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Management of Brain Metastases

General approaches and treatment considerations for patients with brain metastases from lung cancer

Broadening the Concept of the Precocious Metastasis to Define When Local Therapy Makes Sense for Metastatic Cancer

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A couple of nights ago, I was at a “journal club” discussion with several of my thoracic surgery colleagues and some others in the Seattle area who treat lung cancer, discussing how to decide which patients presenting with a solitary brain metastasis could have a realistic chance of being treated with curative intent in the chest as well as the brain.  The idea behind this concept is that, while metastatic disease is generally recognized as a state that is binary (you have metastatic disease or you don’t) and isn’t curable if cancer has spread from the chest to another part of the body through bloodstream, it’s not always that simple.  

There are exceptions to almost every rule, and we know that a minority of patients (perhaps as high as one in four) with a solitary brain or adrenal metastasis as their only evidence of metastatic spread can be treated aggressively in the chest, have their brain or adrenal metastasis treated locally (resected or possibly radiated), and be alive with no evidence of disease years later.  We also know that having earlier stage lung cancer, discounting the single metastasis, is associated with a much better probability of doing very well.  Specifically, the concept of treating metastatic lung cancer for cure tends to be most feasible for node-negative disease in the chest, but not for people who have nodal involvement, and especially not locally advanced, stage III NSCLC.  In this situation, the metastasis probably isn’t “precocious”: it’s just a metastases coming in when you’d expect to see it.

So that’s the concept of the precocious metastasis.  What I started thinking about was how this question can really be broadened to other situations in lung cancer, or other cancers, that really center on one key question: 

Is it likely that one area of the cancer is so far ahead of the rest of the disease process that it will set the pace for problems, or is it more likely that the pace of the disease will be set by multiple disease areas?

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