Current Management of Brain Metastases: Overview and Teaching Cases

Abstract

Over the past two decades, increased global incidence of malignancy, improved systemic disease treatment with prolonged survival, and increased central nervous system (CNS) surveillance in cancer patients have all contributed to a rise in cerebral metastatic disease. As many patients retain good neurologic function, the approach to their management has shifted markedly; a pre-terminal prognosis and palliative treatment have been replaced by individualized care plans to prolong functional survival. However, the rapid shifts in disease characteristics, treatment options and emerging evidence can be challenging to navigate, and a rational approach to brain metastases is needed. We discuss the changing epidemiology of brain metastases and consider approaches to prognostic classification. We review current treatment modalities and discuss the significant studies pertaining to each, with emphasis on Level 1 evidence when available and cooperative group trials, as well as studies on adverse effects. To integrate the information presented, we offer case scenarios that highlight pertinent decision-making factors. The shift in care goal for cerebral metastases from symptom palliation to prolongation of survival is not only feasible, but in many cases indicated. The appropriate application of various treatment modalities must be considered in the context of individual patients and their primary cancer.

Brain Metastases from Uterine Cervical and Endometrial Cancer

“…Moreover, the proportion of patients presenting with a single BM had decreased from 57.8% to 35.9% (before 2010 vs. after 2010). These changes are consistent with those of other solid tumors and are likely due to the increased use of brain MRI for clinical investigations [ 149 , 150 ].…”

Disparities in the Use of Single-fraction Stereotactic Radiosurgery for the Treatment of Brain Metastases From Non-small Cell Lung Cancer

“…Brain metastases are the most common type of intracranial tumor and affect up to 40% of all patients with cancer. More than half of these metastases come from lung cancer histologies [1-2]. Survival from lung cancer continues to improve, which could be explained by improvements in systemic therapies including chemotherapy, targeted agents and immunotherapies [3].…”

A multi‐modality physical phantom for mimicking tumor heterogeneity patterns in PET/CT and PET/MRI

“…(b) From top to bottom: computed tomography (CT), positron emission tomography (PET), and magnetic resonance (MR) images of the phantom. (c) Examples of cancers that are represented with the proposed model; images adapted from previous reports 35–37 …”

“…The phantom comprises three conical tubes. Each tube consists of a homogeneous region containing only the radioactive solution (H) and a heterogeneous region [35][36][37] established by acrylic spheres surrounded by a radioactive solution (S). For this, the tubes (d = 31 mm, h = 110 mm) were half -filled with different sizes of acrylic spheres to recreate three different patterns (S1: 1.6 mm; S2: 50% each of 1.6 and 6.3 mm, and S3: 6.3mm diameter); see Figure 1.…”