Introduction
Brain metastases constitute the most common neurological complication of solid tumours. Metastasis of haematological malignancies (leukaemia, lymphoma) to the brain is also common, but is omitted from this guideline given the different requirements with respect to their diagnosis and treatment. All solid tumours may metastasise to the brain, which generally occurs late in the disease process. Brain metastases most frequently occur with lung and breast carcinoma. Approximately 10-30% of patients with metastatic solid tumours develop metastases in the brain. In the Netherlands, approximately 75,000 patients are diagnosed with cancer each year (http://www.cijfersoverkanker.nl/), consulted on July 1st, 2010), with incidence increasing due to ageing of the Dutch population. Since overall survival of cancer patients is also increasing, the number of patients diagnosed with brain metastases is likewise expected to rise in the coming decades. Part of this increase is explained by improved detection of asymptomatic brain metastases due to the use of Magnetic Resonance Imaging (MRI) and other screening methods.
Brain metastases may cause severe and debilitating complaints. Headache, cognitive and behavioural disorders, epileptic seizures and focal deficits usually occur within several days or weeks. These symptoms have a considerable impact on the daily functioning of patients and their family members.
Survival of patients with brain metastases is only 3-4 months on average and is dependent on a number of factors, the most important being the nature of the primary tumour, age, performance status and extracranial tumour activity (Gaspar, 1997 (1);Sperduto, 2010 (2)). Prognosis of the underlying disease is a decisive factor in therapeutic decision-making. The goal of treatment is to maintain an optimal quality of life for as long as possible. While the choice of treatment mainly depends on the abovementioned factors, the localisation and the number of brain metastases should also be taken into consideration. Next to neurosurgical treatment and conventional radiotherapy, radiosurgery has acquired a prominent role. New systemic therapies and the development of prophylactic treatment have also increased the number of treatment options.
Given the complexity in clinical decision-making, which involves a multitude of factors that have to be considered, multidisciplinary collaboration is a prerequisite in the treatment of patients with brain metastases.
Given new insights and scientific developments in the diagnosis and treatment of patients with brain metastases, the LWNO (Dutch Society for Neuro-Oncology) and Comprehensive Cancer Centre the Netherlands (IKNL) have decided to revise the national guideline for brain metastases of 2001, following a first revision in 2004.
The present guideline consists of:
- text formulated on the basis of an evidence-based literature study to address clinical problems identified in daily practice (evidence-based update): Diagnostics with an unknown primary tumour, Histological verification of suspected brain metastases in a patient with a known malignancy, SRS / neurosurgical resection with or without WBRT, Systemic therapy of symptomatic brain metastases, Synchronous brain metastases, Asymptomatic brain metastasesand Recurrence of brain metastases. (See Related Oncoline.)
- text derived from the previous guideline updated with recent literature not obtained by a systematic literature study (editorial update): Epidemiology and aetiology, Patient history and neurological examination, Neuroradiological diagnostics, Whether or not treatment should be performed, Whole Brain Radiotherapy, Symptomatic treatment of brain metastases, Follow-up, Brain metastases and driving ability and Psychosocial care and guidance. (See Related Oncoline.) Revision of the guideline has been realised with financial as well as methodological support from Comprehensive Cancer Centre the Netherlands (IKNL).
Authorization date and validity
Last review : 01-07-2011
Last authorization : 01-07-2011
The period of validity of the guideline (maximum of 5 years) is being monitored by IKNL. For various reasons, it may be necessary to revise the guideline earlier than intended. Sections of the guideline will be amended in the interim, when required.
Initiative and authorization
Initiative : Nederlandse Vereniging voor Neurologie
Authorized by:- Nederlandse Vereniging van Artsen voor Longziekten en Tuberculose
- Nederlandse Vereniging voor Medische Oncologie
- Nederlandse Vereniging voor Neurochirurgie
- Nederlandse Vereniging voor Neurologie
- Nederlandse Vereniging voor Radiotherapie en Oncologie
- Verpleegkundigen en Verzorgenden Nederland
- Nederlandse Vereniging voor Psychosociale Oncologie
- Nederlands Instituut van Psychologen
Scope and target group
Objective
The guideline covers the processes of diagnosis, treatment, information provision and guidance of adult patients with metastases in the brain originating from solid tumours, thereby focusing on topical clinical problems encountered in daily practice. The guideline's recommendations aim to aid practitioners in their decision-making support when facing these problems. The recommendations are based on the highest available grade of scientific evidence and on consensus within the guideline development group. The guideline provides information on how the recommendations have been reached from the evidence.
The guideline may be used to provide information to patients and offers points of reference for transmural agreements or local protocols to facilitate implementation.
