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Clinical Updates for the Management of Lung Cancer Brain Metastases

*May 2023*

Nearly half of all brain tumors are associated with an underlying cancer diagnosis, and lung cancer is one of the most common of these. As improved cancer therapies are helping patients live longer, the safe and effective management of lung cancer brain metastases is coming to the fore. The goals we always keep in mind in these cases are to extend survival, prevent neurological dysfunction and improve quality of life. This article briefly reviews the progress made toward these goals made in recent years.

Surgery can be essential for making a diagnosis, maximizing resection of a solitary metastasis, and improving survival. It offers many advantages over other management strategies: Not only is the cancer locally removed, but the associated rapid resolution of mass effect and edema many times improves neurological issues and allows for faster tapering of corticosteroids used to treat symptomatic lesions.

Surgical risk can be reduced and neurological deficits minimized by using the following tools and strategies:

  • Image-guided computer-assisted navigation
  • Microsurgery and minimal-access craniotomy
  • Cortical mapping and awake surgery if near critical areas

In most cases, adding whole brain radiation therapy (WBRT) or stereotactic radiosurgery to surgery has been essential to increase survival and reduce tumor recurrences. Sometimes open surgery is not necessary; however, a biopsy may be required to confirm the tumor diagnosis and guide patient management.

Evolving Roles of Radiation Therapies

For decades, whole brain radiation therapy (WBRT) was considered standard treatment for patients with brain metastases. Although 70% to 90% of patients experience improved symptoms in 1 to 3 weeks, toxicities including alopecia, fatigue, skin erythema, headache, otitis media, somnolence syndrome, and leukoencephalopathy are common.
Most importantly, WBRT is associated with neurocognitive decline, which becomes more evident as patients live longer than 1 year. This risk can be lowered by newer approaches such as medications (eg, memantine) or modified radiation delivery such as hippocampal sparing during WBRT; however, delayed impact on cognition continues to be a factor.

This concern regarding delayed toxicity has reduced the role of WBRT in recent years. WBRT is still considered necessary for leptomeningeal disease and for cases involving numerous metastatic lesions, although the threshold is not well defined and is rising as other therapies prove effective for multiple metastases. WBRT is also traditionally standard for small cell lung cancer (SCLC) brain metastases, but evidence now indicates that stereotactic radiosurgery alone may be sufficient, if not favored, for up to 10 lesions.

Stereotactic radiosurgery offers multiple advantages over many other therapies, including lower cost and, in most cases, avoidance of general anesthesia for surgery. It involves a minimally invasive or noninvasive outpatient procedure with no meaningful recovery time. Additionally, in contrast to some of the limitations encountered with open surgery, stereotactic radiosurgery can safely treat lesions that are small, deep, or near critical areas. Read more.