Two-year experience of multi-disciplinary team (MDT) outcomes for brain metastases in a tertiary neuro-oncology centre

Abstract

Brain metastases (BMs) are the most common intracranial tumour in adults and form a significant proportion of the neuro-oncology workload. Their management has progressed significantly in the last few decades but a gold-standard evidence-based management strategy has not been defined to date and several guidelines based on available evidence exist to support clinical decision-making. This paper evaluates the decision-making process of the neuro-oncology multi-disciplinary team (MDT) in a tertiary neuro-oncology centre over a two-year period. A retrospective review of all patients with BM discussed in the MDT was conducted. Data on patient demographics, tumour characteristics and MDT decision were collected from the MDT database, clinical notes and imaging studies. Patients were stratified into the three recursive partitioning analysis (RPA) classes and according to the graded prognostic assessment (GPA) score. MDT decisions were analysed by RPA class and for GPA score as well as single versus multiple BM. There were 362 patients with BM, representing 22% of the total cases discussed at the MDT. Decision-making was largely consistent with available guidelines. A concrete treatment decision was reached in 77.5% of patients and 32.2% of these received neurosurgical input. More patients with solitary BM underwent surgery compared to multiple BM (p = 0.001), and more patients in RPA classes I and II had surgical resection compared to class III (p = 0.005 and 0.001, respectively). Surgical patients also had higher GPA scores compared to palliative patients (p = 0.005). A greater absolute number and proportion of patients in RPA class II vs. class I underwent neurosurgical intervention. These patients were stratified into class II because of their age but would otherwise have been placed into class I. Survival data were available for 195 patients (53.8%) at 1 year post MDT discussion. A pattern of declining survival was observed along RPA classes which was statistically significant (p = 0.0025). Median survival was 4.7 (0-41), 3.7 (0-23), and 2.5 (range 0-24) months for RPA class I, II and III respectively. A similar pattern that did not reach statistical significance was found between GPA scores (p = 0.101). Median survival was 3 (0-13), 4.6 (range 0-41), and 4.6 (0-35) months for GPA scores 0-1.0, 1.5-2.5 and 3-4.0, respectively. Patient selection was generally in accordance to RPA class and GPA scoring, with the exception of surgery offered to elderly patients: this can be explained by the increasing number of otherwise fit patients as population ages.

Dynamic susceptibility MR perfusion in diagnosing recurrent brain metastases after radiotherapy: A systematic review and meta‐analysis

“…We believe that all MRI results should be interpreted in the clinical context (including patient symptoms and clinical findings, date and type of treatment received, and systemic status). This is preferably discussed in a neuro‐oncology multidisciplinary team meeting, which is the optimal place to make decisions regarding further diagnostic work‐up (such as closer follow‐up or stereotactic biopsy) and treatment …”

“…This is preferably discussed in a neuro-oncology multidisciplinary team meeting, which is the optimal place to make decisions regarding further diagnostic work-up (such as closer follow-up or stereotactic biopsy) and treatment. 40,41 In order to validate DSC MR perfusion for clinical application, it is essential to further investigate potential causes of heterogeneity. Ideally, this is done by prospective studies following ASFNR recommendations regarding DSC MR perfusion acquisition and postprocessing.…”

Management evaluation of metastasis in the brain (MEMBRAIN)—a United Kingdom and Ireland prospective, multicenter observational study

“…Two out of three RCTs found a statistically significant longer median survival and better quality of life in the surgical resection group. Two other large RCTs looked at the effect of SRS in combination with WBRT 15,27 in the management of single or multiple CMs and found that a combination of the two treatment modalities may show improved neurological function and intracranial tumor control, however does not show improved median survival. These findings were confirmed by a meta-analysis of 27 RCTs.…”

“…Another reason could be that more surgery is offered to the elderly as an increasing number of otherwise fit patients are referred in an ageing population. 27 There have been efforts to develop new stratification tools such as the Barnholtz-Sloan index 46 , Score Index for Radiosurgery (SIR) and Basic Score for Brain Metastases (BSBM) amongst others 6,47,48 to guide NMDT decision-making for this heterogeneous cohort of patients. These have not been widely adopted into clinical practice for a number of reasons, presumably due to the fact that most of these scores are based on survival data alone without considering other important factors such as quality of life and tumor recurrence.…”

“…Within the subgroup of patients with multiple metastases, patients with two metastases were most commonly referred (18.2% of total) followed by patients with five or more CMs (15.5% of total). The change in practice reflects the fact that 38.2% (n=186) of the patients referred with multiple metastases were recommended specialist intervention, as compared to ~10% of patients in a single-center series of 1640 patients from 2013-2015 27. While treatment recommendation was limited to single CM in the former NICE guidelines of 2006, the newer NICE guidelines of 2018 give some recommendations regarding multiple NOP-D-19-00065R1 metastases management, however lacking any recommendation about surgical resection.Therefore offering an intervention (surgery or SRS) in patients with multiple metastases remains entirely at the discretion of the NMDT and the treating surgeon or oncologist.…”