RAMB - Agosto 2016

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Treatment of brain metastases
Rev Assoc Med B ras 2016; 62(5):389-394 389
GUIDELINES IN FOCUS
Treatment of brain metastases
Tratamento das metástases encefálicas
Authorship: Sociedade Brasileira de Neurocirurgia
Participants: Frederico de Melo Tavares de Lima 1, Ana Lucia Mello de Carvalho1, Joacil Carlos da Silva Jr.1,
Robson Amorim1, Marcos Dellaretti1, Leonardo Augusto Wendling-Henriques1, Marcos Maldaun1,
Daniel Kirchhoff1, Ricardo Vieira Botelho1
Conflict of interest: none
1Sociedade Brasileira de Neurocirurgia
The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standard-
ize procedures to assist the reasoning and decision-making of doctors.
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, de-
pending on the conditions and the clinical status of each patient.
Introduction
Metastases are the most common cancers that affect the in-
tracranial space. They have an incidence of 6 to 10 times
that of primary brain tumors. The estimate is that they oc-
cur in 20 to 40% of all malignant neoplasms affecting the
human body, being symptomatic in 10 to 20% of these pa-
tients. Prevalence is growing due to aging of the population,
greater access to neuroimaging techniques and increased
survival of patients with malignancies. Brain metastases
(BM) occur with equal frequency in men and women, and
have the same effect in all races. Any formof cancer can pro-
mote secondary spread in the brain. Primary tumors that
contribute the most to BMs are, in descending order: lung,
breast, melanoma, kidney and colorectal carcinoma. How-
ever, in over 15% of cases the primary site is unknown. Brain
metastases are most often diagnosed in patients with a
known malignancy (metachronous presentation). Less fre-
quently, the lesions are diagnosed simultaneously with the
primary tumor (synchronous presentation), or even before
the discovery of the primary disease. About 85% of BMs are
located in the supratentorial compartment; 10 to 15% are
in the infratentorial space; and 1 to 3%, in the brainstem.
The most common symptoms in BMs are: headache, sei-
zures, behavioral changes, hemiparesis, vomiting, dyspha-
sia, and consciousness disorders. Most metastases spread
in the brain through the blood but, less often, through the
venous plexus. Without treatment, the median survival is
less than 2 months.
In Brazil, based on the estimate for 2012 by the Na-
tional Cancer Institute, and considering the probable
90,300 new cases of breast, lung and colon cancer, and
melanoma, it is possible to estimate the occurrence of
13,545 new cases of BM per year. That number places BMs
as the fourth most common form of cancer in Brazil, re-
gardless of gender. Furthermore, it is an incidence rough-
ly three times higher than all tumors of the central ner-
vous system taken together.
Treatments include surgery, radiosurgery and radio-
therapy, and in some cases chemotherapy. Treatment can
include one method alone, or a combination of therapies.
Objective
The aim is to clarify the effect of surgery, radiotherapy
and radiosurgery in patients with brain metastases.
Grade of recommendation and strength of
evidence
The grade of recommendation and strength of evidence
were defined in accordance with the Brazilian Medical As-
sociation, as displayed in the Table 1.
Types of study
The primary study for definition of this guideline is the
randomized clinical trial. Clinical studies of lower meth-
odological quality were used in the absence of the first.
1) Clinical question
What is the benefit of surgery in the treatment of brain
metastases compared to radiotherapy?
Description of the evidence collection method
The search strategy was conducted in the MedLine
(PubMed) database to identify articles published from
1964 to 2013. The objective was to identify studies com-
paring patients treated with surgery and radiotherapy
with those undergoing radiation therapy alone.