Modern Multidisciplinary Management of Brain Metastases

Ideal management of brain metastases (BMs) requires simultaneous control of the existing brain metastasis (local brain control), prevention of future BMs (distant brain control), and control of the systemic cancer (systemic control).

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Modern Multidisciplinary Management of Brain Metastases
Abstract Available tools include whole brain radiation therapy (WBRT), surgery, stereotactic radiosurgery (SRS), and systemic therapies, such as chemotherapies, biologic agents, and radiosensitizing agents. Selecting the combination of these tools is highly individualized and is impacted by numerous factors involving the tumor, patient, provider, and evolving evidence. Historically, patients received WBRT, either alone or with local treatments (surgery or SRS). However, concern about the effects of WBRT, coupled with improvements in local control and survival in select patients, with the combination treatment, has led to a reconsideration of the role of WBRT. Additionally, there have been advancements in the efficacy and tolerance of systemic therapies and clarification regarding the relative risks and symptoms of tumor recurrence versus treatment complications. Thankfully, individualizing modern multidisciplinary management for patients with BMs is being aided by numerous recently completed, ongoing, and planned prospective series.
Introduction Secondary metastases to the brain parenchyma (brain metastases [BMs]) are 10 times more common than primary brain tumors and most commonly originate in the lung, breast, skin, kidney, and colon. Twenty percent to 25% of patients with systemic cancer eventually develop symptomatic BMs, which account for about 170,000 new cases diagnosed annually in the United States [1]. There is a 33% chance of BMs presenting as either solitary, oligometastatic (2-3 lesions), or polymetastatic (>4 lesions), and a 80% chance that they will present after the systemic cancer diagnosis [2]. Presenting symptoms include headaches, seizures, encephalopathy, ataxia, and sensory or motor deficits. Patients with BMs may also be asymptomatic. Numerous factors are likely increasing the incidence of brain metastasis. By 2030, an estimated 20% of the US population will be 65 years old, accounting for 70% of all cancers and 85% of all cancer-related mortality [3]. Detection of both symptomatic and asymptomatic disease has increased though the use of T1/T2-weighted gadolinium-contrast MRI. The number of systemic cancer patients living long enough to develop BMs has increased as a result of improved local and systemic therapies. For instance, there has been an increase in survival of colon cancer patients from about 10 to 12 months in the era of 5-flourouracil monotherapy to about 22 to 24 months in the era of combination therapy involving biologic agents [4]. This increased survival coincides with the increased incidence of BMs from 2.3% to between 5% and 6%, respectively [5]. Lastly, the unreliable and likely variable penetration of many systemic therapies through the…

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