Brain metastases treatment guidelines

Brain metastases treatment can vary depending on the type of cancer, the number and location of tumors, and the patient's overall health. However, there are several general guidelines that are commonly followed for the treatment of brain metastases.

Surgery: Brain metastases surgery is often the first line of treatment for brain metastases that are located in a location that is accessible and can be safely removed. Surgery can help to relieve symptoms and improve the patient's overall survival.

Radiotherapy for brain metastases: is often used in combination with surgery or as a stand-alone treatment for brain metastases. It can help to shrink tumors and reduce the risk of recurrence. There are different types of radiotherapy such as whole brain radiation therapy (WBRT), stereotactic radiosurgery (SRS) and proton therapy.

Systemic therapy: Systemic therapy, such as chemotherapy or immunotherapy, is often used to treat brain metastases in conjunction with radiation therapy. It can help to slow the growth of tumors, improve patient's overall survival, and reduce the risk of recurrence.

Supportive care: Supportive care is an important aspect of brain metastases treatment. It can help to relieve symptoms and improve the patient's quality of life. This can include medications for headaches, seizures, and other symptoms, as well as physical therapy, occupational therapy, and other types of rehabilitation.

Follow-up care: Patients with brain metastases require close follow-up care to monitor for recurrence and to manage any symptoms or complications that may arise.

It's important to note that brain metastases treatment guidelines change over time as new treatments become available and more data on the safety and effectiveness of different treatments are obtained.

Please see the full-text version of this guideline for the target population of each recommendation listed below.  

SURGERY FOR METASTATIC BRAIN TUMORS AT NEW DIAGNOSIS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo Brain metastases surgery, Stereotactic radiosurgery for brain metastases (SRS), or whole brain radiotherapy (WBRT)?


Level of Evidence 1: Surgery + WBRT is recommended as first-line treatment in patients with single brain metastases with favorable performance status and limited extracranial disease to extend overall survival, median survival, and local control.

Level of Evidence 3: Surgery plus SRS is recommended to provide survival benefit in patients with metastatic brain tumors

Level of Evidence 3: Multimodal treatments including either surgery + WBRT + SRS boost or surgery + WBRT are recommended as alternatives to WBRT + SRS in terms of providing overall survival and local control benefits.  

SURGERY AND RADIATION FOR METASTATIC BRAIN TUMORS QUESTION: Should patients with newly diagnosed metastatic brain tumors undergo surgical resection followed by WBRT, SRS, or another combination of these modalities?


Level 1: Surgery + WBRT is recommended as superior treatment to WBRT alone in patients with single brain metastases.

Level 3: Surgery + SRS is recommended as an alternative to treatment with SRS alone to benefit overall survival.

Level 3: It is recommended that SRS alone be considered equivalent to surgery + WBRT.  

SURGERY FOR RECURRENT METASTATIC BRAIN TUMORS QUESTION: Should patients with recurrent metastatic brain tumors undergo surgical resection?


Level 3: Craniotomy is recommended as a treatment for intracranial recurrence after initial surgery or SRS.   SURGICAL TECHNIQUE AND RECURRENCE QUESTION A: Does the surgical technique (en bloc resection or piecemeal resection) affect recurrence?


Level 3: En bloc resection of the tumor, as opposed to piecemeal resection, is recommended to decrease the risk of postoperative leptomeningeal disease when resecting single brain metastases.


Does the extent of surgical resection (gross total resection or subtotal resection) affect recurrence?


Level 3: Gross total resection is recommended over subtotal resection in Recursive partitioning analysis class 1 class I patients to improve overall survival and prolong time to recurrence. 1)

Nahed BV, Alvarez-Breckenridge C, Brastianos PK, Shih H, Sloan A, Ammirati M, Kuo JS, Ryken TC, Kalkanis SN, Olson JJ. Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on the Role of Surgery in the Management of Adults With Metastatic Brain Tumors. Neurosurgery. 2019 Mar 1;84(3):E152-E155. doi: 10.1093/neuros/nyy542. PubMed PMID: 30629227.
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