Brain metastases: A Society for Neuro-Oncology (SNO) consensus review on current management and future directions

Abstract

Brain metastases occur commonly in patients with advanced solid malignancies. Yet, less is known about brain metastases than cancer-related entities of similar incidence. Advances in oncologic care have heightened the importance of intracranial management. Here, in this consensus review supported by the Society for Neuro-Oncology (SNO), we review the landscape of brain metastases with particular attention to management approaches and ongoing efforts with potential to shape future paradigms of care. Each coauthor carried an area of expertise within the field of brain metastases and initially composed, edited, or reviewed their specific subsection of interest. After each subsection was accordingly written, multiple drafts of the manuscript were circulated to the entire list of authors for group discussion and feedback. The hope is that the these consensus guidelines will accelerate progress in the understanding and management of patients with brain metastases, and highlight key areas in need of further exploration that will lead to dedicated trials and other research investigations designed to advance the field.

Brain metastases from hepatopancreatobiliary malignancies

“…Interestingly, we observed a rising incidence of BM over the last decades. This is well in line with larger clinical trials including different tumor entities pointing into the same direction [ 10 ]. Several factors may contribute to the rising number of BM.…”

The value of stereotactic biopsy of primary and recurrent brain metastases in the era of precision medicine

“…For example, targeted therapies have established intracranial activity in patients with Her2-positive breast cancer BM ( 10 , 11 ), ALK-rearranged ( 12 , 13 ) or EGFR-mutated NSCLC BM ( 40 ) and for BRAF V600E mutated melanoma BM ( 41 ). For subgroups of asymptomatic patients, targeted systemic therapy as monotherapy even represents a first-line consideration ( 41 – 43 ). Notably, tumor-dependent discrepancies can arise between the actionable mutational profile of the primary tumor and the respective BM ( 17 ).…”

Impact of Perioperative Dexamethasone in the Context of Neurosurgical Brain Metastasis Resection

“…(278 words) BACKGROUND Up to 50% of cancer patients develop brain metastasis within the course of disease 1,2 . Brain metastases are in general associated with a bad prognosis, however a subset of these patients with good clinical performance or good Karnofsky performance status (KPS), surgically accessible and/or symptomatic brain metastases are regularly undergoing extensive treatment including neurosurgical brain metastasis resection followed by radiotherapy (RTx) [3][4][5] . Apart from advances in local therapy (e.g.…”

“…stereotactic radiosurgery (SRS)), systemic treatment approaches have experienced some major changes. Adjuvant therapies have shifted from post-operative RTx and chemotherapy (CTx) to post-operative RTx with targeted therapies including small molecule inhibitors or checkpoint inhibition (CPI) [3][4][5][6][7] . Similar to glioblastoma treatment, patients with symptomatic brain metastases that undergo neurosurgical treatment with craniotomy and microsurgical brain metastasectomy regularly receive pre-and postoperative dexamethasone to treat perifocal edema to alleviate neurological symptoms 8,9 .…”

“…They are used to control the mass effect of perifocal tumor edema and the resulting neurologic deficitsts 12 . Treatment recommendations in this context lack evidence and are primarily based on expert opinion and few retrospective data 3, 4, 10 . With advent of immunotherapy or CPI dexamethasone dosage and down-taper schemes will likely gain importance as for other entities or situations.…”