Brain metastases, the most common malignant brain tumors in adulthood, are caused by the spread of cancer cells from other parts of the body to the brain [1]. An interdisciplinary therapy strategy can improve the course of the disease and the prognosis. Here you will find a comprehensive overview of symptoms, diagnostics and treatment options.
The declared goal is to detect and treat brain metastases as early as possible. At the European Radiosurgery Center Munich (ERCM), we have extensive medical experience at an internationally high scientific level.
Get to know CyberKnife and ZAP-X therapy – innovative methods for the treatment of single or multiple brain metastases. Our experts will be happy to advise you.
Brain metastases are the most common malignant brain tumors in adults [1]: Spreading cancer cells from completely different parts of the body into the brain. These metastases are therefore Metastases of other cancers (primary tumor): e.g. of the breast, lungs or skin. [1] The Cancer cells reach the brain via the bloodstream.
Brain metastases are always malignant, affecting more than 25% of all cancer patients. [2] Frequently occur the metastases at a time when the patients are affected by their original cancer are not yet significantly restricted. [3]
Our innovative treatment methods with robot-guided, radiosurgical Cyberknife therapy or ZAP-X therapy are very well tested and recognized worldwide. The modern Precision technology offers a painless, outpatient and safe form of treatment.
The basis is formed by the highest accuracy requirements, targeted algorithms for the exact planning of your treatment as well as a high-precision application of the therapy. [4] Possible side effects can also be so very low.
As a patient, you will be cared for by interdisciplinary teams of experts from different disciplines in order to ensure the best possible and personalized therapy concepts, taking into account all individually relevant aspects [5, 6, 7].
The specialists in these teams include, for example, neurosurgeons, neurologists, neuroradiologists, oncologists and radiation oncologists. For example, for the right therapy decision, it is also important to know from which initial tumor the brain metastases originate. In addition, there are cases in which the original cancer is not known at all.
Treatment methods include surgical removal of the metastases – called neurosurgical resection – and conventional radiotherapy or whole-brain radiation. An innovative alternative is radiosurgical treatment with the CyberKnife or ZAP-X: Both robotic systems are used either alone or in combination with the other therapeutic approaches [8, 9, 10].
In this way, tailor-made, multimodal therapies are created for the complex clinical picture of brain metastases. If different therapeutic measures work together consistently, the number of affected patients who can be successfully treated increases [5].
In most cases, our patients can go about their usual everyday activities here at the ERCM after their treatment with the CyberKnife or ZAP-X system. An inpatient hospital stay or rehabilitation measures are usually not necessary.
Breast cancer (breast carcinomas), lung cancer (bronchial carcinomas) and melanoma skin cancer (malignant melanomas) are among the most common original cancers that lead to brain metastases [2]. Kidney cancer (renal cell carcinomas) and colorectal cancer (colorectal carcinoma) are also among the possible primary tumors.
Head and neck tumors or bone and soft tissue sarcomas (malignant diseases of the muscle, connective or fatty tissue), on the other hand, rarely spread to the brain.
The majority of brain metastases are located in the cerebrum, preferably in the border area between the white and gray matter of the brain. However, about 10% of all brain metastases are also located deep in the brainstem and often lead to severe neurological deficits [10].
The shape of brain metastases is usually roundish or oval. These lesions increasingly crowd out and infiltrate healthy brain tissue, causing various symptoms depending on their location. Both single (singular) and several (multiple) brain metastases can occur simultaneously.
The symptomatic signs of brain metastases vary greatly. Characteristically, the brain tissue around the metastases is often increasingly swollen due to fluid accumulation (edema). This increases the pressure on the brain. Intracranial pressure or neurological deficits develop in over 80% of patients: Severe headaches, nausea and vomiting, seizures, speech and vision disorders or cognitive disorders, e.g. impairments of memory function, are noticeable, for example [5].
However, severe fatigue or problems with movements or coordination can also occur, as well as changes in character, altered behaviour or general confusion.
It is also typical that the symptoms can either creep in slowly or occur suddenly acutely, as in the case of a stroke. This happens in particular in vascular events, such as bleeding (especially melanoma, kidney or thyroid cancer) or a lack of blood supply in certain areas of the brain (cerebral hemodynamic ischemia).
In modern imaging with computed tomography (CT) or magnetic resonance imaging (MRI), the metastases appear as high-contrast structures. For optimal image quality, you may be injected with a gadolinium-containing contrast agent before the MRI examination.
