How to treat brain metastasis in 2012?

Département de radiothérapie, CRLC Val-d'Aurelle-Paul-Lamarque, Montpellier, France.
Cancer/Radiothérapie (Impact Factor: 1.41). 07/2012; 16(4):309-14. DOI: 10.1016/j.canrad.2012.03.010
Source: PubMed


During the last French radiation oncology society annual congress, the therapeutic options for the management of brain metastases were presented. The indications and limits of surgery, stereotactic radiotherapy and whole brain radiotherapy, as well as their benefit in terms of overall survival, local control and improvement of the functional and neurocognitive status were discussed. The prognosis significance of the different phenotypes of breast cancer on the risk for BM as well as their roles in the treatment of brain metastases were also described. Surgery improves overall survival for patients with a single brain metastase and should be considered in the case of symptomatic lesions. The overall survival of patients treated with stereotactic radiotherapy do not differ from that of patients treated with surgery. These treatments should be mainly considered for patients with good performance status, one to three small brain metastases (<3cm) and limited extracranial disease. Whole brain radiotherapy is more and more discussed in adjuvant setting due to potential late neurocognitive toxicity. This toxicity could be improved with the development of techniques sparing the hippocampus. HER2+ and triple-negative breast cancer patients are at increased risk for brain metastases. Prognosis of these patients differs as the overall survival of HER2+ patients has improved with anti-HER2 therapies. The optimal combination of local and systemic therapies remain to be determined.

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    ABSTRACT: Hippocampi plays a fundamental role in immediate or long-term memory and the spatial learning. This structure is rarely involved by metastasis and their irradiation is at the origin of some impairment of the neurocognitive function. Sparing hippocampi during whole brain radiation therapy becomes possible with volumetric modulated arc therapy (VMAT) or with helical tomotherapy. The delineation of the structures should be performed after coregistration of gadolinium-enhanced T1-weighted MR-images with the planning. The D40 to both hippocampi should not be greater than 7.3Gy. Patients who are more likely to benefit from a hippocampal-sparing strategy must have a 6months or longer life expectancy and a Karnosky index above 70. Hence, patients who are more likely to be deemed fit for this strategy are frequently patients with NSCLC, breast cancer, gastointestinal cancers or patients. Patients with small cell lung carcinoma who are selected for prophylactic cerebral irradiation should be also considered, as they are unfit for ablative treatments such as stereotactic radiotherapy or brain surgery. Moreover, brain metastasis located in the area surrounding the hippocampi are unlikely. To date, no randomized study is available to confirm these assumptions. Two on-going prospective trials (RTOG 0933 and a French phase II trial) are currently investigating whether breast cancer patients with a single resected metastasis could benefit from the hippocampal-sparing strategy during whole brain radiotherapy.
    No preview · Article · Sep 2013 · Cancer/Radiothérapie
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    ABSTRACT: The addition of whole-brain radiotherapy is a standard of care for patients with single, resectable intracranial metastasis. Stereotactic irradiation of the postoperative resection cavity seems to offer excellent local control rates and avoid the neurocognitive risks of whole-brain radiation therapy. The risk of remote intracranial recurrence imposes a strict surveillance imaging in order to proceed to a possible irradiation before a symptomatic stage. It must be validated in future randomized trials.
    No preview · Article · Sep 2013 · Cancer/Radiothérapie
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    ABSTRACT: Brain irradiation can be used for the treatment of cancers in different protocols: focal radiotherapy, whole brain radiotherapy, with or without additive dose on the tumour. Different modalities (conformational, stereotactic radiosurgery) can be used for curative or prophylactic treatment. Brain radiotherapy leads to cognitive deterioration with subcortical profile. This cognitive deterioration can be associated to radiation-induced leukoencephalopathy on brain MRI. Taking into account radiation induced cognitive troubles is becoming more important with the prolonged survival allowed by treatment improvement. Concerning low-grade gliomas, radiation-induced cognitive troubles appear about 6 years after treatment and occur earlier when the fraction dose is important. Primitive cerebral lymphoma treatment can induce cognitive troubles in 25 to 30% surviving patients. These deficits are more frequent in elderly patients, leading to radiotherapy delay in those patients. Patients treated for brain metastasis often have cognitive impairment before radiotherapy (until 66%), this pretreatment impairment is related to global survival. The use of conformational radiation therapy, particularly with hippocampal sparing is conceptually interesting but has not proved its efficiency for cognitive preservation in clinical trials yet. Stereotactic radiation therapy could be an interesting compromise between metastatic tumoral volume reduction and cognitive preservation. Taking care of radiotherapy induced cognitive troubles is a challenge. Before considering its treatment and prevention, we need to elaborate a way of detecting them using a reliable and easy way. CSCT, a computerized test whose execution needs 90 seconds, could be used before treatment and during the clinical follow-up by the patient's oncologist or radiotherapist. If the patient's performance reduces, he can be oriented to a neurologist in order to perform fuller evaluation of its cognitive capacities and be treated if necessary.
    No preview · Article · Oct 2013 · Cancer/Radiothérapie
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