Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Whole Brain Radiation Therapy in Adults With Newly Diagnosed Metastatic Brain Tumors

Neurosurgery, Mar 2019

Mazzola, Catherine A

A PDF file should load here. If you do not see its contents the file may be temporarily unavailable at the journal website or you do not have a PDF plug-in installed and enabled in your browser.

Alternatively, you can download the file locally and open with any standalone PDF reader:

https://academic.oup.com/neurosurgery/article-pdf/84/3/E164/27764715/nyy555.pdf

Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Whole Brain Radiation Therapy in Adults With Newly Diagnosed Metastatic Brain Tumors

The authors1 performed a systematic review of the available literature in order to provide a timely update of prior guidelines and to investigate relevant publications regarding the neurocognitive effects of whole brain radiation therapy (WBRT) for patients with newly diagnosed metastatic brain tumors.2–9 Broad search strategies were employed in order to provide readers with a comprehensive review of available data. Selected articles were screened, and strict exclusion and inclusion criteria were utilized. Four PICO questions were developed for adult patients (18 and older) with newly diagnosed brain metastases. PICO questions are employed for evidence-based guideline development. PICO question elements address specific problems, patients and/or populations (P), interventions or indicators (I), comparisons (C), and outcomes (O). Specific recommendations are then made. The strength of the recommendations is based on supporting evidence. Question 1 Recommendations: Standard WBRT dose/fractionation schedule was recommended (level 1 recommendation). There was a level 3 recommendation recommending WBRT to improve progression free survival (PFS) for patients with more than 4 metastases and because of the concern of negative neurocognitive side effects, higher dosing, per fraction, could only be recommended when patients have a short life expectancy or if they have a pretreatment, impaired cognitive status. Questions 2 Recommendations: There was insufficient evidence to support any recommendation about the impact of tumor histopathology or molecular status on the decision to use or delay WBRT for patients with newly diagnosed brain metastases. Questions 3 Recommendations: There were significant data supporting a level 2 recommendation to employ local therapy, either surgery or WBRT, for patients with less than 4 brain metastases, in order to avoid neurocognitive toxicity. Additionally, the literature reviewed provided the same level 2 evidence recommending the avoidance of WBRT doses exceeding 30 Gy except in patients where life expectancy is limited or cognitive abilities are limited prior to treatment. Prophylactic WBRT (<25 Gy) for small cell lung cancer can be utilized as long as patients are aware of the possibility of neurocognitive decline (level 2). There is level 3 evidence that supports the utilization of memantine to patients receiving WBRT for 6 months, in order to potentially minimize cognitive side effects of radiation. Memantine acts on glutamatergic, serotonergic, cholinergic, and dopaminergic receptors. Questions 4 Recommendations: Because WBRT does not improve overall survival, and only improves intracranial PFS, WBRT is not recommended for patients with up to 4 mets and who have good cognitive function (WHO performance status 0-2; level 2 recommendation). Local therapy, with surgery or radiosurgery, is recommended in these cases (level 2). There was a level 3 recommendation against the addition of WBRT for patients with more than 4 brain metastases unless there was excessive tumor volume, more than 15 metastases, or local therapy was not possible. I commend the authors for their dedication to the pursuit of excellence as it relates to evidence-based recommendations, because in my opinion, the work that was performed and the results and recommendations which were made provided excellent data for patients, their families, and their physicians. Disclosures The views expressed in this commentary represent only the author's personal opinions and are not provided on behalf of the AANS/CNS Joint Guidelines Review Committee. The author has no personal, financial, or institutional interest in any of the drugs, materials, or devices described in this article. REFERENCES 1. Gaspar LE , Prabhu RS , Hdeib A et al.  Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of whole brain radiation therapy in adults with newly diagnosed metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E159 - E162 . 2. Olson JJ , Kalkanis SN , Ryken TC . Congress of Neurological Surgeons systematic review and evidence-based guidelines for the treatment of adults with metastatic brain tumors: executive summary . Neurosurgery  . 2019 ; 84 ( 3 ): 550 - 552 . 3. Nahed BV , Alvarez-Breckenridge C , Brastianos RK et al.  Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of surgery in the management of adults with metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E152 - E155 . 4. Graber JJ , Cobbs CS , Olson JJ . Congress of Neurological Surgeons systematic review and evidence-based guidelines on the use of stereotactic radiosurgery in the treatment of adults with metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E168 - E170 . 5. Sherman JH , Lo SS , Harrod T et al.  Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of chemotherapy in the management of adults with newly diagnosed metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E175 - E177 . 6. Chen CC , Rennert RC , Olson JJ . Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of prophylactic anticonvulsants in the treatment of adults with metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E195 - E197 . 7. Ryken TC , Kuo JS , Prabhu RS , Sherman JH , Kalkanis SN , Olson JJ . Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of steroids in the treatment of adults with metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E189 - E191 . 8. Elder JB , Nahed BV , Linskey ME , Olson JJ . Congress of Neurological Surgeons systematic review and evidence-based guidelines on the role of emerging and investigational therapies for the treatment of adults with metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E201 - E203 . 9. Ammirati M , Nahed BV , Andrews D , Chen CC , Olson JJ . Congress of Neurological Surgeons systematic review and evidence-based guidelines on treatment options for adults with multiple metastatic brain tumors . Neurosurgery  . 2019 ; 84 ( 3 ): E180 - E182 . Copyright © 2019 by the Congress of Neurological Surgeons This article is published and distributed under the terms of the Oxford University Press, Standard Journals Publication Model (https://academic.oup.com/journals/pages/open_access/funder_policies/chorus/standard_publication_model)


This is a preview of a remote PDF: https://academic.oup.com/neurosurgery/article-pdf/84/3/E164/27764715/nyy555.pdf

Mazzola, Catherine A. Commentary: Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Whole Brain Radiation Therapy in Adults With Newly Diagnosed Metastatic Brain Tumors, Neurosurgery, 2019, E164-E165, DOI: 10.1093/neuros/nyy555