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It Is Time to Reevaluate the Management of Patients With Brain Metastases

Kondziolka, Douglas MD, MSc, FRCSC*; Kalkanis, Steven N. MD; Mehta, Minesh P. MD§; Ahluwalia, Manmeet MD; Loeffler, Jay S. MD

Neurosurgery:
doi: 10.1227/NEU.0000000000000354
Special Article: Editor's Choice
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Abstract

There are many elements to the science that drives the clinical care of patients with brain metastases. Although part of an understanding that continues to evolve, a number of key historical misconceptions remain that commonly drive physicians' and researchers' attitudes and approaches. By understanding how these relate to current practice, we can better comprehend our available science to provide both better research and care. These past misconceptions include: Misconception 1: Once a primary cancer spreads to the brain, the histology of that primary tumor does not have much impact on response to chemotherapy, sensitivity to radiation, risk of further brain relapse, development of additional metastatic lesions, or survival. All tumor primary histologies are the same once they spread to the brain. They are the same in terms of the number of tumors, radiosensitivity, chemoresponsiveness, risk of further brain relapse, and survival. Misconception 2: The number of brain metastases matters. This number matters in terms of subsequent brain relapse, survival, and cognitive dysfunction; the precise number of metastases can also be used as a limit in determining which patients might be eligible for a particular treatment option. Misconception 3: Cancer in the brain is always a diffuse problem due to the presence of micrometastases. Misconception 4: Whole-brain radiation therapy invariably causes disabling cognitive dysfunction if a patient lives long enough. Misconception 5: Most brain metastases are symptomatic. Thus, it is not worth screening patients for brain metastases, especially because the impact on survival is minimal. The conduct and findings of past clinical research have led to conceptions that affect clinical care yet appear limiting.

ABBREVIATIONS: CI, confidence interval

HVLT, Hopkins Verbal Learning Test

SRS, stereotactic radiosurgery

WBRT, whole-brain radiotherapy

Author Information

*Departments of Neurosurgery and Radiation Oncology, NYU Langone Medical Center, New York, New York;

Department of Neurosurgery, Henry Ford Health System, Detroit, Michigan;

§Department of Radiation Oncology, University of Maryland, Baltimore, Maryland;

Department of Medicine (Neuro-Oncology), Cleveland Clinic Foundation, Cleveland, Ohio;

Department of Radiation Oncology, Harvard Medical School, Boston, Massachusetts

Correspondence: Douglas Kondziolka, MD, Department of Neurosurgery, NYU Langone Medical Center, 530 First Ave., Suite 8R, New York, NY 10016. E-mail: douglas.kondziolka@nyumc.org

Supplemental digital content is available for this article. Direct URL citations appear in the printed text and are provided in the HTML and PDF versions of this article on the journal's Web site (www.neurosurgery-online.com).

Received February 18, 2014

Accepted March 07, 2014

Copyright © by the Congress of Neurological Surgeons