An MRI scan offers us and our experts great advantages, because with this method a comparatively higher sensitivity is possible than with CT [5].
Other functional examinations depending on the individual situation are:
A complete up-to-date staging – meaning the examination that records the spread of the disease – should be carried out in any case. This is the only way to accurately diagnose the spread of the tumor [5]. In addition, there are various individual checks on the function of your nervous system, including tests with regard to muscle strength, reflexes or balance. In addition, vision and hearing tests or a test of cognitive abilities or your memory.
If the original cancer is unknown or the findings are unclear, a histological examination of the tissue (biopsy) is also performed. The same applies to a longer period of time that has elapsed from the diagnosis of the original cancer to the detection of brain metastases.
Left: In this case of a patient with breast cancer, a single (singular) brain metastasis occurred – surrounded by edema and critically located in the central region of the brain, which is responsible for motor functions, among other things.
Right: The radiosurgical treatment effectively eliminated the brain metastasis, but it was no longer detectable in the MRI 22 months after the CyberKnife therapy (treatment duration: 25 minutes). The fluid accumulation (edema) had also completely decreased.
Regardless of the type of treatment, in addition to controlling the original cancer, the general condition of affected patients before starting treatment of brain metastases is decisive for the overall prognosis [9].
The decision about which treatments are carried out individually depends on various aspects, including above all your personal situation and your general condition (Karnofsky index). However, the activity of the original cancer and the question of the number and location of metastases in the brain also play a role in therapy.
In order to restore the best possible quality of life as quickly as possible, measures are initiated to alleviate symptoms. If, for example, fluid accumulation is present, therapy with cortisone alone can reduce this edema in the brain and temporarily alleviate symptoms that are often associated with them.
For patients with epileptic seizures, treatment with special active ingredients (anticonvulsants) is useful.
Every neurosurgical resection aims to remove as completely as possible and thus subjectively improve quality of life. The decision to undergo surgery also depends primarily on the size, number and location of the metastases [3]. In particular, surgery is always necessary if individual brain metastases are acutely symptomatic and have a diameter of 3 cm or more.
The advantages of microsurgical intervention lie in the immediate improvement of neurological deficits – i.e. impairments that have arisen, for example, due to the pressure of metastases on important functional areas of the brain [3].
For a long time, whole-brain irradiation was a common method for many brain metastases as a sole therapy or in combination with surgery. This has changed due to increasing scientific knowledge and a correspondingly large data density due to new international studies: Today, modern treatment concepts often dispense with the subsequent whole-brain irradiation after complete surgical removal – and also after radiosurgery. In this way, the side effects associated with whole-brain irradiation with cognitive decline are to be reduced and the overall burden of therapy is to be reduced [3].
Another treatment option for some brain metastases is systemic chemotherapy – depending on the previous treatment or the success of previous therapies. According to previous studies, chemotherapies have been successfully used for brain metastases in patients with small cell lung cancer, breast cancer and germ cell cancer who have not been treated systemically. Overall, however, knowledge and scientific data on systemic chemotherapy are currently still limited [5]. However, targeted therapy plays an increasing role in brain metastases, e.g. tyrosine kinase inhibitors in certain lung carcinomas.
The targeted precision technique of robot-guided radiosurgery has established itself in the last more than 20 years for various tumor diseases in the head area, and we can now successfully apply these state-of-the-art systems throughout the body for numerous diseases [7].
The therapy is comfortable for you and less stressful than other methods, because brain metastases can be treated with the CyberKnife or ZAP-X robotic systems, for example, without invasive fixation (head frame), without anesthesia and without open surgery.
Individually, either a single radiosurgical session (one-time radiosurgery, SRS) or several sessions (fractional stereotactic radiotherapy, FSRT) are performed, whereby the therapy dose in FSRT is divided (fractionated) over the number of individual treatments [10].
Especially for patients with brain metastases of a maximum diameter of up to approx. 3 cm, CyberKnife or ZAP-X therapy can be a very good treatment option. The same applies if the metastases are not accessible to surgery because they are located, for example, in deep brain regions such as the brainstem: Current studies show an excellent benefit-risk ratio for the radiosurgical treatment of brainstem metastases [10, 11].
Various scientific studies also prove that the innovative precision treatment we carry out at our ERCM is fundamentally not inferior to surgical therapy of brain metastases. Radiosurgical treatment with the CyberKnife or ZAP-X can also be the appropriate standard therapy compared to conventional radiotherapy in cases with up to 10 brain metastases [12, 13, 14].
