Table 2.

Clinical Decision Making in Treatment of Brain Metastases

Consider systemic therapy when: BM from highly chemotherapy-sensitive PT BM found on screening MRI with planned systemic treatment BM from PT with identified molecular alteration amenable to targeted therapy Other therapeutic options have been exhausted and there is a reasonable drug available Consider WBRT when: CNS and systemic POD, with few systemic treatment options and poor PS Multiple (> 3-10)* BMs, especially if PT known to be radiotherapy sensitive Large (> 4 cm) BM, not amenable to SRS Postsurgical resection of a dominant BM with multiple (> 3-10)* remaining BMs Salvage therapy for recurrent BM after SRS or WBRT failure Consider SRS when: OM (1-3) or multiple BMs,* especially if PT is known to be radiotherapy resistant Postsurgical resection of a single BM, especially if ≥ 3 cm and in the posterior fossa Local relapse after surgical resection of a single BM Salvage therapy for recurrent OM (1-3)* after WBRT Consider surgical resection when: Uncertain diagnosis of CNS lesion(s) 1-2 BMs, especially when associated with extensive cerebral edema Dominant BM in a critical location No treatment is reasonable when: Systemic POD, with few treatment options and poor PS

Abbreviations: BM, brain metastases; MRI, magnetic resonance imaging; OM, oligometastases; POD, progression of disease; PS, performance status; PT, primary tumor; SRS, stereotactic radiosurgery; WBRT, whole-brain radiation therapy.

^*Current data support use of SRS for up to three BMs. However, there is a trend toward using SRS in treatment of up to 10 BMs.