Table 3.

Recommendations regarding treatment of newly diagnosed brain metastases

• Surgical resection should be considered in patients with a limited number (1 to 3) of newly diagnosed brain metastases, especially in case of lesions of ≥3 cm in diameter (symptomatic or not), lesions with necrotic or cystic appearance and edema/mass effect, lesions located in the posterior fossa with associated hydrocephalus, and lesions located in symptomatic eloquent areas (Good Practice Point).

• Surgical resection is recommended when the systemic disease is absent/controlled and the KPS is 60 or more, as it can prolong survival (level A).

• Surgical resection can be an option when the systemic disease is active but effective systemic treatment options are available or when the primary tumor is relatively radioresistant (ie, melanoma, renal carcinoma, colon carcinoma) (Good Practice Point).

• Stereotactic radiosurgery should be considered in patients with metastases of a diameter of ≤3–3.5 cm (level B).

• Stereotactic fractionated radiotherapy (SFRT) should be considered in patients with metastases larger than 3 cm in maximum diameter and a larger irradiation volume than 10 or 12 cm3 due to increased toxicity and radiation necrosis of normal brain tissue (Good Practice Point).

• Stereotactic radiosurgery and/or stereotactic fractionated radiotherapy should be considered in patients with metastases that are not resectable due to location (ie, basal ganglia, brain stem, eloquent cortical areas) or with comorbidities precluding surgery (ie, older age, cardiovascular disease, etc) (Level C).

• When both surgical resection and SRS/SFRT are feasible, the choice should be made on a case-by-case basis with consideration given to tumor size, site, type of neurological symptoms, need for steroids, patient preference, and/or physician expertise (Good Practice Point).

• Following complete surgical resection or SRS for a limited number of brain metastases, adjuvant WBRT is not unequivocally recommended due to lack of a survival advantage and risk of neurocognitive dysfunctions (level A).

• When withholding adjuvant WBRT following complete surgical resection or SRS, a close monitoring with MRI (every 3–4 mo) is recommended (Good Practice Point).

• When withholding adjuvant WBRT after surgical resection of brain metastases, postoperative stereotactic radiosurgery or stereotactic fractionated radiotherapy to the resection cavity should be given to maintain and increase local control (level C). As the post-resection cavity volume is usually smaller than pre-resection metastasis volume, it is recommended to perform a postoperative dedicated brain MRI for the SRS/SFRT, while the timing appears not to be relevant (Good Practice Point).

• When employing initial WBRT, a monitoring of cognitive functions with specific batteries is recommended (Good Practice Point).

• The decision regarding whether to employ SRS, SFRT, WBRT, alone or in combination, for patients with multiple brain metastases comes down to clinical discretion, patient preference and logistical considerations with the absolute number of brain metastases becoming less crucial (Good Practice Point).

• WBRT or best supportive care should be considered for patients with short life expectancy (low KPS score and/or progressive systemic disease) (level B).