Metastatic Brain Cancer

Overview

Spread of cancer  to the brain or spinal cord from a primary cancer outside the brain is estimated to occur in 20% to 60% of all cancer patients. Although every cancer may spread to the brain, the risk of developing metastases to the brain is higher for lung cancer, breast cancer and melanoma than for other cancers. The highest incidence appears to be in patients with advanced small cell lung cancer, where 60% of patients will ultimately develop metastases to the brain. The incidence of brain metastases is rising as a result of an improved ability to detect the metastases with sophisticated imaging procedures, computerized tomography (CT) scans and magnetic resonance imaging (MRI). In addition, improvements in the treatment of primary cancers leaves more patients at risk for spread to the brain or spinal cord. Metastatic cancers are by far the most common cause of brain cancer, with an incidence rate higher than all types of primary brain tumors combined.

Cancer cells spread to the brain from other locations through the blood supply, lymphatic system, or by direct extension. Nervous system metastases usually involve the brain or spinal cord, the covering of the brain or spinal cord or the cerebrospinal fluid surrounding the brain and spinal cord. Depending on the location of cancer, neurologic symptoms often include headache, weakness, or mental problems. 

The following is a general overview of the treatment of cancer metastatic to the brain. Circumstances unique to your situation and prognostic factors of your cancer may ultimately influence how these general treatment principles are applied to your situation. In addition to this treatment overview, the Clinical News web site feature presents the results of the clinical trials that determine the standard treatments of cancer metastatic to brain and new treatment strategies as they have been discovered and applied by cancer physicians around the world.

All new treatments are developed in clinical trials. Participation in a clinical trial may offer access to better treatments and advance the existing knowledge about treatment of this cancer. Remember, this web site information is intended to help educate you about your treatment options and to facilitate a mutual or shared decision-making process with your treating cancer physician

The prognosis (outlook) for patients with brain metastases predominantly depends on the success of treatment for the primary cancer located elsewhere in the body.  If the primary cancer cannot be eradicated, treatment of metastasis to the brain is unlikely to be curative. However, treatment can reduce disability and prolong life in many patients with cancer metastatic to brain.

The optimal treatment for patients with cancer metastatic to brain continues to evolve. Generally, surgery or stereotactic radiation therapy followed by whole-brain radiotherapy are appropriate treatment options for patients with limited brain metastases and controlled cancer elsewhere in the body. Supportive care accompanied by whole brain radiation therapy is the standard treatment for all patients with multiple symptomatic metastatic brain cancers or with isolated symptomatic brain metastasis in the presence of uncontrolled cancer outside the brain.

Generally, cancers metastatic to the brain have a poor prognosis. Patients who experience spread of cancer to the brain from a primary cancer outside the brain have an average survival of 1-2 months with current medical management. Treatment of the whole brain with radiation can prolong survival to 3-6 months and surgical resection of the brain metastases following whole-brain radiation therapy or stereotactic radiation therapy may further improve survival to 10-12 months in some patients.

A retrospective review of 740 patients with brain metastases treated over a 20-year period at a single institution identified 51 patients that survived 2 or more years from the time of diagnosis of the brain metastasis. In the 51 patients, 69% had a single site of metastatic cancer and 31% had multiple cancers. For all cancer types, the actuarial survival rate was 8.1% at 2 years, 4.8% at 3 years, and 2.4% at 5 years. At 2 years, patients with ovarian carcinoma had the highest survival rate (23.9%) and patients with small cell lung cancer had the lowest survival rate (1.7%). The presence of a single metastatic cancer, surgical resection, young age, the administration of chemotherapy and the administration of whole-brain radiation therapy were favorable prognostic variables for extended survival. The presence of multiple bilateral metastases was a poor prognostic indicator. Twenty-nine patients (57%) died of cancer progression outside the brain, 18% died of central nervous system progression, and the cause of death was unknown in 6%. It was concluded that patients with a single metastasis from non-small cell lung cancer, breast cancer, melanoma, renal cell cancer, or ovarian carcinoma had the best chance for long-term survival if treated with surgical resection and whole-brain radiation therapy.

