Table 5.

Recommendations regarding medical therapy

• Conventional chemotherapy may be the initial treatment for patients with brain metastases from chemosensitive tumors, like SCLC or breast cancer, especially when small and/or asymptomatic (Good Practice Point).

• No targeted agents are currently registered for the treatment of brain metastases from any solid tumors (Good Practice Point).

• Patients with brain metastases from NSCLC harboring activating EGFR mutations or ALK rearrangements can derive benefit from the use of specific TKIs (level C).

• Continuous HER2 blockade should be offered to patients with CNS metastases of HER2 positive breast cancer (Good Practice Point).

• Patients with brain metastases from HER2 positive breast cancer can derive benefit from the use of lapatinib, alone or associated with capecitabine (level C).

• Patients with melanoma and brain metastases can derive benefit from targeted agents either ipilimumab or BRAF inhibitors (level C).

• Patients with renal cell carcinoma and brain metastases can derive benefit from multitarget TKIs, in particular sunitinib (Good Practice Point).

• Overall, while SRS or WBRT remain the mainstay of initial therapy, in selected patients with asymptomatic and small brain metastases targeted agents may be a reasonable option for an upfront treatment (Good Practice Point).

• Ultimately, patients with solid tumors and brain metastases should be encouraged to participate in clinical trials with targeted agents, when available (Good Practice Point).

• Pausing of treatment with novel systemic agents during radiotherapy to the brain should be considered to minimize the risk of unexpected toxicities (Good Practice Point).