Estudiante

Oncologist
Neuro-Oncology
a

The

®

Multidisciplinary Management of Brain Metastases
APRIL F. EICHLER,a,b,d JAY S. LOEFFLER,a,c,d Pappas Center for Neuro-Oncology, Departments of bNeurology and cRadiation Oncology, Massachusetts General Hospital and dHarvard Medical School, Boston, Massachusetts, USA
Key Words. Neoplasm metastasis • Brain neoplasms • Therapeutics • Ionizing radiation •Drug therapy

LEARNING OBJECTIVES
After completing this course, the reader will be able to: 1. Identify the clinical factors that predict survival after a diagnosis of brain metastasis. 2. Select appropriate multidisciplinary treatments for patients with new and recurrent brain metastases. 3. Describe the circumstances in which focal therapy, such as surgery or stereotactic radiosurgery, islikely to be beneficial for patients with brain metastases.
CME

Access and take the CME test online and receive 1 AMA PRA Category 1 Credit™ at CME.TheOncologist.com

ABSTRACT
Metastatic brain tumors are the most common intracranial neoplasms in adults. The incidence of brain metastases appears to be rising as a result of superior imaging modalities, earlier detection, and more effectivetreatment of systemic disease. Therapeutic approaches to brain metastases include surgery, whole brain radiotherapy (WBRT), stereotactic radiosurgery (SRS), and chemotherapy. Treatment decisions must take into account clinical prognostic factors in order to maximize survival and neurologic function whilst avoiding unnecessary treatments. The goal of this article is to review important prognosticfactors that may guide treatment selection, discuss the roles of surgery, radiation, and chemotherapy in the treatment of patients with brain metastases, and present new directions in brain metastasis therapy under active investigation. In the future, patients will benefit from a multidisciplinary approach focused on the integration of surgical, radiation, and chemotherapeutic options with the goal ofprolonging survival, preserving neurologic and neurocognitive function, and maximizing quality of life. The Oncologist 2007;12:884 – 898

Disclosure of potential conflicts of interest is found at the end of this article.

INTRODUCTION
Metastatic brain tumors are the most common intracranial neoplasm in adults, and although the exact incidence is unknown, it has been estimated to be as high as200,000 cases per year in the U.S. alone [1]. Recent population-based data

suggest that 8%–10% of adults with cancer will develop symptomatic brain metastases during their lives [2, 3]. The majority of brain metastases originate from one of three primary malignancies: lung cancer (40%–50%), breast cancer (15%–25%), and melanoma (5%–20%). Among these,

Correspondence: April F. Eichler, M.D.,Pappas Center for Neuro-Oncology, Massachusetts General Hospital, 55 Fruit Street, Yawkey 9E, Boston, Massachusetts 02114, USA. Telephone: 617-724-1548; Fax: 617-724-8769; e-mail: aeichler@partners.org Received February 21, 2007; accepted for publication April 30, 2007. ©AlphaMed Press 1083-7159/2007/$30.00/0 doi: 10.1634/theoncologist.12-7884

The Oncologist 2007;12:884 – 898www.TheOncologist.com

Eichler, Loeffler

885

melanoma has the highest propensity to metastasize to the brain, with a 50% rate of brain involvement reported in patients dying of melanoma [4]. The frequency of metastatic brain tumors appears to be rising as a result of superior imaging modalities and earlier detection as well as longer survival after a primary cancer diagnosis because of more effectivetreatment of systemic disease. The distribution of brain metastases generally parallels blood flow, with 80% occurring in the cerebral hemispheres, 15% in the cerebellum, and 5% in the brainstem [5, 6]. In the era of magnetic resonance imaging (MRI), the majority of patients have multiple brain metastases at diagnosis. Common clinical features include headache, neurological deficit, and seizures....