Most physicians advocate whole brain irradiation after surgical excision, but the efficacy of this treatment has not been established. Patients with multiple or surgically inaccessible metastatic tumors are treated with whole brain irradiation to eradicate both the visible tumor and micrometastases that may be present elsewhere in the brain. Conversely, the brain acts as a so-called sanctuary for small, nonenhancing metastases. Because these metastases are not exposed to systemic water-soluble chemotherapy, solitary CNS relapse in patients with peripherally controlled breast cancer frequently occurs. Epidural spinal cord compression by a metastatic tumor is a neurologic emergency.
Definitive therapy entails irradiation with or without surgical decompression.
Surgical procedures include laminectomy or removal of a vertebral body. Surgical decompression has not been proven to be superior to radiation therapy. Patients who are ambulatory when treated usually remain so after treatment. Those who are not ambulatory may or may not regain the ability to walk, and those who are paraplegic rarely do so. The incidence of leptomeningeal metastases appears to be increasing.