Management of cerebral metastasis: evidence-based approach for surgery, stereotactic radiosurgery and radiotherapy

Brain metastases constitute a significant disease burden and have a major impact on morbidity and mortality. This review discusses the relative merits of open surgery, whole brain radiotherapy (WBRT) and stereotactic radiosurgery (SRS), which have been used alone and in combination with varying degrees of success for the treatment of newly diagnosed brain metastasis. Treatment aims to provide disease control with a good quality of life, although prolonged survival may not always be achieved. Decision to treat is based on several prognostic factors including age, performance status and control of the primary cancer. The recently developed disease-specific graded prognostic assessment (DS-GPA) scales can aid in clinical decision making for individual patients. Whole brain radiotherapy remains the mainstay of treatment and provides effective palliation. Omission of WBRT results in worse local and distant control, though not survival. Local tumour control can be achieved by either resection of stereotactic radiosurgery (SRS). In long-term survivors WBRT may cause cognitive decline and SRS is being explored as an alternative method of disease control. Increasingly, quality of life and neuro-cognitive function are being used as end-points in clinical trials.