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Brain Metastases 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.
    Our 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.