Abstract
BackgroundThe incidence of oligometastases to the brain in good performance status patients is increasing due to improvements in systemic therapy and MRI screening, but specific management pathways are often lacking.MethodsWe established a multi-disciplinary brain metastases clinic with specific referral guidelines and standard follow-up for good prognosis patients with the view that improving the process of care may improve outcomes. We evaluated patient demographic and outcome data for patients first seen between February 2007 and November 2011.ResultsThe clinic was feasible to run and referrals were appropriate. 87% of patients referred received a localised therapy during their treatment course. 114 patients were seen and patient numbers increased during the 5 years that the clinic has been running as relationships between clinicians were developed. Median follow-up for those still alive was 23.1 months (6.1-79.1 months). Primary treatments were: surgery alone 52%, surgery plus whole brain radiotherapy (WBRT) 9%, radiosurgery 14%, WBRT alone 23%, supportive care 2%. 43% received subsequent treatment for brain metastases. 25%, 11% and 15% respectively developed local neurological progression only, new brain metastases only or both. Median overall survival following brain metastases diagnosis was 16.0 months (range 1–79.1 months). Breast (32%) and NSCLC (26%) were the most common primary tumours with median survivals of 26 and 16.9 months respectively (HR 0.6, p=0.07). Overall one year survival was 55% and two year survival 31.5%. 85 patients died of whom 37 (44%) had a neurological death.ConclusionCareful patient selection and multi-disciplinary management identifies a subset of patients with oligometastatic brain disease who benefit from aggressive local treatment. A dedicated joint neurosurgical/ neuro-oncology clinic for such patients is feasible and effective. It also offers the opportunity to better define management strategies and further research in this field. Consideration should be given to defining specific management pathways for these patients within general oncology practice.
Highlights
Brain metastases occur in approximately 20-30% of all cancer patients and have an incidence at least four times higher than primary brain tumours [1]
Brain metastases were considered to be associated with a uniformly poor prognosis and whole brain radiotherapy was the mainstay of treatment
The same neurosurgeon carried out all elective brain metastases surgery, all cases were discussed at the neuro-oncology multi-disciplinary meeting (MDM) and emergency cases treated by other neurosurgeons were referred into the brain metastases service via the MDM
Summary
Brain metastases occur in approximately 20-30% of all cancer patients and have an incidence at least four times higher than primary brain tumours [1]. Brain metastases were considered to be associated with a uniformly poor prognosis and whole brain radiotherapy was the mainstay of treatment. This view has changed gradually in the last two decades with increasing interest in the use of surgery and radiosurgery (RS). An increased focus on local treatment for oligometastatic disease is increasingly relevant due to improved systemic therapies in several common cancers, leading to better control of extra-cranial disease and earlier diagnosis of brain metastases due to more widespread use of MRI. The incidence of oligometastases to the brain in good performance status patients is increasing due to improvements in systemic therapy and MRI screening, but specific management pathways are often lacking
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