Dr. Gutt is a radiation oncologist at the Washington DC VAMC. Dr. Dawson and Dr. Cheuk are radiation oncologists at the James J. Peters VAMC in the Bronx, New York, and assistant professors at Mount Sinai School of Medicine in New York. Dr. Kelly and Dr. Dawson are radiation oncologists at the New Jersey VAHCS in East Orange, New Jersey. Dr. Fosmire is a radiation oncologist at the Richard L. Roudebush VAMC in Indianapolis, Indiana. Dr. Moghanaki is a radiation oncologist at the Hunter Holmes McGuire VAMC and an assistant professor at Virginia Commonwealth University Massey Cancer Center, both in Richmond, Virginia. Dr. Jolly is a radiation oncologist at the VA Ann Arbor HCS in and an associate professor at the University of Michigan, Ann Arbor.
References
Factors that have been correlated with improved survival include younger age, better performance status, fewer brain metastases, and lower burden of systemic disease. 41,42 Prognostic assessment tools such as the Graded Prognostic Assessment and RTOG-Recursive Partitioning Analysis can be used to predict life expectancy in patients with brain metastases. 41,43 However, routine use of these tools is lagging, as evidenced by a recent survey of VHA radiation oncologists. Use of these tools in the clinic will enhance the quality of end of life care and decision making.
Corticosteroids have classically been used in the treatment of brain metastases either alone for supportive care or in combination with RT. Steroids are recommended to provide symptom relief in patients with symptoms related to cerebral edema or mass effect. 44 Steroids have been shown to mitigate edema and improve neurologic deficits in about two-thirds of patients with brain metastases. 36,45 The effect of corticosteroids is thought to be mediated through inhibition of prostaglandin synthesis, reduction in vascular permeability, and anti-inflammatory properties. 46 A common corticosteroid regimen is a 10-mg loading dose of dexamethasone, followed by 16 mg daily in divided doses. For patients without neurologic deficits or cerebral edema, it is reasonable to defer corticosteroid use only when patients are symptomatic.
In general, WBRT is considered an appropriate treatment option for patients with multiple brain metastases based on data suggesting an improvement in OS compared with the use of corticosteroids alone. 47 Whole brain radiation has been shown to result in the improvement of baseline neurologic deficits or the prevention of further symptom progression. 48 The partial or complete metastasis response rates are on the order of 60%.38 Tumor regression after WBRT has been associated with preservation of neurocognitive function as well as prolonged survival. 49
For good prognosis patients with a single brain metastasis and good performance status, the use of surgery or radiosurgery added to WBRT has been associated with improved OS (Table). The RTOG 9508 randomized trial of WBRT with or without SRS demonstrated a survival advantage with SRS, with median survival times of 6.5 months with WBRT + SRS vs 4.9 months with WBRT alone. 50 Similarly, a randomized trial evaluating WBRT alone compared with surgery followed by WBRT in patients with good prognosis demonstrated significantly improved OS in the surgery group (median 40 weeks vs 15 weeks).51 In general, WBRT or postoperative RT to the tumor bed is still indicated after surgical resection, based on randomized data showing a reduction in tumor bed recurrence with postoperative RT. 52
For patients with only 1 to 3 brain metastases and a favorable prognosis, surgery and SRS can be considered treatment options, oftentimes with WBRT. The EORTC randomized trial of patients with 1 to 3 brain metastases was designed to determine the benefit of WBRT after treatment with surgery or SRS. In this study, 119 patients underwent SRS and 160 patients underwent surgical resection. 53 Both groups of patients were randomized to observation vs adjuvant WBRT. This study demonstrated reduced rates of intracranial relapse with WBRT, however, without any change in OS. Although there is concern that WBRT may impair cognitive function with no clear survival benefit after surgery or SRS, WBRT does reduce recurrence rates in the brain and the need for further treatment. 54 Therefore, decisions regarding WBRT in such a setting should be made only after a detailed discussion with a radiation oncologist regarding risks vs benefits of treatment as part of the informed decision-making process.