Treatment of a Single Brain Metastasis

Patients with a single brain metastasis typically experience more prolonged survival than patients with multiple brain metastases, especially if the primary cancer outside the brain is controlled. The treatment of a single brain metastasis has evolved substantially over the last decade. The advent of contrast-enhanced MRI scans has improved the ability to diagnose brain cancers when they are small and more treatable. In addition, improved scanning has resulted in a declining percentage of brain metastases classified as single. Using MRI, 25% to 30% of brain metastases are single. A single brain metastasis in the absence of cancer elsewhere in the body (successful treatment of systemic cancer) is called a solitary brain tumor.

Patients with a single brain metastasis and refractory progressive cancer elsewhere are usually offered treatment with whole-brain radiation therapy. Patients with highly radiosensitive primary tumors such as small cell lung cancer, lymphoma, and germ cell tumors are also typically treated with whole-brain radiotherapy. Otherwise healthy patients with inactive or controllable systemic cancer may benefit from the addition of treatment with surgery or stereotactic radiation therapy in addition to whole-brain radiation therapy. Although surgery and stereotactic radiation therapy have not been directly compared in a randomized controlled clinical trial, most studies suggest that the results for these two approaches are similar. Single metastases that are 1.5 inches or smaller in diameter are treated with stereotactic radiation therapy because there are fewer side effects than with surgery. Patients with larger or cystic tumors, with obstructive hydrocephalus, or neurologic instability are more frequently treated with surgery (craniotomy). Whole-brain radiation therapy following surgical or stereotactic radiation therapy of single brain metastasis appears to decrease the risk of recurrent brain metastasis, although it has not been shown to improve survival.

In one study, stereotactic radiation therapy was compared to microsurgery for treatment of 133 patients with a single brain metastasis. All patients received additional whole-brain radiation therapy. Sixty-seven patients were treated with stereotactic radiation therapy and 66 patients were treated with microsurgery. Stereotactic radiation therapy was associated with a better control of local cancer regrowth than surgery. It was suggested that stereotactic radiation therapy should be used for all cases of single brain metastases except for cases of large tumors.

Radiation Therapy

External beam radiation therapy (EBRT) alone to the whole brain or, more often, in conjunction with surgery, has been the primary treatment for patients with cancer metastatic to the brain. Radiation can be administered before or after surgery and doctors are trying to determine the optimal sequence of surgery and EBRT and evaluate the role of stereotactic radiation therapy.

Stereotactic Radiation Therapy (Radiosurgery, Gamma Knife Therapy): Increasingly, CT and MRI scans are being utilized to pinpoint radiation administered to cancer metastatic to the brain. Potential damage to normal brain cells limits the total dose of radiation therapy that can be administered to the brain. Typically, there is residual cancer or a recurrence after EBRT. Some methods have been developed to deliver radiation therapy only to the cancer, while sparing healthy cancer cells from damage. Stereotactic radiation therapy, called radiosurgery or gamma knife therapy is increasingly being used to treat patients with cancers metastatic to the brain and is usually administered after a complete course of EBRT. This approach allows radiation to be delivered to cancer cells anywhere in the brain and then pinpointed to the highest radiation dose to the area with the greatest amount of cancer.

In a recent study, patients with 2-4 metastases that are all less than or equal to one inch in size, from an identifiable primary cancer (including melanoma, lung, breast, and renal cell cancers) were treated with either whole-brain radiation therapy or whole-brain radiation therapy plus stereotactic radiation therapy and the results were then directly compared. The clinical trial was closed early because the group of patients receiving stereotactic radiation therapy had results that appeared superior. Brain metastases recurred in 100% of the patients who received whole-brain radiation therapy alone, compared to only 8% of the patients who received whole-brain radiation therapy plus stereotactic radiation therapy. The average survival was 11 months in the stereotactic radiation therapy group, compared to 7.5 months in the whole-brain radiation therapy alone group. This trial demonstrated the superiority of whole-brain radiation therapy combined with stereotactic radiation therapy. Currently, the patients who would benefit from stereotactic radiation therapy are those who have four or fewer relatively small brain metastases and a relatively good performance status. Virtually all patients in this trial still ultimately died of cancer even when the brain metastases were controlled, which further emphasizes the great need for effective treatment of the primary cancer. Control of the primary cancer is still the principal factor determining a patientís survival.

Another trial compared whole-brain EBRT to stereotactic radiation therapy alone.  In the group who received stereotactic radiation therapy, large cancers were removed surgically and all other small cancers were treated by stereotactic radiation therapy alone.  Patients who received stereotactic radiation therapy had a better survival and quality of life than patients who received radiation therapy alone. The researchers concluded that stereotactic radiation therapy without whole-brain radiation therapy could also be a primary choice of treatment for patients with as many as 10 cerebral metastases from non-small cell lung cancer.

