Managing brain metastases

In Lancet Neurology, authors reviewing the management of brain metastases provide a decision tree for treatment according to patient prognosis.The authors review supporting data for the various treatment strategies and provide justifiable therapeutic options for patients with a good prognosis. Options to improve quality of life are provided for patients with a poorer prognosis.The decision tree divides patients according to their recursive partitioning analysis (RPA) class. RPA class 1 and 2 is subdivided according to whether the patient has single or multiple brain metastases, and class 2 is further subdivided into patients with or without active extracranial disease.The authors say, "Class 1 and 2 patients without active extracranial disease may be treated with surgery (single metastasis) or radiosurgery (one to four metastases, and possibly more). This therapy can either be followed by WBRT or, alternatively, by regular MRI follow-up. Patients with less favourable prognostic factors (eg. KPSPatients with chemosensitive tumours may also benefit from chemotherapy after surgery or radiation. Chemosensitive tumours include metastases from small cell lung cancer, breast, and germ-cell primary tumours. In general, the choice of chemotherapeutic agent for the brain metastasis should be based on the chemosensitivity of the primary tumour. The review describes chemotherapy agents that easily cross the blood brain barrier and also novel chemotherapeutic approaches.Reference...