This E-Learning module on the management of patients with brain metastases, with a special focus on radiotherapy, belongs to the current ESMO strategy to satisfy the needs of medical professionals across oncology disciplines. The problem of brain metastases is clinically very relevant, with 20-40% of adult cancer patients developing brain metastases during the course of their disease. This percentage is even higher; however autopsy is no longer routinely performed in patients with metastatic spread of the disease.
Approximately 60% of patients present with multiple brain metastases (≥4). Due to treatment advances cancer patients are living longer, it’s therefore more likely their cancer will eventually spread. Furthermore improvements in imaging and functional imaging technologies allow to evaluate brain tissue in better detail, making it easier to spot abnormal areas. In fact, more patients than ever are being diagnosed with brain metastases.
The symptoms and signs of brain metastases can be subtle and difficult to recognise. What patients experience usually relates to where the metastasis is located and its size. Most brain metastases develop in the cerebral cortex, about 15% of brain metastases develop in the cerebellum, and about 5% of metastases develop in the brain stem. Possible symptoms include headaches, sometimes with nausea and vomiting, seizures and partial seizures, problems with speech, vision, and understanding, physical weakness, numbness, and problems with movement.
It is important to underline that brain metastases are the manifestation of a primary tumour and not a diagnosis per se. Key clinical questions in patients with brain metastases are whether the primary tumour is known, its histology, sensitivity to chemotherapy, or targeted agents; whether a patient presents with single or multiple brain metastases, which, along with other important patient/tumour characteristics, is important for a treatment decision strategy (surgery vs. radiosurgery vs. whole brain radiotherapy); whether the systemic disease is controlled or controllable, and if systemic treatment is needed. Are the brain metastases causing the symptoms? Is there any improvement after steroids? Key questions are also the treatment goal and the expected outcome in terms of general condition and quality of life.
This module elaborates the prognostic factors important for the treatment decision in patients with brain metastases. Although treatment is dictated by histology and origin of the primary tumour, the module provides important therapeutic algorithms for patients, according to the number of metastases: in patients with 1-3(1-4) brain metastases according to possibility for complete resection and life expectancy; in patients with ≥4(≥5) metastases according to radiosensitivity and prognosis for life expectancy.
Beside advances in radiotherapy and the possibility of a cure in case of solitary brain metastasis, medical oncologists should remember that brain metastases respond well to systemic treatment if the drug reaches its target, the blood brain barrier. In this regard, the recommendations for treatment are disease-specific.