The care of patients with a brain metastasis from an unknown primary site is controversial. One study reviewed the outcomes of 15 patients who had solitary or multiple brain metastases without a detectable primary site at the time of initial presentation. In five patients, a histologic diagnosis of cancer was obtained from extracranial metastatic sites. In 10 patients, a diagnosis was obtained from the brain. A total of 31 tumors underwent treatment with stereotactic radiation therapy. The average survival was 15 months after stereotactic radiation therapy and 27 months after their initial diagnosis of cancer. Three patients (20%) were still living between 21-48 months after treatment. It was concluded that stereotactic radiation therapy was an effective strategy for patients with brain metastases from an unknown primary site. Disease progression outside of the brain was the usual cause for patient death. For more information about the various techniques, go to Radiation Therapy.

Surgery

In some instances, there is increased intra-cranial pressure because the tumor blocks the flow of cerebrospinal fluid. When this is the case, an operation is necessary for decompression. In some patients, surgical placement of a temporary or permanent shunt (tube) is required to drain excess cerebrospinal fluid.

Stereotactic surgery uses computers to create a three-dimensional image in order to provide precise information about a tumor's location and its position relative to the many structures in the brain. Stereotactic techniques can be used by the surgeon to map out the surgical procedure and "rehearse," or by the radiation specialist to plan radiation therapy.

The development of new surgical techniques over the past twenty years has led to a reduction in operative morbidity and mortality. Surgery followed by whole-brain radiation therapy is still considered the method of choice for the treatment of metastases to the brain.

Non-Small Cell Lung Cancer

One study evaluated the role of chemotherapy for patients with brain metastases from non-small cell lung cancer. Among 121 patients with non-small cell lung cancer, 30 had metastasis to the brain and were treated with combination chemotherapy including cisplatin, ifosfamide and CamptosarÆ with NeupogenÆ support. Fourteen patients achieved a partial response, but there was no change in 13 patients and progressive disease in 1. The response rate was 50% in brain metastases and 62% in extracranial primary and other metastatic lesions. The average duration of response for intra- and extracranial cancer was 140 and 147 days, respectively. After chemotherapy, stereotactic radiation therapy was performed on 2 patients in remission and 8 patients at the time of disease progression. The average survival time was approximately one year. The researchers concluded that both the response rate and survival data suggested a high degree of activity for this combination of chemotherapy in patients with brain metastases from non-small cell lung cancer.

In one clinical trial, 23 patients with brain metastases from non-small cell lung cancer (average age 62 years) were treated with cisplatin and teniposide every 3 weeks. The objective response rate of brain metastases was 35%; three patients achieved a complete response and five a partial response. The average response duration was 24 weeks for complete remission patients and 32 weeks for partial remission patients. The average survival was 21 weeks overall and 45 weeks for responding patients. It was concluded that cisplatin and teniposide was an active regimen against brain metastases for non-small cell lung cancer.

Small Cell Lung Cancer

For patients with small cell lung cancer, pooled data from 5 studies indicate a 66% response rate in 64 patients with initial brain metastasis. In addition, 5 studies indicate an average response rate of 36% in 135 patients with delayed brain metastasis treated with systemic single agent chemotherapy.

In one clinical trial, small cell lung cancer patients with brain metastases were randomly allocated to receive teniposide with or without whole-brain radiation therapy. Teniposide was given intravenously three times a week, every 3 weeks. The combined-modality arm exhibited a 57% response rate and the teniposide-alone arm exhibited a 22% response rate . Time to progression in the brain was longer in the combined-modality group. Clinical response and response outside the brain were not different. The average survival time was 3.5 months in the combined-modality arm and 3.2 months in the teniposide-alone arm. It was concluded that adding whole-brain radiation therapy to teniposide results in a much higher response rate of brain metastases and a longer time to progression of brain metastases than teniposide alone. Survival was poor in both groups and not significantly different.

Locally Administered Chemotherapy

Neoplastic meningitis is the spread of cancer cells to the cerebrospinal fluid, which surrounds the brain and spinal cord. Chemotherapy can be injected into the cerebrospinal fluid, which can produce a regional and local effect. This can be accomplished by repeated lumbar puncture or placement of an Ommaya reservoir. This apparatus allows repeated injection of drugs into the cerebrospinal fluid. This is called local-regional therapy. Drugs that are commonly injected into the spinal fluid to treat metastatic cancer include methotrexate and cytarabine.

