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  • Brain Metastases Program

    Dana-Farber/Brigham and Women's Cancer Care

    The Brain Metastases Program (BMP) at Dana-Farber/Brigham and Women's Cancer Center (DF/BWCC) is one of the most comprehensive programs in the United States for patients whose cancer has metastasized to the brain. With the most advanced treatment options available — including surgery, radiation therapy, chemotherapy, immunotherapy and targeted therapies, and with extensive clinical trial options — our program is in a unique position to treat patients with brain metastases (spread of cancer to the brain).

    About Our Program and Care

    What are brain metastases?

    Brain metastases are tumors that have spread to the brain from a primary cancer located elsewhere in the body — most often, from the lung, breast, colon/gastrointestinal tract, skin (melanoma), or kidney, although almost any cancer can spread to the brain.

    A significant percentage of patients with cancer will develop brain metastases. However, the treatment of brain metastases has advanced substantially in recent years. So, with modern treatments, some patients with brain metastases are living longer and with good quality of life.

    Our multidisciplinary approach

    At DF/BWCC, our multidisciplinary Brain Metastases Program team develops an individualized treatment plan for each patient — whether for a first-time diagnosis or for a recurrence of brain metastases since prior treatment. The BMP brings together the expertise of our nationally acclaimed programs in radiation oncology, neurosurgery, medical oncology, neuro-oncology, neuroradiology, and neuropathology. The combination of physicians you see will be tailored to your specific needs.

    In planning and delivering your care, we work closely with your primary oncologist, who has been caring for you and knows your medical history. Your primary oncologist may be from Dana-Farber, or from around the country or around the world.

    Treatment options

    We offer the latest advances in the treatment of metastatic brain tumors. Treatment options may include:

    • Surgery
    • Laser ablation
    • Radiation therapy
    • Systemic therapies including immunotherapy, targeted therapy, and chemotherapy
    • Clinical trials

    Metastases to the nervous system

    In addition to patients with brain metastases, we also treat patients with cancer that has metastasized to other parts of the central nervous system, including the:

    • Inner covering and fluid that surrounds the brain and spinal cord (leptomeningeal disease)
    • Spinal cord (intramedullary spinal cord metastases)
    • Outer covering of the brain (dural metastases)

    Support for patients and families

    At the BMP, we offer comprehensive care of each patient — mind and body. We offer special support services and follow-up care designed for patients with brain tumors. Our psychosocial oncology, cancer neurology, and pain specialists can help patients manage their symptoms, including neurocognitive deficits, in order to maintain the best possible quality of life during and after treatment.

    Our Leonard P. Zakim Center for Integrative Therapies incorporates complementary therapies into traditional cancer care, helping patients to feel better by reducing the pain, stress, and anxiety caused by cancer and its treatment.

    Patients and their families can also access a wide array of Dana-Farber support services, including social workers, nutritionists, resource specialists, and support groups.

    View an informative video featuring Erica Mayer, MD, MPH, and Nancy Lin, MD, as they describe the many new treatments being studied for metastatic breast cancer patients.

     
     

    Our Treatment Approach

    Surgery

    When surgery is indicated, our cancer neurosurgeons use the most advanced technologies available to remove as much of the tumor as possible, while preserving the surrounding brain tissue. Pre-surgical and surgical techniques include:

