Contemporary management of intracranial metastatic disease
- 1Neurosurgery, St. Michael's Hospital, Canada
- 2University of Toronto, Canada
- 3SunnyBrook Hospital, Canada
On behalf of my radiation oncology partner, Dr. Arjun Sahgal, I am pleased to offer to the readers of Frontiers in Oncology our topic collection entitled, “Contemporary management of intracranial metastatic disease.” The development of intracranial metastatic disease (IMD) complicates the course of approximately 20% percent of patients with cancer, with the highest frequency of brain metastases arising in patients with melanoma, breast cancer, and lung cancer (1,2). Modern therapeutic options available for treatment of IMD include surgical resection, stereotactic radiosurgery (SRS) and to an expanding degree, targeted and immuno-therapies (3). Despite improvements in patient survival with more aggressive treatment options as compared to the prior standard of palliative whole brain radiation, outcomes for patients who develop IMD remain dispiriting. There is need to celebrate our advances; but a major collaborative multidisciplinary effort is needed to push the field to achieve more meaningful survival benefits for our patients with IMD.
In this topic collection, we have assembled work detailing the latest innovations in brain metastases imaging and management. Greg Stanisz and colleagues have reviewed work in the MR imaging field to identify advanced biomarkers that characterize the cellular, biophysical, micro-structural and metabolic features of tumors to improve the management of brain metastases from early detection and diagnosis, to evaluating treatment response. Priscilla Brastianos and colleagues review the contribution of genomic analysis of brain metastases to our understanding of variations in the driver mutations compared to the primary malignancy, and provide an in-depth review of the completed and ongoing clinical trials of drugs targeting the molecular pathways enriched in brain metastases. Suneel D. Kamath and Priya U. Kumthekar review the biological rationale for systemic immunotherapy to treat CNS metastatic disease, and summarize existing clinical data on immune checkpoint inhibitors in this setting and ongoing clinical trials designed to study immune checkpoint inhibitor therapy in patients with IMD. Nir Lipsman and colleagues review the prospect of focused ultrasound-mediated blood-brain barrier disruption to improve local drug delivery for patients with IMD. Minimally invasive surgical strategies using tubular retractors or laser interstitial thermal therapy (LITT) have been presented by Kaisorn Chaicana and collagues and Albert Kim and colleagues, respectively. Daniel Trifiletti and colleagues review data to support the use of SRS as a neoadjuvant therapy to improve treatment contouring and diminish the risk of tumor cell dissemination during surgical resection and associated leptomeningeal spread. Laura Masucci and Trifiletti and colleagues detail the role of hyprofractionated SRS and post-operative SRS, respectively, for patients with IMD. Tyler P. Robin and Chad G. Rusthoven and Stephanie Combs and colleagues have reviewed efforts to minimize disease- and treatment-related cognitive and motor decline in patients with IMD. Sahgal and colleagues explore the pathophysiology of radiation necrosis, risk factors for its development, and the strategies for its evaluation and management. Finally, Samuel Chao and colleagues define a treatment algorithm to guide treatment of patients with a limited number of brain metastases, while David Roberge and colleagues describe plans for a prospective randomized control trial to define the role of SRS in patients with more severe burden of IMD.
In all of this, we owe thanks to our many colleagues who contributed to this topic collection and offered us their time, intellect and energy. Many thanks as well to Jakob Mainusch and the editorial team at Frontiers. We thank Frontiers for appreciating the importance of this topic and for supporting the collection. We hope that you find it a valuable resource.
Keywords: Brain metastases (BM), Intracranial metastatic disease, Surgery, Immunotharapy, focused ultrasound, Chemothearpy, targeted therapy, Radiotherapy, Radiation necrosis, SRS
Received: 18 Jun 2019;
Accepted: 09 Aug 2019.
Copyright: © 2019 Das and Sahgal. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
* Correspondence: Dr. Sunit Das, St. Michael's Hospital, Neurosurgery, Toronto, M5B 1T9, Ontarior, Canada, DasS@smh.ca