Multidisciplinary approach to management of patients with brain metastases

The incidence of brain metastases has increased over time as a consequence of an increase in the overall survival of patients with various types of cancer and the improved detection by magnetic resonance imaging (MRI). In this study, the guidelines and evidence for the radiotherapeutic, surgical, and chemotherapeutic management of patients newly diagnosed with brain metastases have been reviewed. For patients with good prognosis (expected survival, ≥ 3 months) and single brain metastases (> 3-4 cm) in whom safe complete resection is possible, whole brain radiotherapy (WBRT) and surgery (level 1) should be considered. Another alternative is surgery and radiation boost to the resection cavity (level 3). For single brain metastases (< 3-4 cm) that are not resectable, WBRT and radiosurgery, or radiosurgery alone should be considered (level 1). For selected patients with a limited number of multiple brain metastases (all < 3-4 cm) and good prognosis (expected survival, ≥ 3 months), radiosurgery alone, WBRT and radiosurgery, or WBRT alone should be considered (level 1). However, data from recent clinical trials have shown that adjuvant WBRT after radiosurgery or surgery for a limited number of brain metastases reduces intracranial relapses and neurologic deaths but fails to improve the duration of functional independence and overall survival. Many clinical studies have reported the effectiveness of molecular targeted therapies for brain metastases. Gefitinib or erlotinib should be considered for the treatment of asymptomatic patients harboring activating epidermal growth factor receptor (EGFR) mutations. Lapatinib should also be considered for the treatment of patients with brain metastases from human epidermal growth factor receptor (HER)-2-overexpressing metastatic breast cancer. In Japan, the intravenous administration of bevacizumab is currently being used for the treatment of symptomatic radiation necrosis of the brain.