    • Functional MRI (fMRI) prior to surgery: Helps to identify where important functions live in the brain; maps areas of the brain responsible for critical functions, such as movement and speech; also measures blood flow and activity throughout the brain.
    • Intra-operative MRI in our advanced multimodality image-guided (AMIGO) operating suite: A revolutionary, open-style MRI scanner that lets our neurosurgeons see MRI images in real time during surgery. The intra-operative MRI helps the neurosurgeon to remove the tumor more precisely, reducing the risk of damage to other parts of the brain.
    • 3-D navigation system (NeuroNavigation), a GPS-like system for the brain: Allows our neurosurgeons to precisely locate deep-seated or small brain tumors. This allows us to make surgery safer and more effective by minimizing the amount of brain exposure and manipulation needed to find and remove the tumor.
    • Intraoperative monitoring: The activity and integrity of important areas of the brain, for example those controlling movement and speech, can be monitored in real time during surgery by measuring their electrical activity. This helps the surgeon when deciding which parts of the brain are safe to operate on, and which parts should not be touched. The final result is a major increase in surgical safety and positive outcomes.
    • "Awake surgery": Occasionally, when tumors are very close to essential brain areas, the best way to prevent brain damage is to perform the surgery with the patient awake, so that our cancer neurosurgeons can have a continuous assessment of the brain function and maximize tumor resection, while keeping the risk of brain injury to a minimum.
    • Interstitial laser ablation: a minimally-invasive technique that uses small probes to deliver laser energy into a tumor in order to heat and destroy tumor cells.
    Advanced Multimodality Image-Guided Operating (AMIGO) SuiteOur Advanced Multimodality Image-Guided Operating (AMIGO) Suite is a state-of-the-art medical and surgical research operating suite whose advanced imaging equipment and interventional surgical systems guide the intra-operative removal of brain tumors. Neurosurgeons and neuroradiologists in the Brain Metastasis Program may use this equipment to efficiently and precisely guide treatment with imaging before, during, and after a surgical procedure, without the patient or medical team ever leaving the operating room.

    Radiation therapy

    Radiation therapy is often a treatment option for patients with cancer which has spread to the brain, and for most patients, is very effective.

    There are multiple ways in which radiation can be delivered to the brain:

    SRS and SRT

    • Stereotactic radiosurgery (SRS) is a technique for delivering high-dose radiation very precisely to a specific region of the brain. When SRS is used, the target receives a very high dose, but the surrounding brain receives only a minimal amount of radiation. SRS treatment is non-invasive, the likelihood of serious long-term side effects is typically low, and recovery periods are often short.
    • Although many patients can be treated in a single session, patients with large tumors sometimes need a smaller dose of radiation given over multiple treatment days – a technique called stereotactic radiotherapy (SRT).

    When a patient and his/her doctor decide on treatment with SRS or SRT, the first step is planning the delivery of radiation. This pre-treatment step — called a "simulation" — customizes the radiation delivery to the specific patient. During the simulation, a plastic head mask is made, which will be worn during the actual radiation treatment. In addition, a CT scan, and possibly a repeat MRI scan, may be obtained.

    After the simulation, a team of radiation oncologists, radiation physicists, and radiation therapists designs the patient's optimal radiation treatment plan.

    For the SRS or SRT treatment itself, the patient lies on the table with the mask in place. CT scans and X-rays ensure that the patient is in the exact location needed for treatment to begin. Radiation is then delivered in a single day (SRS) or over several days (SRT).

    Whole brain radiation therapy

    In patients with 1 to 4 brain metastases, SRS is generally favored over whole brain radiation, which treats the entire brain. But in patients with significantly more than 4 brain metastases, whole brain radiation is considered more standard; however, SRS may be an option in some cases.

    New radiation therapy techniques

    • Radiation oncologists and physicists at DF/BWCC have developed and optimized a technique to treat many targets in the brain in one session — one-isocenter, multi-target volumetric modulated arc therapy. Historically, if multiple tumors were present in the brain, radiation had to be delivered to each tumor in sequence, leading to treatments that could last several hours. Now, using modulated arc therapy, all tumors in the brain can be treated in 15 to 30 minutes, resulting in shorter treatments for patients.
    • With the availability of one-isocenter treatment, radiation oncologists at DF/BWCC have now designed a clinical trial to test whole brain radiation against SRS in patients with 5-15 brain metastases, with the specific goals to compare quality of life, cognitive functioning, and tumor control between the two approaches. If successful, this may be the first trial to assess whether patients with 5-15 brain metastases can be safely treated with SRS.
    • Radiation oncologists and physicists at DF/BWCC have also implemented a real-time patient-tracking system called the optical surface monitoring system (OSMS). Using OSMS, patient motion is tracked in real time. If the patient moves outside the tolerance threshold of 1 millimeter (1mm), treatment will stop until patient motion has ceased. This new monitoring system will help to confirm the precision of the treatment, with the goal of better patient outcomes.

