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Case history

image A 70-year-old woman with known oesophageal squamous cell carcinoma (T4N3M1; retroperitoneal nodal disease) completed palliative chemotherapy, with an excellent response. A few months later she developed sudden-onset left-sided weakness and difficulty mobilizing. CT brain showed an enhancing solitary lesion in the right frontal lobe with surrounding vasogenic oedema, consistent with a metastatic deposit. Her symptoms resolved with dexamethasone. Her WHO performance status was 1.

A repeat staging CT showed stable extracranial disease. MRI brain demonstrated metastasis in the right frontal lobe (29 × 23 mm) and in the right cerebellum (11 × 8 mm). Stereotactic radiosurgery (SRS) of the brain at a dose of 30 Gy in five fractions to the frontal lesion and 21 Gy in one fraction to the cerebellar lesion was carried out.

The patient continues to be remarkably well and has discontinued steroid therapy.

What are the treatment options for this patient’s intracranial disease?

Who should be referred for SRS treatment?

What acute toxicities of cranial irradiation may the patient experience?

What late toxicities could develop?

What are the treatment options for this patient’s intracranial disease?

Treatment options to consider include one or more of best supportive care, surgery, whole brain radiotherapy (WBRT) or SRS. Factors influencing the choice of treatment include patient preference, the presence or absence of extracranial disease, prognosis and performance status, as well as the size, number and location of tumours. Treatment decisions should be made by a specialist neuro-oncology multidisciplinary team (MDT) and involve input from the primary disease site specialist.

WBRT is often not a favoured option for treatment in the modern era, as an increasing number of studies show that, while it reduces local recurrence rates, there is little benefit to survival in the majority of tumour types. It also produces neurocognitive side effects, which may be costly to manage.1 Neurosurgery may be considered for patients with pressure symptoms that do not respond to medication and for those with solitary tumours, providing metastases are surgically accessible and not in close proximity to critical structures such as the optic chiasms. In some tumours, for example germ cell tumours or metastatic serine/threonine-protein kinase B-Raf (BRAF)-positive melanoma, systemic treatment options may be the first choice of treatment for brain metastases; specialist opinion should be sought on the most appropriate treatment.

SRS is a radiation therapy where multiple focused intersecting radiation beams result in the delivery of a highly conformal, high dose of radiation to the target tumour(s), reducing the radiation to surrounding normal tissues and, therefore, side effects. SRS can be delivered via linear accelerator, cyberknife or gamma knife. It is typically used only for brain metastases ≤3 cm in diameter; doses usually range from 15 Gy to 24 Gy for a single fraction.

There are prognostic tools to determine patients’ average survival with brain metastases. Recursive partitioning analysis (RPA) is often used as a scoring ...

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