Recommendation 2.6
➤ Ipilimumab plus nivolumab (for all patients regardless of BRAF status)
or dabrafenib plus trametinib (for patients with BRAF-V600E mutation)
may be offered to patients with asymptomatic brain metastases from
melanoma. If these agents are used, local therapy may be delayed until
there is evidence of intracranial progression. (Weak recommendation;
IC-L)
Recommendation 2.7
➤ The combination of tucatinib, trastuzumab, and capecitabine may be
offered to patients with HER2 positive metastatic breast cancer who
have asymptomatic brain metastases and have progressed on previous
trastuzumab, pertuzumab, and/or trastuzumab emtansine-based
therapy. If these agents are used, local therapy may be delayed until
there is evidence of intracranial progression. (Weak recommendation;
EB-L)
Recommendation 3.1
➤ Radiation therapy should not be offered to patients with asymptomatic
brain metastases who have:
• Performance status KPS ≤50 or less, OR
• Performance status KPS <70 and no systemic therapy options.
(Moderate recommendation; EB-L)
Recommendation 3.2
➤ SRS alone (as opposed to WBRT or combination of WBRT and SRS)
should be offered to patients with 1 to 4 unresected brain metastases,
excluding small cell carcinoma.
Qualifying Statement: The inclusion criteria of the randomized trials that underlie
this recommendation were generally tumors of less than 3 or 4 cm diameter and did not
include radioprotectant strategies of memantine or hippocampal avoidance.
(Moderate recommendation; EB-I)
