Recommendation 3.4
➤ In a patient who has a large (>3 to 4 cm) lesion associated with
symptomatic mass effect, clinicians may discuss surgical resection of the
larger lesion, if the lesion is deemed resectable. The remaining lesions
and resection bed may be treated with SRS, HSRT with or without WB-M
+ HA. Clinicians should also provide symptom management. (Weak
recommendation; FC-I)
Recommendation 4.0 (diffuse disease or extensive metastases
c
)
Recommendation 4.1
➤ If a patient has symptomatic brain leptomeningeal metastases,
clinicians may recommend WBRT plus memantine. The management
of leptomeningeal metastases is complex, and recommendations
regarding intrathecal therapy and/or systemic therapy for leptomeningeal
metastases are outside the scope of this practice guideline. (Moderate
recommendation; FC-L)
Recommendation 4.2.1
➤ If a patient has a more favorable prognosis
a
and presents with many
diffuse and/or extensive brain metastases
c
(≥ five metastases) without
leptomeningeal disease, clinicians may recommend SRS or WB-M + HA.
For patients with metastases <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; FC/IC-L)
Recommendation 4.2.2
➤ Patients with favorable prognoses
a
are those with good performance status
and effective systemic therapy options. The criteria may include Karnofsky
performance status (KPS) >70, controlled extracranial disease, and/or
whether good additional systemic therapy options for extracranial disease
are available. (Weak recommendation; FC-L)
Recommendation 5.0 (patients with poor prognosis)
➤ If a patient has brain metastases and a poor prognosis, clinicians should
discuss the options of best supportive care (BSC) and/or palliative care,
which may or may not include radiation therapy, on a case-by-case basis.
(Weak recommendation; FC-L)
Recommendation 5.1
➤ For a patient with symptomatic brain metastases and poor prognosis,
WB-M + HA may be offered if there is a reasonable expectation of
symptomatic improvement that outweighs the acute and subacute
treatment-related toxicities, including fatigue and decline in neuro-
cognitive function. (Weak recommendation; FC-L)
