Brain Metastasis with Poor Prognosis

Key components:

  1. Control of peritumoral edema and increased ICP with steroids
  2. Treatment of seizures
  3. Management of venous thromboembolic disease

Modalities:

  1. whole brain radiation therapy (WBRT)
  2. surgery
  3. stereotactic radiosurgery (SRS)

Supportive care + corticosteroids – median survival of 1-2 months

WBRT – average survival of 3-6 onths

3 factors determining survival:  performance status, extent of extracranial disease, age

Three prognostic classes:

  1. Class 1 Karnofsky performance score (KPS) 70/+, <65y, controlled primary tumor, no extracranial metastases à median survival 7.1 months
  2. Class 2 KPS 70/+ but with other unfavorable characteristics à2 months
  3. Class 3 KPS <70 à median survival 2.3 months

DS-GPA: (diagnosis-specific graded prognostic assessment) = separate criteria for patients with NSCLC, SCLC, melanoma, RCC, breast cancer, GI cancer

  1. NSCLC or SCLC – all factors were significant
  2. Melanoma or RCC – only KPS and # of brain mets significant factors
  3. Breast CA or GI Ca – KPS only

NOTES:

  • Aggressive treatment not warranted
  • If active treatment – prefer WBRT.
  • SRS and surgery for favorable prognosis
  • 2 exceptions: poor performance status due to mets, SRS associated with improved survival; also lesions <5, SRS instead of WBRT (SRS is 1 day, while WBRT is multiple days)

WBRT:

  • goal is to improve deficits, questionable if survival is improved
  • response rate 40-60% (breast and SCLC responsive, less with melanoma or RCC; small, solid tumors more likely than large, necrotic or cystic)
  • Overall survival determined by activity and extent of extracranial disease rather than control of brain mets; there is a trial that compares WBRT with best supportive care showing no difference I survival between optimal supportive care compared with adding WBRT
  • Most common regimen: total dose 30Gy in 10 daily fractions of 3 Gy
  • Acute toxicity: mild and self-limited; cerebral edema may worsen, so start steroids 48 hours prior
  • Late toxicity: leukoencephalopathy, brain atrophy à dementia, radiation necrosis, NPH, hypothyroidism, cerebrovascular disease

Recurrent brain mets:  surgery, SRS, reirradiation, systemic chemo?

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