Strategies to Improve Treatment

The progress that has been made in the treatment of cancer metastatic to brain has resulted from early diagnosis, improved surgical and radiation therapy techniques and doctor and patient participation in clinical studies. Future progress in the treatment of cancer metastatic to brain will result from continued participation in appropriate studies. There are several areas of active exploration to improve the treatment of cancer metastatic to the brain.

• Improvement in Radiation Therapy: The majority of patients with cancer metastatic to the brain will be treated with radiation therapy. Researchers are developing several techniques to improve radiation treatment. Many of the newer radiation treatment techniques will be administered in combination with chemotherapy.

• New Chemotherapy Drugs: There is an emerging role for systemic chemotherapy for the treatment of some cancers metastatic to the brain, particularly with the use of new active drugs as part of combined modality treatments. The major limitation of chemotherapy for the treatment of brain tumors is that very few drugs pass through the blood-brain barrier. Therefore, the choice of active agents is limited. The most commonly used drugs that penetrate the blood-brain barrier are carmustine, lomustine, procarbazine, vincristine and more recently temozolomide. There are many clinical trials evaluating new chemotherapy agents for the treatment of newly diagnosed patients with cancer metastatic to the brain or for recurrent disease.

Temozolomide: Temozolomide is the first new chemotherapy agent in more than 20 years to be approved for the treatment of high-grade malignant gliomas. This novel oral alkylating agent has demonstrated promising activity not only in brain tumors, but in a variety of solid tumors, including malignant melanoma. Temozolomide can be taken orally and is able to cross the blood-brain barrier. In patients with advanced metastatic melanoma, brain metastases are a major cause of treatment failure. In this setting, temozolomide has been shown to be as effective as dacarbazine, with a similar safety profile. More importantly, there is evidence to suggest that temozolomide-treated patients have a lower incidence of central nervous system relapse compared with dacarbazine-treated patients. Therefore, temozolomide is actively being investigated for the treatment and prevention of brain metastases in melanoma patients with other cancers.

Fotemustine: Nitrosoureas, carmustine and lomustine, are the most commonly used drugs to treat brain cancer since they cross the blood-brain barrier. Fotemustine is a new nitrosourea. Clinical studies using fotemustine have been conducted in malignant glioma, non-small cell lung cancer, and disseminated malignant melanoma. In brain metastases of non-small cell lung cancer, fotemustine proved to be active with a response rate of 16.7%. Combined with cisplatinum, fotemustine is still under study, but preliminary results are promising. In cerebral metastases of disseminated malignant melanoma, fotemustine has been evaluated in a total of 140 patients in the various studies, with the response rate ranging from 8.3% to 60.0% and a median response rate of 24.3%.

• Biological Agents: Biological agents are substances that normally occur in the body and have activity against some cancers. Some are biological response modifiers, which enhance immune responses, while others have other biological effects. Available biologic agents include the interferons and some interleukins. Melanoma and renal cell cancer sometimes respond to interleukin 2 and/or alfa interferon. Although no formal studies of brain metastases have been performed, patients with melanoma sometimes respond to alfa interferon in combination with chemotherapy and this would be logical treatment for some patients with melanoma with metastases to the brain. Patients with renal cell cancer respond to interleukin-2 and alfa interferon, which are  logical agents for the treatment of metastases to the brain.

• Disruption of the Blood-Brain Barrier: The brain has a natural barrier that protects it from foreign substances. This protective blood-brain barrier makes it difficult for drugs, such as those used in chemotherapy, to reach the brain. Researchers have administered a drug called mannitol to disrupt the blood-brain barrier before chemotherapy with the goal of helping the chemotherapy penetrate the barrier into the brain. Results showed that 75% of patients with lymphoma of the brain achieved a complete response to treatment. All individuals with neuralectodermal cancer, germ cell cancer, or other metastatic cancer (spread to the brain from other areas in the body) had at least a stabilization of the cancer (no growth or progression). Seventy-eight percent of patients with glioblastoma multiforme also had at least a stabilization of the cancer. In responsive brain cancers, this treatment was effective with chemotherapy alone, without radiation therapy and without any loss of mental function. These results indicate that the use of mannitol to disrupt the blood-brain barrier and administration of the chemotherapy via the artery appears promising.

