Management of brain metastases from breast carcinoma

Brain metastases occur clinically in about 10% of patients with stage IV breast cancer, in the setting of widespread extracranial metastases. Prognosis is poor and management is aimed at relieving acute symptoms and improving neurologic status, as well as controlling the metastatic disease. Therapies include surgery, radiotherapy, chemotherapy, and hormonal therapy, used alone or in combination. Performance status is the single most important factor determining treatment choice. In selected patients, surgery can improve survival and performance status. Radiotherapy is the palliative treatment of choice, providing rapid relief of symptoms, especially headache. Recent innovations include accelerated split courses of radiotherapy given in two or three daily fractions, use of radiosensitizers, brachytherapy, and radiosurgery. Systemic therapy remains controversial, but studies show that cytotoxic agents can be palliative against brain metastases if the primary tumor is sensitive to the drug or drugs used.