Systemic therapy of brain metastases

Background. Local therapy of brain metastases is frequently effective but not applicable in multiple cerebral metastases and not able to target systemic metastases or the primary tumor. Systemic therapies are advantageous in this respect as they simultaneously treat the systemic disease which is frequently decisive for the prognosis. Objective. The current role of systemic therapy in the management of brain metastases is presented. Material and methods. Representative publications, particularly those more recent, on the systemic therapy of brain metastases of solid tumors were assessed and the results critically analyzed. Results. In general, a substantial improvement in the overall prognosis of patients with brain metastases by treatment with systemic therapy has not yet been achieved; however, in certain entities, as in brain metastases of small-cell lung cancer and germ cell tumors, systemic chemotherapy should be used as first line treatment whenever possible and can be amended during the course of the disease by whole-brain radiotherapy (WBRT) and/or resection. With this treatment long-term survival can be achieved in many patients with germ cell tumors. In other solid tumors systemic chemotherapy should be considered for patients in a good general physical condition with clinically asymptomatic multiple brain metastases, particularly with active systemic disease and when pretreatment with WBRT has already been carried out. For some tumors the spectrum of therapeutic options has been extended by targeted therapy and immunotherapy. Conclusion. Systemic therapy should often be regarded as a meaningful therapeutic supplement to neurosurgical and radiation therapeutic measures for therapy of brain metastases as a part of a multimodal treatment approach.