• Photodynamic Therapy:  Photodynamic therapy works through the use of a photosensitizing agent and light. The photosensitizing agent is typically comprised of a porphyrin, which is a naturally occurring substance in the body involved in a variety of biological processes. The photosensitizing agent is injected into a patient's vein a couple of hours prior to surgery. During this time, the agent selectively collects in rapidly growing cells such as cancer cells. During surgery, the physician applies a certain wavelength of light through a hand held wand directly to the site of the cancer and surrounding tissues. The energy from the light activates the photosensitizing agent, causing the production of a toxin that accumulates in the cancer cells and ultimately destroys them. 

Photodynamic therapy for the treatment of a variety of brain tumors, particularly gliomas, has been extensively investigated in laboratory studies and in a few clinical trials. The main advantage of photodynamic therapy lies in its ability to select out tumor cells that are infiltrating the brain gliomas. Photodynamic therapy has been shown to be safe clinically, but adequate trials have yet to be performed to prove its efficacy and much work remains to be done in order to optimize treatment.

 In one study, photodynamic therapy was used to treat 20 patients with newly diagnosed malignant gliomas. Eleven patients had glioblastoma multiforme and 9 had malignant astrocytoma. Intravenous porphyrin photo-sensitizer was administered 12-36 hours prior to surgery and photo-illumination. At operation, all patients had the tumor sub-totally resected followed by intra-operative cavitary photo-illumination. No untoward effects of radiation in conjunction with photodynamic therapy were identified. There was 1 post-operative death and 1 patient had a persistent increase in post-operative neurological deficit. The average survival of these 20 patients with newly diagnosed malignant gliomas was 44 weeks, with a 1-year survival of 40% and a 2-year survival of 15%. The average survival of patients with newly diagnosed glioblastoma multiforme was 37 weeks, with a 1-year survival of 35%. It was concluded that photodynamic therapy is safe in newly diagnosed patients with malignant gliomas who undergo post-operative radiation and appears to prolong survival in selected patients when an adequate light dose is used.

• Gene therapy: Gene therapy can be defined as the transfer of genetic material into a patient's cells for therapeutic purposes. Currently, there is no gene therapy approved by the FDA for treatment of brain cancers. To date, a diverse and creative assortment of treatment strategies utilizing gene therapy have been devised, including gene transfer for modulating the immune system, enzyme pro-drug ("suicide gene") therapy, oncolytic therapy, replacement/therapeutic gene transfer, and antisense  therapy. For malignant glioma, gene-directed pro-drug therapy using the herpes simplex virus thymidine kinase gene was the first gene therapy attempted clinically. A variety of different strategies have now been pursued experimentally and in clinical trials. Although, to date, gene therapy for brain tumors has been found to be reasonably safe, concerns still exist regarding issues related to viral delivery, transduction efficiency, potential pathologic response of the brain, and treatment efficacy. Improved viral vectors are being sought, and potential use of gene therapy in combination with other treatments is being investigated. 

GLI-328 is a newly developed form of investigational gene therapy currently in clinical trials for patients diagnosed with primary glioblastoma multiforme. Therapy with GLI-328 involves the insertion of a gene derived from a deactivated herpes simplex virus into the rapidly dividing glioblastoma tumor cells. Once taken up by the tumor cells, the gene produces a substance called thymidine kinase. Patients  then receive a non-toxic agent called ganciclovir. Thymidine kinase within the cell converts ganciclovir into a toxic substance which ultimately destroys the cell. The rationale behind this therapy is that since normal brain cells do not divide, and tumor cells do divide, only the tumor cells will be infected with the thymidine kinase gene and receive the toxic effects of ganciclovir. GLI-328 therapy was recently used to treat approximately 30 patients in a multi-center trial for patients with recurrent glioblastoma multiforme. A phase III, randomized study involving GLI-328 is currently open for enrollment. This study is being conducted in 40 centers worldwide and will enroll approximately 250 patients with newly diagnosed primary glioblastoma. The two arms of the study involve surgical resection of the tumor and radiation therapy/or surgical resection, treatment with GLI-328 and radiation therapy.

• High-Dose Chemotherapy with Autologous Stem Cell Support: High-dose chemotherapy with autologous stem cell (bone marrow or peripheral blood) rescue has not been extensively evaluated in adults with cancer metastatic to brain.

