Local Therapies: Radiation and Resection

Chapter 8 - Management of CNS Metastases

Neurosurgical resection of CNS metastases is performed in selected patients. 

Indications include one or few brain metastases, controlled extracranial disease, unknown primary tumour and acute decompression need.

Local Therapies Radiation Resection Figure 1

Courtesy A. Berhghoff, Medical University of Vienna, Vienna

Tumour tissue derived from neurosurgical intervention may help to guide systemic therapy by securing a histological diagnosis or enabling Biomarker analysis.

Stereotactic radiosurgery (SRS) delivers single-dose high-precision focused radiotherapy (RT).

Local Therapies Radiation Resection Figure 2

Courtesy B. Gatterbauer, Medical University of Vienna, Vienna

SRS is typically considered for small (maximal diameter up to 3 cm) CNS metastases.

SRS may achieve good local control, but can induce significant radiation necrosis with brain oedema.

Whole brain radiotherapy (WBRT) is a treatment option in patients with multiple brain metastases and is used for prophylaxis of small cell lung cancer (SCLC) brain metastases.

WBRT is associated with significant neurotoxicity and a high risk of neurocognitive decline.

In patients treated with neurosurgical resection or SRS for few brain metastases, postoperative WBRT can be omitted in favour of radiological follow-up.

Revision Questions

  1. Discuss the indications and contraindications for neurosurgical resection of CNS metastases.
  2. Up to which CNS metastasis size is SRS feasible?
  3. What is the main adverse event associated with WBRT in patients with CNS metastases?

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Last update: 18 September 2017