Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines on Treatment Options for Adults With Multiple Metastatic Brain Tumors

TARGET POPULATION These recommendations apply to adult patients newly diagnosed with multiple (more than 1) brain metastases. QUESTION 1 In what circumstances should whole brain radiation therapy be recommended to improve tumor control and survival in patients with multiple brain metastases? RECOMMENDATION Level 2: It is recommended that whole brain radiation therapy can be added to stereotactic radiosurgery to improve local and distant control keeping in mind the potential for worsened neurocognitive outcomes and that there is unlikely to be a significant impact on overall survival. QUESTION 2 In what circumstances should stereotactic radiosurgery be recommended to improve tumor control and survival in patients with multiple brain metastases? RECOMMENDATIONS Level 1: In patients with 2 to 3 brain metastases not amenable to surgery, the addition of stereotactic radiosurgery to whole brain radiation therapy is not recommended to improve survival beyond that obtained with whole brain radiation therapy alone. Level 3: The use of stereotactic radiosurgery alone is recommended to improve median overall survival for patients with more than 4 metastases having a cumulative volume <7 cc. QUESTION 3 In what circumstances should surgery be recommended to improve tumor control and survival in patients with multiple brain metastases? RECOMMENDATION Level 3: In patients with multiple brain metastases, tumor resection is recommended in patients with lesions inducing symptoms from mass effect that can be reached without inducing new neurological deficit and who have control of their cancer outside the nervous system. The full guideline can be found at https://www.cns.org/guidelines/guidelines-treatment-adults-metastatic-brain-tumors/chapter_6.