Germ Cell Cancer and High-Dose Chemotherapy: In one study, 22 patients with brain metastases at initial diagnosis of germ cell cancer were treated with high-dose cisplatin, etoposide and ifosfamide followed by autologous stem-cell transplantation. Radiation therapy to the brain was administered to patients with symptomatic central nervous system disease or as consolidation in case of residual cancer after high-dose chemotherapy. Ten patients received high-dose chemotherapy alone and twelve were treated with high-dose chemotherapy plus radiation therapy. Two early deaths occurred in 22 patients. The 2-year progression-free and overall survival rates were 72% and 81%, respectively. These survival rates are substantially higher than those observed following conventional dose chemotherapy. It was concluded that high-dose chemotherapy with autologous stem-cell support with or without radiation therapy was feasible without increased therapy-related mortality in patients with advanced metastatic germ cell tumors and brain metastases.

One patient with retroperitoneal pure choriocarcinoma of advanced stage who had failed conventional dose chemotherapy and had multiple brain metastases was treated with high-dose chemotherapy and autologous stem cell transplantation. The high-dose regimen consisted of etoposide, carboplatin, and ranimustine, which can penetrate the blood-brain barrier. Twenty-four months after treatment the patient had no sign of cancer recurrence.

Breast Cancer and High-Dose Chemotherapy: In patients with breast cancer, most clinical trials using high-dose chemotherapy with autologous stem cell support exclude patients with brain metastases. This exclusion was based on anecdotal experience reflecting high treatment-related mortality. In one study, the outcomes of 11 patients with metastatic breast cancer who had brain metastases were evaluated after treatment with high-dose chemotherapy with autologous stem cell support. In three patients, deaths were attributed to non-central nervous system regimen-related toxicity. Five patients died as a result of non-brain cancer progression. One patient died as a result of both brain and non-brain cancer progression. Two patients are alive without cancer progression with follow-up of 13.4 and 7.3 months, respectively. Of the five patients who have survived 1 year, four have hormone receptor expression and continued on antihormone therapy after high-dose therapy. These results show that breast cancer patients having brain metastases who receive high-dose chemotherapy do not experience more treatment-related complications or treatment failure as a result of the metastatic brain disease. Exclusion of these patients from high-dose chemotherapy trials is not warranted. For more information, go to Stem Cell Transplantation.

• Monoclonal Antibodies: Monoclonal antibodies are proteins that can be made in the laboratory and are designed to recognize and bind to very specific cells such as cancer cells. This binding action stimulates the immune system to attack and kill the cancerous cells. Monoclonal antibodies can also be fused with a toxin or radioactive substance which is delivered to the cancer cell upon binding with the antibody. A significant benefit of this approach is that monoclonal antibodies only target cancer cells, sparing healthy cells from destruction. This is in contrast to chemotherapy or radiation, which do not differentiate between cancer cells and healthy cells in the body, leading to potentially destructive side effects. 

Researchers  have conducted an early phase clinical trial involving the surgical removal of the cancer followed by an injection of a radioactive isotope linked to a monoclonal antibody, called Iodine-131 Antitenascin 81C6 (I-labeled 81C6). Antitenascin 81C6 identifies cancerous glioma cells by recognizing small proteins displayed on the surface of the cancer cells, called tenascin. When antitenascin binds to the cancerous glioma cells, the immune system is stimulated to attack the cancer cells. I-131 is a radioactive isotope substance that is attached to antitenascin 81C6. Radioactive isotopes kill cancer cells by spontaneously emitting forms of radiation. When antitenascin binds to cancer cells, the attached I-131 destroys these cells by emission of its radiation. I-labeled 81C6 not only provides two separate treatment strategies, but also allows the delivery of greater amounts of radiation directly to the cancer cells, while minimizing radiation exposure to normal cells. In this study, I-labeled 81C6 was injected directly into the cavity of the brain from which the cancer was removed in 42 patients with malignant gliomas who had not received prior treatment. The average duration of survival for patients was extended over standard treatment to one and half years. Some patients experienced neurological complications from the procedure, including seizures, memory loss, an inability to coordinate muscle movement and slight weakness on one side of their body. Future clinical trials evaluating this treatment approach will be conducted to further refine the overall strategy and confirm these encouraging results.

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