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The Role of Surgery, Radiosurgery and Whole Brain Radiation Therapy in the Management of Patients with Metastatic Brain Tumors

DOI: 10.1155/2012/952345

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Brain tumors constitute the most common intracranial tumor. Management of brain metastases has become increasingly complex as patients with brain metastases are living longer and more treatment options develop. The goal of this paper is to review the role of stereotactic radiosurgery (SRS), whole brain radiation therapy (WBRT), and surgery, in isolation and in combination, in the contemporary treatment of brain metastases. Surgery and SRS both offer management options that may help to optimize therapy in selected patients. WBRT is another option but can lead to late toxicity and suboptimal local control in longer term survivors. Improved prognostic indices will be critical for selecting the best therapies. Further prospective trials are necessary to continue to elucidate factors that will help triage patients to the proper brain-directed therapy for their cancer. 1. Introduction Brain metastases are the most common intracranial tumor, arising in 10%–40% of all cancer patients [1, 2] and accounting for up to 170,000 new cases per year in the United States [3]. The observation of rising incidence is most likely related to the aging population, improved systemic treatment for the primary disease, and improved imaging techniques [4]. As a result, brain metastases are an increasing source of morbidity and mortality as well as cognitive impairment at the time of cancer diagnosis [5, 6]. Cancers with a high incidence in the general population (e.g., lung and breast) are the most frequently encountered source of brain metastases, accounting for up to two thirds of new cases [7]. Solid tumors constitute 95% of brain metastases, while leptomeningeal involvement makes up the remaining 5% [8–10]. Approximately 50%–60% of patients with solid tumors present with multiple metastases, while the remaining patients harbor a single mass [1, 11, 12]. The prognosis for patients with brain metastases from any histology is poor overall, with a median survival of only 4–7 months following treatment with WBRT alone [12–22]. For patients harboring a single, surgically amenable lesion, resection followed by WBRT has been found to be favorable to WBRT alone in two of three randomized controlled trials [17, 19, 22]. The local control rates and overall survival for patients with a single metastasis treated either with surgical resection followed by WBRT or with stereotactic radiosurgery (SRS) alone have been found to be similar [18, 19, 22–28]. On the other hand, SRS may yield superior local control rates for radioresistant brain metastases (e.g., from melanoma and renal cell) and

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