Métastases cérébrales d'un cancer bronchique non à petites cellules : du traitement standardisé au traitement personnalisé

In 2013, it is difficult to define the optimal management of brain metastases from nonsmall cell lung cancer using data from the literature. In fact, large trials of surgery, radiotherapy or stereotactic radiotherapy (SRT) have included various primary tumors without distinction of histological subtypes or of molecular expression profiles. The analysis of these studies shows that surgery improves survival in case of a single metastasis in a patient with good general health condition and whose systemic disease is controlled. It optimizes local control and allows rapid improvement of neurological symptoms. After surgery, the analysis of risk factors for recurrence (tumor size, quality of resection) is required when discussing further irradiation, classically using whole brain irradiation (WBRT), although several retrospective studies suggest the feasibility of an additional SRT boost. Despite the absence of randomized comparison, SRT seems to be an alternative to surgery when several conditions are fulfilled (≤ 3 metastases, size ≤ 3 cm, good general health condition), possibly completed with WBRT (improves intracranial control without survival benefit, increases neurotoxicity). WBRT remains a standard in the case of multiple metastases or when patients are not eligible to focal treatments. After WBRT, an additional irradiation boost improves local control if there are less than three metastases and even survival in case of a single metastasis. There is an increasing role for systemic treatments in this multidisciplinary discussion because those act against both intracranial and extracranial disease and allow delaying the start of WBRT in case of asymptomatic brain metastases. The role of targeted therapies remains to be defined, but the integration of predictive and prognostic molecular factors should help improving the care of patients and provide them the best strategy adapted to their life expectancy and their risk of progression. Multidisciplinary discussion is required.