. Kaba SE, Kyritsis AP, Hess K, et al.: TPDC-FuHu chemotherapy for the treatment of recurrent metastatic brain tumors. J Clin Oncol 1997, 15:1063–1070.

    PubMed  CAS  Google Scholar 

  73. Malacarne P, Santini A, Maestri A: Response of brain metastases from lung cancer to systemic chemotherapy with carboplatin and etoposide. Oncology 1996, 53:210–213.

    Article  PubMed  CAS  Google Scholar 

  74. Pors H, Edler von Eyben F, Sorensen OS, et al.: Longterm remission of multiple brain metastases with tamoxifen. J Neurooncol 1991, 10:173–177.

    Article  PubMed  CAS  Google Scholar 

  75. Van der Gaast A, Alexieva-Figusch J, Vecht C, et al.: Complete remission of a brain metastasis to third line hormonal treatment with megestrol acetate. Am J Clin Oncol 1990, 13:507.

    Article  PubMed  Google Scholar 

  76. Carde P, Timmerman D, Koprowski C, et al.: Gadolinium- texaphyrin (GD-TEX) radiation sensitizer: improved survival in a phase IB/II trial in patients with brain metastases [abstract]. Proc Am Soc Clin Oncol 1998, 17:379a.

    Google Scholar 

  77. Viala J, Vanel D, Meingan P, et al.: Phases IB and II multidose trial of gadolinium texaphyrin, a radiation sensitizer detectable at MR imaging: preliminary results in brain metastases. Radiology 1999, 212:755–759.

    PubMed  CAS  Google Scholar 

  78. Kleinberg L, Grossman SA, Piantadosi S, et al.: Phase I trial to determine the safety, pharmacodynamics, and pharmacokinetics of RSR 13, a novel radioenhancer, in newly diagnosed glioblastoma multiforme. J Clin Oncol 1999, 17:2593–2603.

    PubMed  CAS  Google Scholar 

  79. Johnson FE, Harrison BR, McKirgan LW, et al.: A phase II evaluation of pentoxifylline combined with radiation in the treatment of brain metastases. Int J Oncol 1998, 13:801–805.

    PubMed  CAS  Google Scholar 

  80. Del Rowe JD, Bello J, Mitnick R, et al.: Accelerated regression of brain metastases in patients receiving whole brain radiation and the topoisomerase II inhibitor, lucanthone. Int J Radiat Oncol Biol Phys 1999, 43:89–93.

    PubMed  Google Scholar 

  81. Cosgrove GR, Hochberg FH, Zervas NT, et al.: Interstitial irradiation of brain tumors using a miniature radiosurgery device: initial experience. Neurosurgery 1997, 40:518–523.

    Article  PubMed  CAS  Google Scholar 

  82. Ram Z, Culver KW, Oshiro EM, et al.: Therapy of malignant brain tumors by intratumoral implantation of retroviral vector-producing cells. Nat Med 1997, 3:1354–1361.

    Article  PubMed  CAS  Google Scholar 

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  1. Division of Neuro-oncology, Department of Neurology, Brigham and Women's Hospital, 75 Francis Street, 02115, Boston, MA, USA

    Patrick Y. Wen MD

  2. Northeast Proton Therapy Center, Massachusetts General Hospital, Fruit Street, 02114, Boston, MA, USA

    Jay S. Loeffler MD

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Wen, P.Y., Loeffler, J.S. Brain metastases. Curr. Treat. Options in Oncol. 1, 447–457 (2000). https://doi.org/10.1007/s11864-000-0072-3

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