Integrated treatment of brain metastases

Abstract

Purpose of review Optimal treatment of brain metastases has been limited to local treatment with few systemic options. Increasing use of systemic targeted therapies, chemotherapy and immunotherapy and combination of local and systemic treatments has resulted in plethora of publications. We review the existing evidence for individual treatments and new evidence for the integration of systemic and combination of local treatments. Recent findings Encouraging efficacy of systemic therapies supports combination of systemic and local treatment albeit with little randomized trial data. Efficacy particularly of targeted agents provides an opportunity to delay local treatments including radiosurgery and whole brain radiotherapy. Randomized trials testing the integration of surgery, radiotherapy and radiosurgery are reviewed with emphasis on patient relevant endpoints to guide the clinician in the choice and sequence of treatments and integrating systemic and local therapies. Summary There is increasing tendency to use focused radiation for single and oligometastases with or without surgery and decline in whole brain radiotherapy which is limited to multiple metastases in tumours without effective systemic options. Systemic therapies have promising intracranial efficacy and the sequence and combination with localized radiation is awaiting trials. Changes in practice with a move to primary systemic treatment for brain metastases without radiation, should be undertaken with caution and close monitoring.

Identifying Topics and Evolutionary Trends of Literature on Brain Metastases Using Latent Dirichlet Allocation

“…The major omission is surgery. Despite the key role of surgery in the management of brain metastases, especially for large metastases ( Soffietti et al, 2017 ; Rosenfelder and Brada, 2019 ) and several randomized trials showing the benefits of surgery combined with WBRT ( Mintz et al, 1996 ; Gállego Pérez-Larraya and Hildebrand, 2014 ), surgically associated terms such as resection occurred only in topics related to radiosurgery (T7 in the 2000’s, T3 in the 2010’s) ( Supplementary Table S2 ). This is in keeping with a general lack of research in surgery, and is a good example where the small number of studies examining surgery is a reflection of the weakness of the literature, rather than a measure of the relative importance of surgery.…”

Brain metastases: increasingly precision medicine—a narrative review

“…Even allowing for the costs associated with MRI surveillance and salvage therapy, SRS alone also demonstrates superior costeffectiveness over SRS+WBRT (40)(41)(42). Hence, SRS alone has become standard of care for fit patients with ≤4 BM, where close MRI surveillance is logistically possible (43)(44)(45)(46)(47)(48).…”

High-Resolution Intratumoral Susceptibility Signal (ITSS) as an Adjunctive Imaging Tool in the Evaluation of Treatment Response of Brain Metastases Following Stereotactic Radiosurgery

“…3 Stereotactic radiosurgery (SRS) is the mainstay for treatment of oligometastases in patients with good performance status. [11][12][13] Due to the high inherent soft tissue contrast, Magnetic Resonance Imaging (MRI) is the imaging modality of choice for evaluation of primary and metastatic brain tumors, post-surgical and therapeutic surveillance, and for monitoring treatment response. 14,15 The conventional MRI sequences such as T2 FLAIR and post contrast T1 lack specificity to differentiate between local progression versus radiation changes, and also lack predictive value.…”