In the case of metastases in the immediate vicinity of sensitive functional areas of the brain, e.g. speech center or motor center, the high-precision technology with the CyberKnife or ZAP-X also has significant advantages over the classic surgical procedure.
Local tumor control with radiosurgery – i.e. the complete destruction of the cancer cells, ideally without a recurrence of the cancer – is about 90% overall.
Therapy options that have become more complex mean that the decision for a particular treatment should always be made with a view to your individual life situation. It is important to us that you, as well as your relatives and people who support and accompany you, have a good understanding of all aspects of your illness and its treatment options and can classify them for yourself.
If brain metastases are discovered, it is not only physically but also emotionally and psychologically enormously stressful. You don't have to go this way and decisions for therapy alone. Together with our team and our partners, we take the time to develop the right treatment concept for you personally.
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In radiosurgical treatment, the entire metastasis is treated, the metastases scar and recede.
Yes, Cyberknife and ZAP-X are effective methods for the treatment of single or multiple brain metastases. Their size and location play an important role in the treatment decision.
Treatment of recurrences depends on various factors, including the number and size, the patient's general condition, and the therapy previously used. Often, re-radiosurgery with the Cyberknife or ZAP-X can be considered, especially if the metastases are small and well defined.
The speed at which brain metastases grow and spread can vary. It depends on various aspects, including the original cancer and also the aggressiveness of the metastases. Some can develop quickly, while others grow slowly. Regular imaging and medical monitoring are therefore very important to detect such growth in time and treat brain metastases.
Depending on their location in the brain, the metastases can also lead to changes in character or changed behavior.
The therapy is usually carried out as a one-time treatment session, especially in the case of small brain metastases. The high precision of the robotic systems makes it possible to concentrate a high dose of radiation on the metastases while sparing the surrounding healthy tissue.
This also depends, among other things, on the location of the brain metastases in the brain, and dizziness or headaches can occur in general.
Auch das ist u. a. abhängig von der Lage der Hirnmetastasen im Gehirn, allgemein können Schwindel oder Kopfschmerzen auftreten.
Rehabilitation is not required after treatment with the Cyberknife or ZAP-X system.
Driving should be avoided due to the risk of seizures in the presence of brain metastases.
[1] Thon, N., Karschnia, P., von Baumgarten, L., Niyazi, M., Steinbach, J. P., Tonn, J. C., Neurosurgical interventions for cerebral metastases of solid tumors. Dtsch Arztebl Int. 2023;120:162-169.
https://di.aerzteblatt.de/int/archive/article/230130
[2] Diehl, C. D., Shiban, E., Straube, C., Gempt, J., Wilkens, J. J., et al., Neoadjuvant stereotactic radiosurgery for intracerebral metastases of solid tumors (NepoMUC): a phase I dose escalation trial. Cancer Commun (Lond). 2019;39(1):73.
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https://link.springer.com/article/10.1007/s00066-018-1416-x
[5] Schmieder, K., Keilholz, U., Combs, S., The interdisciplinary management of brain metastases. Dtsch Arztebl Int 2016;113:415-421.
https://di.aerzteblatt.de/int/archive/article/179923
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https://link.springer.com/article/10.1007/s00761-024-01512-3
[7] Muacevic, A., Wowra, B., Siefert, A., Tonn, J. C., Steiger, H. J., Kreth, F. W., Microsurgery plus whole brain irradiation versus Gamma Knife surgery alone for treatment of single metastases to the brain: a randomized controlled multicentre phase III trial. J Neurooncol. 2008;87:299-307.
https://link.springer.com/article/10.1007/s11060-007-9510-4
[8] Seegenschmiedt, M. H., Hochpräzisionsstrahlentherapie und Radiochirurgie. Gezielte Behandlung von Hirnmetastasen. Im Fokus Onkologie 2013;16:6.
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https://onlinelibrary.wiley.com/doi/10.1002/ijc.34980
[11] Trifiletti, D. M., Lee, C. C., Kano, H., Cohen, J., Janopaul-Naylor, J., Stereotactic Radiosurgery for Brainstem Metastases: An International Cooperative Study to Define Response and Toxicity. Int J Radiat Oncol Biol Phys 2016;96(2):280-288.
https://linkinghub.elsevier.com/retrieve/pii/S0360301616303200
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