Systemic Antineoplastic and Supportive Therapy

Chapter 8 - Management of CNS Metastases

Systemic Antineoplastic Supportive Therapy Figure 1

Courtesy A. Berhghoff, Medical University of Vienna, Vienna

The blood–brain barrier (BBB) limits drug penetration into the CNS. However, pathological microvessels in CNS metastases may allow adequate drug penetration.

Responses of CNS metastases to cytotoxic chemotherapy (ChT) are not uncommon and there is a high correlation between extra- and intracranial response, thus systemic therapy is a feasible treatment option.

For selected patients with CNS metastases, therapy with targeted agents should be considered, ideally within a multidisciplinary tumour board.

Responses of CNS metastases have been documented to HER2 blockers, BRAF inhibitors, Epidermal growth factor receptor (EGFR) inhibitors, anaplastic lymphoma kinase (ALK) inhibitors, bevacizumab and immune checkpoint inhibitors.

Combination of targeted agents with RT may have synergistic effects, but for some drugs also carries the risk of excess toxicity.

Systemic Antineoplastic Supportive Therapy Figure 3

Courtesy J. Furtner, Medical University of Vienna, Vienna

Peritumoural brain oedema is a common finding in CNS metastases and may cause significant symptoms such as raised intracranial pressure and seizures.

Dexamethasone is the drug of choice to treat symptomatic brain oedema, but prolonged administration has multiple and severe adverse effects.

The initial daily dexamethasone dose is usually 12–16 mg and should be rapidly tapered to individual need (“as much as needed, as little as possible”).

Revision Questions

  1. Are CNS metastases a contraindication for systemic cytotoxic ChT?
  2. Name three biologicals for which therapeutic responses of CNS metastases have been seen.
  3. Which drug is indicated for the treatment of symptomatic brain oedema in patients with CNS metastases?

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Last update: 18 September 2017