Brain Metastasis

Approximately 20 to 40 percent of people with cancer will develop brain metastasis as a complication from their primary/original cancer. This is equivalent to more than 200,000 people per year in the United States alone. The rates of brain metastasis have been steadily rising as cancer treatments have improved over the last decade. People are living longer, giving more time for cancer to spread to the brain.

Advances in medical imaging technologies enable clinicians to visualize the brain in greater detail, leading to increased detection of brain metastasis. Cancers that commonly metastasize to the brain include lung, breast, melanoma, kidney, and colon cancers.

Peter Fecci, MD, PhDSurgery may be a viable option preceding radiation therapy in select patients with brain metastasis. Historically, cancer that has spread to the brain has been difficult to treat surgically in some patients, as it may arise in delicate parts of the brain that can be difficult to safely access. With advances in imaging and surgical techniques, however, few patients at Duke are truly deemed inoperable. Duke offers the latest technologies and minimally invasive techniques, all at the hands of some of the best-trained neurosurgeons in the world.

Patients at Duke have access to rare benefits and advantages not available at most hospitals, such as awake and asleep motor mapping techniques, intra-operative MRI, subcortical mapping, advanced intra-operative navigation, high resolution Synaptive Bright Matter intra-operative imaging and optics platforms, and minimally invasive endoscopic and exoscopic surgical options within the brain. Importantly, Duke is also one of the highest volume centers in the U.S. for a new robotic-assisted laser surgical technique within the brain, called laser interstitial thermal therapy (LITT).

LITT is our preferred surgical approach for patients with recurrent brain metastases, for those that are too difficult to remove by open surgery, or for patients with radiation necrosis (tissue damage), a complication of radiation therapy. This is a minimally invasive robotics-assisted procedure for patients performed in our intra-operative MRI suite, enabling the precise targeting of the tumor/s by the surgeon. A laser probe is inserted via a small incision in the scalp and laser heat is used to treat these lesions. Offered at only a handful of other centers nationwide, Duke is one of the highest volume centers offering the LITT procedure. Surgeons nationwide come to Duke to learn how to perform LITT.

Radiation therapy is the most critical component of the overall treatment for brain and/or spinal metastasis. Benefits of radiation therapy include:

• Reducing or even eliminating the tumor
• Alleviating pain, relieving spinal cord compression, or allowing for easier surgical removal
• Preventing further tumor growth
• Providing a non-invasive, outpatient treatment

Duke radiation oncologists employ innovative techniques to deliver extremely precise high doses of radiation only to the tumor, and not to surrounding normal tissues.

Stereotactic radiosurgery (SRS) is the gold standard for radiation care when treating the majority of patients with brain and/or spinal metastasis. SRS is a typical front line approach to brain or spine metastasis. When surgery is a more appropriate up front strategy, SRS is still indicated after a surgical procedure to help prevent growth of residual microscopic cancer cells.

SRS precisely delivers high dose radiation to the tumor, but significantly spares healthy tissue/organs, blood vessels, and nerves surrounding the tumor/s. It is more specific and in general offers better disease control and less side effects than whole brain radiation therapy (WBRT) or conventional radiation to the spine. Depending on the size and location of the tumor/s, some patients may only require a single dose of SRS while others may require treatment over three to five sessions.

Although the name suggests SRS involves surgery, SRS is a non-surgical procedure where no incisions are required. The word surgery simply refers to the surgical precision with which the radiation is delivered. WBRT or conventional spine radiation may still be the best treatment in certain situations, however. Our world-class radiation oncologists will present all realistic treatment, discuss what is most appropriate for your situation and explain why.

The Duke radiation oncology team has several radiation therapy clinical trials open for patients with brain and spine metastasis. All patients are screened and considered for clinical trials by the treating team at the time of their initial consultation.

In addition to surgery and radiation therapy, systemic therapies may be recommended by your treatment team to help control tumor growth and prevent further metastasis. Systemic therapies for both brain and spinal metastasis include chemotherapy, immunotherapy, targeted therapy, hormone therapy, and/or therapies to protect your bones. Your medical oncologist will help you decide which treatment options are best for you.

Much of the research on brain metastasis pays particular focus on developing therapies that can safely enter the brain through the circulation. The brain is often and for good reason protected by a barrier called the blood brain barrier (BBB) that normally serves to prevent toxic substances from entering. While it usually helps to protect us, the BBB unfortunately also makes it more difficult to deliver systemic therapies into tumors harbored within the brain.

We have several drugs available now that are successfully penetrating the brain, and our current clinical trials are focused on developing new drugs that also have this ability. Likewise, Duke offers the latest in immunotherapies, which are the newest and often most successful class of FDA-approved drugs for certain types of cancers.

Duke’s Brain Tumor Immunotherapy Program, led by Peter Fecci, MD, PhD, and John Sampson, MD, PhD, is one of the largest and successful such programs in the world.

Palliative care, often referred to as supportive care, provides an additional layer of support for people facing serious life-threatening illnesses and their families. It is important to understand that it can be provided together with curative treatment. Research has shown that people with cancer have better outcomes when supportive care forms a regular part of treatment.

This team plays a pivotal role within our center. We work towards ensuring that all patients and their families have the opportunity to meet with a member of the team within their first couple of visits to Duke. Their expertise in a range of services builds on and complements the care provided by other specialists within our team.

These services include:

• Pain management, post-operatively or in a medically complex patients like those living with brain and/or spinal metastasis
• Aggressive symptom management (e.g. fatigue, nausea, depression, anxiety and other symptoms)
• Psychosocial support for patients, caregivers, and families
• Goals of care clarification with patients and families, ensuring cancer care matches up with patients’ priorities and value
• Ensuring clear communication between patients, their families, and the entire care team
• Spiritual care

Advance Care Planning

For more information, go to:

•    Five Wishes
•    Duke Health