Postoperative Management of Resected Brain Metastases: When Can Radiotherapy Be Deferred?

The Oncology Grand Rounds series is designed to place original reports published in the Journal into clinical context. A case presentation is followed by a description of diagnostic and management challenges, a review of the relevant literature, and a summary of the authors' suggested management approaches. The goal of this series is to help readers better understand how to apply the results of key studies, including those published in Journal of Clinical Oncology, to patients seen in their own clinical practice. A 67-year-old woman was diagnosed 17 months ago with stage IIIB non-small-cell lung cancer (NSCLC; adenocarcinoma), without a targetable mutation, for which she received chemotherapy and thoracic radiotherapy. She developed new-onset gait ataxia, nausea, morning emesis, and headaches. A brain magnetic resonance imaging (MRI) scan demonstrated a 3.2-cm left cerebellar enhancing metastatic lesion, with surrounding vasogenic edema and mass effect, and three additional enhancing cortical, parenchymal lesions, each < 1.2 cm in maximum diameter, and none with significant mass effect ( Fig 1A ). A restaging positron emission tomography scan revealed no new sites of metastatic disease and no obvious intrathoracic progression. She underwent craniotomy, with piecemeal resection of the cerebellar metastatic lesion that proved to be recurrent lung cancer ( Fig 1B ). Her medical history was significant for mild hypertension and diet-controlled type II diabetes. She had smoked one pack a day for 32 years and had quit 3 years earlier. Postoperatively, her neurologic symptoms resolved, and physical and neurologic examinations were unrevealing; she had an Eastern Cooperative Oncology Group performance status (PS) of 0 and a Mini-Mental State Examination (MMSE) score of 29 of 30. A 3-week postoperative MRI scan confirmed the presence of 1-cm right frontal, 1.2-cm right parietal, and 1.2-cm left temporal enhancing lesions with minimal enhancement and no evidence of mass effect or edema. In addition, there was an ill-defined residual tumor bed, estimated to be approximately 3.7 cm in maximum diameter ( Fig 1C ). The patient was no longer receiving any steroids and was not receiving any anticonvulsants. Because of the residual three brain metastatic lesions, as well as the consideration of a high risk of surgical failure, she was referred for radiotherapy.