- Immunotherapy has an increasing role for the treatment of brain metastases (BMs).
- The role of whole brain radiotherapy (WBRT) may be decreasing.
Why this matters
- BMs are often treated with surgery and RT. As systemic treatments such as immunotherapy become options too, many elements must be considered.
For patients taking dexamethasone, adding WBRT has produced a small difference in quality-adjusted life years (QALYs), no difference in survival and quality of life, and little additional clinically significant benefit.
Factors that favour RT are:
- Adequate performance status.
- Single or solitary metastases.
- No or stable (more than 3 months) extracranial tumour manifestations.
- In favour of stereotactic radiotherapy (SRT), there are lesions that not surgically accessible, and a high surgical risk.
Factors that favour surgery are:
- Neuroradiologically uncertain lesions.
- Unknown primary tumour.
- Presentation of the tumour (large cystic or necrotic lesion, mass effect).
- Need for molecular profiling.
Immunotherapy or other systemic treatments should be chosen based on the primary tumour, its molecular characteristics, and prior treatments. Other factors are:
- No or mild neurological deficits.
- Multiple small BMs.
- Extra-CNS progression.
- Radioresistant tumour.
In conclusion, personalised treatment should be based on:
- Cancer type and its molecular characteristics.
- Neurological and general status; use of supportive treatments.
- BMs’ imaging presentation.
- Extra-central nervous system disease status.
- Therapeutic options available.
In terms of response assessment to stereotactic radiosurgery or immunotherapy there are:
- Clinical challenges (neurological deterioration related to concomitant complications/toxicities and steroids).
- Imaging challenges (haemorrhages, pseudo progression, and radio necrosis).