    Systemic therapies

    The brain is protected by the blood-brain barrier that is formed by a network of special cells surrounding the brain and connected through what are called tight junctions. Many drugs — including most chemotherapy agents — are unable to pass through the blood-brain barrier. However, some cancer cells can get past the blood-brain barrier. When they do, the same chemotherapy agents that can control disease in the body are unable to get to the cancer cells in the brain. In addition, the unique environment of the brain can sometimes contribute to drug resistance in tumor cells.

    Fortunately, ongoing drug development efforts have led to the successful development of new therapies that can get through the blood-brain barrier. This means that for some patients, the same treatment can be used to treat metastatic disease in the body and metastatic tumors in the brain. In some cases, these treatments can even be used instead of surgery or radiation. In other cases, these treatments work best in situations where cancer has recurred in the brain or worsened despite previous treatments with surgery or radiation.

    Systemic treatment options for patients with brain metastases can be quite different depending on the types of treatment(s) you have previously received, the underlying type of cancer, the genetic/molecular characteristics of the cancer, and your overall health.

    Depending on the site of your primary cancer, systemic therapy options for brain metastases may include:

    DF/BWCC researchers have been on the forefront of developing new systemic treatment options for brain metastases. A few examples are:

    • Breast Cancer
      • The combination of lapatinib (Tykerb; a pill that blocks the activity of the HER2 protein) and capecitabine (Xeloda, a chemotherapy pill) has been shown to lead to tumor shrinkage in both the brain and the body.
       
    • Lung Cancer
      • Many targeted therapies for patients with mutations in the EFGR gene or rearrangements in the ALK or ROS1 gene are able to treat disease in both the body and the brain. In some cases, these targeted therapies can even be effective in patients with leptomeningeal disease (where the cancer cells grow in a layer on top of the brain or the spinal cord). Clinical trials are ongoing to develop the best ways to use these targeted therapies in conjunction with other forms of treatment.
       
    • Melanoma
      • Immunotherapies such as ipilumumab, nivolumab, pembrolizumab, and others have been shown to lead to tumor shrinkage in both the brain and the body. Clinical trials are ongoing, testing these agents in patients with brain metastasis with and without radiation.
      • Targeted therapy with combined BRAF and MEK inhibition in patients whose melanoma has a mutation in the BRAF gene. These agents have led to tumor shrinkage in the brain and body.
       

    Depending on your needs, you will have the opportunity to meet with a medical oncologist who specializes in your primary cancer and/or a neuro-oncologist who specializes in brain metastases to discuss systemic therapies that can treat disease in the brain and in the body.

    Clinical trials

    Clinical trials are research studies that evaluate the safety and effectiveness of new treatments, such as new systemic therapies, surgical techniques, or radiation treatments.

    DF/BWCC offers an extensive number of clinical trials for patients with brain metastases, including those appropriate for recurrent disease, or even as a first treatment before surgery or radiation therapy.

    DF/BWCC researchers are nationally and internationally recognized for their leadership and expertise in designing and implementing clinical trials for brain metastases.

    You can meet with a medical oncologist who specializes in your primary cancer and/or a neuro-oncologist who specializes in brain metastases to discuss clinical trial options. We offer clinical trials for patients with brain metastases arising from breast cancer, lung cancer, melanoma, and a variety of other cancers.

     

    Contact Us

    For patients

    It is easy to schedule an appointment with our multidisciplinary team. To make an appointment, please call 877-442-3324 or use our online form.

    You can schedule your first appointment for as soon as the next day. After scheduling, we will call you to answer your questions and help you prepare for your appointment. Before your appointment, we can help obtain imaging and medical records regarding your diagnosis.

    For referring physicians

    Whether you are referring from within Dana-Farber or from around the country or around the world, we will coordinate and collaborate closely with you, your patient's primary medical oncologist or radiation oncologist.

    Refer a patient by phone or online.

    Refer a patient by email.

    Learn more about our services for referring physicians.

     
     
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