Management of Brain Metastases

Initial Assessment and Management

The American Society of Clinical Oncology recommends that the treatment of brain metastases should be based on a multidisciplinary approach with specific therapies determined by tumor characteristics, patient performance status, and extent of disease, with surgery, stereotactic radiosurgery, whole brain radiation therapy, and targeted systemic therapies forming the cornerstone of management 1, 2
For patients with brain metastases, MRI is the preferred diagnostic imaging modality due to its higher resolution and sensitivity in detecting multiple lesions 6
The National Comprehensive Cancer Network suggests that dexamethasone is the first-line treatment for symptomatic brain metastases with initial dosing of 4-8 mg/day for moderate symptoms, increasing to 16 mg/day for severe symptoms with marked mass effect 4

The American Association of Neurological Surgeons recommends that surgery is a reasonable option for patients with brain metastases, particularly those with large tumors with mass effect 1, 5
Standardly-accepted indications for craniotomy include diagnostic uncertainty, brain metastases causing symptoms refractory to steroids, bulky metastases, and solitary brain metastases 6

The American Society for Radiation Oncology recommends that for patients with asymptomatic brain metastases and no systemic therapy options, stereotactic radiosurgery alone should be offered to patients with one to four unresected brain metastases, excluding small-cell lung carcinoma 1, 5
For patients with resected brain metastases, SRS alone to the surgical cavity should be offered to patients with one to two resected brain metastases 1, 5
The National Comprehensive Cancer Network suggests that memantine and hippocampal avoidance should be offered to patients who receive WBRT and have no hippocampal lesions and 4 months or more expected survival 1, 5

The European Society for Medical Oncology recommends that systemic therapy as monotherapy is now a first-line consideration for subgroups of asymptomatic patients with certain tumor types 2, 7
The American Society of Clinical Oncology suggests that the efficacy of systemic therapy depends on the primary tumor type and the presence of targetable mutations 8
For non-small cell lung cancer, particularly adenocarcinomas with targetable mutations or gene rearrangements, small-molecule targeted drugs can achieve intracranial penetration 8

The American Academy of Neurology recommends that for radiation necrosis, first-line treatment should be glucocorticoids, and if unsuccessful, consider neurosurgical resection, laser interstitial thermal therapy, or bevacizumab 9
For seizures, anti-seizure medications should not be used prophylactically, and when required, prefer agents that don't impact hepatic metabolizing enzymes 3, 10
For neurocognitive decline, consider acetylcholinesterase-inhibiting medication and cognitive rehabilitation 9