Local Therapy
Recommendation 2.4
➤ For most patients with brain metastases who undergo surgical resection,
clinicians should recommend postoperative radiotherapy (includes SRS,
hypofractionated stereotactic radiotherapy [HSRT], and for large or multiple
resection beds possibility of whole-brain radiation therapy-memantine plus
hippocampal avoidance [WB-M + HA]) to the resection bed to reduce the
risk of local recurrence. (Weak recommendation; FC/IC-I)
Recommendation 2.5
➤ If a patient has a favorable prognosis
a
and a single brain metastasis >3 to
4 cm, which clinicians and a MDT deem unresectable and unsuitable for
SRS, clinicians may discuss the options of HSRT or WB-M + HA. MDTs
should consult with patients in this situation. (Weak recommendation; FC/
IC-L)
Recommendation 2.6
➤ After treatment, serial imaging every 2 to 4 months may be used to monitor
for local and distant brain failure (also known as local recurrence or new
brain disease). (Weak recommendation; FC-L)
Recommendation 3.0
➤ If a patient has a favorable prognosis
a
and presents with multiple, but
limited, metastases (defined as two to four lesions) treatment options
depend on the size, resectability, and mass effect of the lesions.
Recommendation 3.1
➤ In a patient who presents with limited metastases
b
(defined as two to four
lesions) suitable for SRS, clinicians may discuss SRS without WB-M + HA.
(Weak recommendation; FC-I)
Recommendation 3.2
➤ In a patient with symptomatic lesions that are unresectable and unsuitable
for SRS HSRT, clinicians may recommend WBRT plus memantine and, if
feasible, hippocampal avoidance and may discuss SRS after WB-M + HA.
(Weak recommendation; FC/IC-L)
Recommendation 3.3
➤ For patients with limited metastases
b
<2 cm and not associated with
symptomatic mass effect, and who have an option to proceed with HER2-
directed therapy with known CNS activity, then clinicians and patients may
discuss deferring local therapy with a MDT. (Moderate recommendation;
IC-L)
