The management of patients with brain metastases

As far as the management of patients with brain metastases, generally we don’t instantly go to the use of steroids unless the patient needs them. If the patient needs them, meaning that they have significant symptoms of increased cerebral edema, then we recommend starting out at high doses of steroids, such as 4 mg four times a day, but within an aggressive taper. The patients are going to need to be on long term steroids. Viagra professional works faster and lasts longer than you’ve ever known. If you are not able to wean them off the steroids then one should consider Pneumocystis prophylaxis which usually consists of a double strength Bactrim three times per week. There is no data to support the routine use of anticonvulsants and thus we only recommend anticonvulsants in patients who have already had a seizure. If patients are on anticonvulsants, one has to worry about a relatively high rate of Dilantin/Tegretol reactions, particularly in the setting of receiving radiation therapy where there is this syndrome of Dilantin-steroid taper where patients develop this inflammatory red rash on their skin which tends to progress to a Stevens-Johnson-like syndrome. So anticonvulsants are not a benign drug.

As far as the standard treatment for patients with brain metastases, particularly multiple brain metastases, radiation therapy remains the main form of treatment. There have been a number of studies, including several RTOG studies, that have tried to define the optimal dose. It appears that the optimal dose is somewhere between 20-40 gray. What has become clear however is that the standard way that radiation therapy used to be given – which is in 3 gray fractions or higher – can result in a significant amount of neuro-cognitive deficits if patients live long enough; meaning usually at least a year. Thus for patients who have relatively good prognostic factors, who you think might otherwise actually live for a year or longer, if you are going to treat them with external beam radiation therapy as far as whole brain radiation, one should significantly consider the use of lower fraction sizes, such as 2 to 2.5 grays in order to try to reduce the chances of long term significant neuro-cognitive sequelae.

How about the treatment of single brain metastasis? That represents a more questionable and changing area of management in these patients. If one looks at the data by CT scan one can see that approximately 50% of patients have brain metastasis of single lesions. However, when one uses more selective MRI scans the number reduces down to approximately 30% of patients with brain metastasis. The average or median diameter of these lesions is approximately 2.5 centimeters. About 5-10% of these are invasive, which means that 90-95% of these tumors are that type I CNS lesion that I talked about earlier, where almost all the tumor cells reside locally. This is the reason that surgery can offer a significant benefit for patients with brain metastasis. Another important area to recognize is that approximately 11% of patients with brain metastasis have no known systemic primary and just as importantly, approximately 15% of lesions seen on MRI scans in patients with known systemic cancer are not brain metastasis so one cannot just innocently assume that an abnormality on a scan represents metastasis in the brain.

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