Users
The guideline is intended for all professionals involved in the diagnostics, treatment and guidance of adult patients with brain metastases of solid tumours. These professionals include:
- Primary specialists: neurologists, neurosurgeons, radiotherapists, medical oncologists, pulmonologists, (oncology) nurses, general practitioners, specialists (working) in palliative care
- Supporting specialists: radiologists, pathologists
- Healthcare providers specialised in psychosocial care: social workers, psychologists, psychiatrists and geriatric medicine specialists
Members of the guideline panel
2011:
Chair:
mw. dr. J.M.M. Gijtenbeek, neuroloog, Universitair Medisch Centrum St Radboud, Nijmegen
Other members:
dr. L.V. Beerepoot, medisch oncoloog, St. Elisabeth Ziekenhuis, Tilburg
dr. W. Boogerd, neuroloog, Nederlands Kanker Instituut / Antoni van Leeuwenhoekziekenhuis, Slotervaartziekenhuis, Amsterdam
mw. S. Bossmann, nurse practitioner, Universitair Medisch Centrum St Radboud Nijmegen
mw. dr. M. van Dijk, internist-oncoloog, Maastricht Universitair Medisch Centrum, Maastricht
mw. dr. A.C. Dingemans, longarts, Maastricht Universitair Medisch Centrum, Maastricht
mw. dr. C. van Es, radiotherapeut-oncoloog, Utrecht Universitair Medisch Centrum, Utrecht, niet actief betrokken (is betrokken geweest bij het initiëren van de werkgroep maar kon vanwege onvoorziene omstandigheden niet aan de totstandkoming van de richtlijn meewerken)
dr. A. de Graeff, medisch oncoloog, Utrecht Universitair Medisch Centrum, Utrecht
dr. P.E.J. Hanssens, radiotherapeut-oncoloog, Gamma Knife Centrum, Tilburg
dr. H.F.M. van der Heijden, longarts, Universitair Medisch Centrum St Radboud, Nijmegen
dr. M.A.A.M. Heesters, radiotherapeut-oncoloog Universitair Medisch Centrum Groningen, Groningen
dr. P.A. M. Hofman, neuroradioloog, Maastricht Universitair Medisch Centrum, Maastricht
dr. R.L.H. Jansen, medisch oncoloog, Maastricht Universitair Medisch Centrum, Maastricht, niet actief betrokken
drs. E. Kurt, neurochirurg, Medisch Centrum Alkmaar
dr. F. J. Lagerwaard, radiotherapeut-oncoloog, Vrije Universiteit Medisch Centrum, Amsterdam
mw. prof.dr. J.B. Prins, klinisch psycholoog, Universitair Medisch Centrum St Radboud, Nijmegen
drs. J.H.C. Voormolen, neurochirurg, Leids Universitair Medisch Centrum, Leiden
drs. V.K.Y. Ho, epidemioloog/procesbegeleider, Integraal Kankercentrum Nederland (IKNL), locatie Utrecht
mw. M.L. van de Kar, ambtelijk secretaris, Landelijke Werkgroep Neuro-Oncologie (LWNO), Bussum
Ondersteuning methodologie
mw. dr. M. Brink, epidemioloog, IKNL, locatie Utrecht
drs. J.M. van der Zwan, MSc, epidemiologisch onderzoeker, IKNL, locatie Enschede
Leden werkgroep voorgaande revisie (2004)
dr. R.H. Boerman, neuroloog, Rijnstate Ziekenhuis, Arnhem (voorzitter)
dr. W. Boogerd, neuroloog, Nederlands Kanker Instituut / Antoni van Leeuwenhoekziekenhuis, Slotervaartziekenhuis, Amsterdam
mw. dr. W.M.H. Eijkenboom, radiotherapeut-oncoloog, Daniel den Hoed Kliniek, Rotterdam
dr. P.E.J. Hanssens, radiotherapeut-oncoloog, Dr. Bernard Verbeeten Instituut, Tilburg
dr. R.L.H. Jansen, medisch oncoloog, Academisch Ziekenhuis Maastricht
dr. F. J. Lagerwaard, radiotherapeut-oncoloog, Vrije Universiteit Medisch Centrum, Amsterdam
prof.dr. C.J.A. Punt, inetrnist-oncoloog, Academisch Ziekenhuis Nijmegen
drs. J.H.C. Voormolen, neurochirurg, Leids Universitair Medisch Centrum, Leiden
prof.dr. J.T. Wilmink, neuroradioloog, Academisch Ziekenhuis Maastricht
dr. J.G. Wolbers, neurochirurg, Academisch Ziekenhuis Dijkzigt, Rotterdam
Declaration of interest
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Method of development
Implementation
Considerations concerning the implementation of the guideline as well as the feasibility of recommendations have been taken into account as much as possible in drafting the revised guideline.
The guideline is summarised and may be consulted in its entirety on http://www.oncoline.nl/. The guideline has been brought to the attention of members of the LWNO, hospitals in the Netherlands, oncology commissions, as well as the scientific and professional associations involved. To further stimulate awareness and implementation of the guideline, regional tumour working groups on neuro-oncology of IKNL were invited to discuss its recommendations.
Given the highly progressive and unfavourable course of the disease, the guideline development group decided not to develop care indicators to measure the level of guideline implementation.