|15 Cerebral Metastasis|
Cerebral metastasis is the most common malignancy affecting the brain. The 3 most common sites of the primary tumor are the lung, breast and gastrointestinal tract. Seventy percent of the patients with cerebral metastasis have 1 or 2 lesions and 80% are located in the cerebral hemispheres (1).
Patients with good a neurologic function, a long disease free interval between the diagnosis of the primary tumor and development of the metastases, and lack of progressive systemic disease, tend to have the best prognosis. Therefore, the management of patients with cerebral metastases depends on following factors: the performance status of the patient, the status of the systemic disease, and the number of cerebral lesions.
For patients with progressive systemic disease and/or poor performance status, palliative WBRT or supportive management with dexamethasone alone is considered the most appropriate treatment. On the other hand, patients with solitary brain metastasis, who otherwise have no or stable systemic disease and a good performance status, should be considered for palliative surgical resection prior to whole brain radiotherapy (WBRT). Surgery followed by WBRT has shown to significantly improve both the survival time and the quality of life of patients in this category, when compared to treatment with WBRT alone (2).
The role of single fraction SRT/radiosurgery in the primary treatment of cerebral metastases is an area of ongoing investigation. Retrospective studies have shown that it benefits patients with good performance status, absence of systemic disease and up to 3 cerebral lesions. Moreover, it seems to produce similar results to those reported in surgical series when the criteria used for patient selection are similar (3,4). Recently, this hypothesis has been tested in a prospective randomized manner and the results have been published in an abstract form (5). In light of the results, it is reasonable to consider using a radiosurgery boost in addition to WBRT as initial treatment for patients with the following circumstances: 1) inoperable solitary brain metastasis, 2) up to 3 cerebral lesions, provided that the performance status is good and there is no progressive systemic disease. It may also be useful in the palliation of recurrent cerebral metastases following WBRT in carefully selected cases which there are no more than 3 lesions, performance status is good and there is no progressive systemic disease.
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