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10 slides generated from the cancer page, with a quiz from the open benchmark and speaker notes that cite the sources. Arrow keys move between slides; Print gives one slide per page.
Brain metastases are cancers that have spread to the brain from elsewhere, most often from the lung, breast or skin. Focused radiation aimed at each spot (radiosurgery) has largely replaced radiation to the whole brain, and for some cancers modern targeted drugs and immunotherapy reach the brain well enough to shrink the deposits on their own.
Brain metastases seed the grey-white junction and watershed zones through the arterial circulation; they are recognised on contrast MRI and, with a known primary, rarely need biopsy. Prognosis depends on the primary, its molecular subtype, performance status, extracranial disease and number of lesions (graded prognostic assessment). Dexamethasone relieves oedema. Management has moved in twenty years from whole-brain radiotherapy for nearly everyone to a choice among surgery, stereotactic radiosurgery, systemic therapy with brain penetration and, for some, no brain-directed treatment at all.
Surgery is used for a large or symptomatic single lesion or when tissue is needed (Patchell, 1990), followed by radiosurgery to the cavity rather than whole-brain radiotherapy (N107C, 2017). For a limited number of metastases, Alliance N0574 (JAMA 2016) showed that adding whole-brain radiotherapy to radiosurgery worsened cognition at three months in 91.7 percent of patients against 63.5 percent with radiosurgery alone, without lengthening survival, and radiosurgery alone is now standard for up to four lesions and increasingly for more. When whole-brain radiotherapy is still used, NRG CC001 (JCO 2020) showed hippocampal avoidance with memantine preserves cognition. QUARTZ (Lancet 2016) found no meaningful gain in quality-adjusted survival from whole-brain radiotherapy in non-small cell lung cancer patients unsuited to surgery or radiosurgery, so best supportive care alone is legitimate in poor-prognosis patients.
| Setting | Approach | Guideline |
|---|---|---|
| Symptomatic oedema | Dexamethasone, tapered as quickly as symptoms allow; anticonvulsants only after a seizure. | not mapped |
| Single large or symptomatic lesion, fit patient | Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy. | not mapped |
| Limited number of metastases | Stereotactic radiosurgery alone (Alliance N0574); whole-brain radiotherapy withheld because it worsens cognition without lengthening life. | not mapped |
| Many metastases or leptomeningeal spread | Hippocampal-avoidance whole-brain radiotherapy with memantine (NRG CC001) where whole-brain treatment is chosen; radiosurgery to many lesions in selected patients; best supportive care alone in poor-prognosis lung cancer (QUARTZ). | not mapped |
| Driver-positive lung cancer, asymptomatic metastases | Brain-penetrant targeted therapy first: osimertinib (EGFR), lorlatinib or alectinib (ALK); radiosurgery for progression. | not mapped |
| HER2-positive breast cancer | Tucatinib with trastuzumab and capecitabine (HER2CLIMB) or trastuzumab deruxtecan (DESTINY-Breast12), with local therapy for symptomatic lesions. | not mapped |
| Melanoma | Nivolumab plus ipilimumab for asymptomatic metastases (CheckMate 204); dabrafenib plus trametinib for BRAF V600-mutant disease (COMBI-MB); radiosurgery for symptomatic or progressing lesions. | not mapped |