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Table 2. RPA classes
Prognostic factors Class I Class II* Class III
Age (years) < 65 Any Any
Controlled primary tumor Yes Any Any
KPS > 70 > 70 <7 0
Extracranial metastasis No Any Any
Estimated survival (months) 7.1 4.2 2.3
Abbreviations: RPA: recursive partition analysis; KPS: Karnofsky performance score. *All patients not in class I or III.

By contrast, the use of anticonvulsants in patients with seizures, although it does not have an impact
on overall survival, is useful for the relief and decrease of the number of convulsive episodes. The drugs
used most often that have been proven to be effective and safe include levetiracetam, oxcarbazepine, and
topiramate [38,39] .

INITIAL ASSESSMENT
A therapeutic approach must be preceded by an adequate assessment of the patient’s condition, evaluating
parameters such as functional status and extracranial disease so that the best available treatment may be
offered, without compromising the oncological outcome or overtreating patients in whom poor survival may
be anticipated and for whom support measures are more adequate.

PROGNOSTIC SCALES IN BRAIN METASTASES
At present, several useful prognostic scales are available for the clinical decision-making process, the first of
which is recursive partition analysis (RPA by Gaspar et al. ), developed in 1997. This scale was formed by the
[40]
Radiation Therapy Oncology Group (RTOG) clinical trials that defined three prognostic classes according
to four prognostic factors: performance according to the Karnofsky performance scale (KPS), control of the
primary disease, presence or absence of extracerebral disease, and age greater or less than 65 years, dividing
patients with brain metastases and their respective median survivals into three prognostic classes [Table 2].

Patients with a class III RPA are usually candidates for only supportive care, with local management
performed either through surgery or radiotherapy for patients with classes I and II [40,41] .

The histological type of the primary tumor should also be considered an important prognostic factor;
however, the previous scale does not take this into account. There is a more specific scale for primary disease
that takes melanoma, gastrointestinal tumors, breast cell carcinoma, renal cell carcinoma and non-small-
cell lung carcinoma into account. This scale is known as DS-GPA [42,43] .

The prognosis derived from these scales depends on various prognostic factors in relation to each histology,
namely, age, KPS score, presence or absence of extracranial metastasis in the case of lung carcinoma, number
of cerebral metastases in the case of lung carcinoma, melanoma, and renal cell carcinoma. Likewise, breast
cancer, with its several molecular patterns that determine prognosis, is integrated into this scale [Table 3].

For more information on the estimation of global survival according to tumor type and characteristics, we
recommend visiting a website made for this purpose: http://brainmetgpa.com/.

SURGICAL MANAGEMENT
Surgery plays an important role in the management of brain metastases, enabling a definitive histologic
diagnosis in patients with no previously known history of cancer, allowing clinicians to alleviate the
symptoms of intracranial hypertension (thus providing immediate relief to patients), and serving as a