Contemporary Management of Brain Metastases
Sharpe, John P.
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Brain metastases are the most common neurological complication of systemic cancer and their incidence is rising. A majority of intracranial metastases originate from lung, melanoma, breast, colon and renal primary sites. With the advancement of magnetic resonance imaging techniques, it is now evident that most patients diagnosed with this disease harbor multiple lesions. Individual tumor foci typically contain areas of necrosis and neovascularity and are classically associated with extensive vasogenic edema Intracranial metastases are generally localized to areas of decreased vascular caliber, such as the gray-white matter junction of the cerebral cortex and in the border zones of the arterial territories. Patients with brain metastases often develop focal neurologic symptoms related to the functions subserved by brain areas adjacent to the lesion(s). Generalized symptoms such as headaches are also quite frequent. Corticosteroids and antiepileptic drugs are the mainstays of initial management. If patients with metastatic lesions have not been previously diagnosed with cancer, physicians may perform a biopsy of the intracranial tumor to help determine the primary site. The histopathologic features of the metastatic lesions are generally similar to those of the primary tumor from which they originate. The best choice for therapy is generally related to the location, size, and number of metastases, the patient's age and physical/neurological condition, the status of the patient's systemic disease, the patient's response to previous treatments, and possible future outcomes. Existing therapies include chemotherapy, Whole Brain Radiation Therapy (WBRT), surgical resection, and Stereotactic Radiosurgery (SRS). Most of these therapeutic modalities can offer effective intracranial palliation, and the majority of patients suffering from brain metastases will ultimately succumb to their systemic disease. Combination therapies and novel focused 'therapies have the potential to prolong survival in these patients. A further elucidation of the molecular and cellular mechanisms essential to the metastatic process may ultimately yield more promising treatment options.