How is a single brain metastasis treated in patients without prior whole-brain radiation therapy (WBRT)?

Updated: Aug 01, 2018
  • Author: Victor Tse, MD, PhD; Chief Editor: Nicholas Lorenzo, MD, MHA, CPE  more...
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Answer

The algorithm for the management of a solitary brain tumor (patient with no or stable systemic disease) is easier than that of a single metastatic tumor. If the solitary lesion is symptomatic and/or in a noneloquent area, then surgical resection is the best option; this provides tissue confirmation and reduces mass effect.

Even then, the use of WBRT or radiosurgery as adjuvant therapy remains controversial. It is a general belief that adjuvant radiotherapy is indicated since the hazard ratios for local recurrence and distance recurrence in patients without WBRT are 3.14 and 2.16 (as compared to 0.58 and 0.42), respectively. However, the use of stereotactic radiosurgery as an adjuvant therapy is gaining momentum. A body of clinical evidence suggests that radiosurgery to the rim of the tumor resection cavity is equally effective in achieving local control. An upcoming NCCTG-N107C study is designed to categorically address this issue.

Radiosurgery has been used effectively in treating multiple lesions as an upfront therapy; therefore, there is no reason to doubt it will not be able to control local diseases around the resection cavity if an adequate marginal dose is achievable; thus, reserve WBRT to be used in distance relapse with multiple lesions, local progression, or in cases in which leptomeningeal spread is suspected. It is also possible to perform re-resection in cases in which local progression is evidenced, as well as in cases in which the differentiation of local recurrence and radiation necrosis is not possible.


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