Brain metastases are a common cause of morbidity and mortality. Surgical resection (SR), Radiosurgery (SRS) and Whole brain radiotherapy (WBRT) are the main treatment modalities aimed at attaining local control. SR allows for tissue diagnosis and for a swifter symptomatic relief, yet surgical morbidity in these frail patients, continues to taint its advantages.
SR: Surgical Resection; SRS: Radiosurgery; WBRT: Whole Brain Radiotherapy; NSCLC: Non-Small-Cell Lung Carcinoma; CT: Computed Tomography
SRS is an attractive treatment option for patients harboring a limited intracranial metastatic burden due to its single session, high dose, highly conformal nature. SRS has minimal side effects or time delay to starting systemic therapy as well. With regards to local control, reports from the last decade have shown good and comparable rates of SRS and SR, with lower morbidity in SRS and a swifter relief in SRS.
A large body of evidence suggests WBRT should be used as an adjunct tool. As primary treatment, WBRT is inferior to SRS or SR in attaining local control. WBRT is reserved for lesions unsuitable for SRS or SR due to size, number or location constraints. Still, omitting WBRT as an adjunct tool after SR or SRS has led to worse local and distant intracranial control, with no influence on functional or overall survival.
As an integral part of the radiosurgical team, the nurse’s role is characterized by greater autonomy with emphasis on the patient’s quality of live, as well as guidance for the patient and family.
Treatment should be multidisciplinary. SRS is comparable to SR, in attaining local control (Figure 1). This is a 52 years old man with a Non-Small-Cell Lung Carcinoma (NSCLC). A+B, 02.2013 T1WI MRI axial and coronal sections respectively, showing a solitary right cerebellar metastatic lesion. The patient was treated with upfront stereotactic radiosurgery (SRS). C+D, 05.2013, T1WI MRI axial and coronal sections respectively, showing a marked decrease in the size of the metastatic lesions, portraying local tumor control. E+F+G, 04.2014, T1WI MRI sagittal and axial sections respectively, as well as a T2WI 3-dimensional reconstruction showing distant disease progression (elsewhere in the brain, see arrows). A large cerebellar vermis lesions is shown, compressing the fourth ventricular with subsequent development of obstructive hydrocephalus. The patient underwent a microsurgical open resection of this lesion and SRS for the distant spread. H+I, Computed Tomography (CT) without and with contrast agent sagittal and axial sections respectively (MRI was not performed due to the presence of a new ventriculoperitoneal shunt), showing adequate local control of all lesions (both resected and irradiated).
The authors have no personal or institutional financial interest in drugs or materials in relation to this paper.