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Brain metastases are cancers that have spread to the brain from elsewhere, most often from the lung, breast or skin. Focused radiation aimed at each spot (radiosurgery) has largely replaced radiation to the whole brain, and for some cancers modern targeted drugs and immunotherapy reach the brain well enough to shrink the deposits on their own.
Brain metastases seed the grey-white junction and watershed zones through the arterial circulation; they are recognised on contrast MRI and, with a known primary, rarely need biopsy. Prognosis depends on the primary, its molecular subtype, performance status, extracranial disease and number of lesions (graded prognostic assessment). Dexamethasone relieves oedema. Management has moved in twenty years from whole-brain radiotherapy for nearly everyone to a choice among surgery, stereotactic radiosurgery, systemic therapy with brain penetration and, for some, no brain-directed treatment at all.
Surgery is used for a large or symptomatic single lesion or when tissue is needed (Patchell, 1990), followed by radiosurgery to the cavity rather than whole-brain radiotherapy (N107C, 2017). For a limited number of metastases, Alliance N0574 (JAMA 2016) showed that adding whole-brain radiotherapy to radiosurgery worsened cognition at three months in 91.7 percent of patients against 63.5 percent with radiosurgery alone, without lengthening survival, and radiosurgery alone is now standard for up to four lesions and increasingly for more. When whole-brain radiotherapy is still used, NRG CC001 (JCO 2020) showed hippocampal avoidance with memantine preserves cognition. QUARTZ (Lancet 2016) found no meaningful gain in quality-adjusted survival from whole-brain radiotherapy in non-small cell lung cancer patients unsuited to surgery or radiosurgery, so best supportive care alone is legitimate in poor-prognosis patients.
Systemic therapy now controls brain disease in several subtypes: osimertinib in EGFR-mutant and lorlatinib in ALK-positive lung cancer (CROWN), tucatinib with trastuzumab and capecitabine (HER2CLIMB) and trastuzumab deruxtecan (DESTINY-Breast12) in HER2-positive breast cancer, nivolumab plus ipilimumab in melanoma (CheckMate 204) and dabrafenib plus trametinib in BRAF-mutant melanoma (COMBI-MB), so asymptomatic small metastases in these groups are often treated with drugs first and radiosurgery held in reserve. Trials have historically excluded patients with brain metastases; their inclusion, the management of leptomeningeal disease, radionecrosis after radiosurgery, and drugs designed to cross the blood-brain barrier are the open fronts.
Averages across everyone diagnosed, often years ago. A median is the middle of a group: half the people counted lived longer than the figure shown, and some lived far longer. Your stage, subtype, age, fitness and the treatment you receive matter more than the average, and the numbers are improving quickly.
The commonest intracranial tumour in adults, many times more frequent than primary brain tumours; lung cancer, breast cancer, melanoma, kidney cancer and bowel cancer account for most, and incidence is rising as people live longer with systemic disease.
Gliomas infiltrate along white matter and can cross the corpus callosum, medulloblastoma sits in the cerebellum, and CNS lymphoma favours deep periventricular tissue; none spread through lymph nodes.
No conventional lymphatics: gliomas spread along white matter tracts and, rarely, through cerebrospinal fluid; medulloblastoma can seed the spine.
Same organ: Lactotroph pituitary neuroendocrine tumour (prolactinoma), Somatotroph pituitary neuroendocrine tumour (acromegaly), Corticotroph pituitary neuroendocrine tumour (Cushing disease and silent corticotroph tumour), Gonadotroph pituitary neuroendocrine tumour (non-functioning adenoma), Thyrotroph pituitary neuroendocrine tumour (TSH-secreting), Pineocytoma and pineal parenchymal tumour of intermediate differentiation, Pineoblastoma, Papillary tumour of the pineal region, Choroid plexus carcinoma, Glioma & glioblastoma, Primary CNS lymphoma, Medulloblastoma, Paediatric low-grade glioma, Diffuse midline glioma, H3 K27-altered (including DIPG), Atypical teratoid/rhabdoid tumour (ATRT), Ependymoma, Craniopharyngioma, Pituitary tumours (pituitary neuroendocrine tumours) and pituitary carcinoma, Brain and spinal cord tumours (all types), Astrocytoma, IDH-mutant (grades 2 to 4), Oligodendroglioma, IDH-mutant and 1p/19q-codeleted, Paediatric high-grade glioma (excluding diffuse midline glioma), Meningioma, Vestibular schwannoma (acoustic neuroma), Central nervous system germ cell tumours (germinoma and non-germinomatous), Spinal cord tumours (intramedullary and intradural), WNT-activated medulloblastoma, SHH-activated medulloblastoma, Group 3 and group 4 medulloblastoma (non-WNT/non-SHH)
Nothing recorded yet.
Nothing recorded yet.
Also on OnCo: Symptoms and red flags · Early detection roadmap.
Dexamethasone, tapered as quickly as symptoms allow; anticonvulsants only after a seizure.
Surgical resection followed by radiosurgery to the cavity (N107C) rather than whole-brain radiotherapy.
Stereotactic radiosurgery alone (Alliance N0574); whole-brain radiotherapy withheld because it worsens cognition without lengthening life.
Hippocampal-avoidance whole-brain radiotherapy with memantine (NRG CC001) where whole-brain treatment is chosen; radiosurgery to many lesions in selected patients; best supportive care alone in poor-prognosis lung cancer (QUARTZ).
Brain-penetrant targeted therapy first: osimertinib (EGFR), lorlatinib or alectinib (ALK); radiosurgery for progression.
Tucatinib with trastuzumab and capecitabine (HER2CLIMB) or trastuzumab deruxtecan (DESTINY-Breast12), with local therapy for symptomatic lesions.
Nivolumab plus ipilimumab for asymptomatic metastases (CheckMate 204); dabrafenib plus trametinib for BRAF V600-mutant disease (COMBI-MB); radiosurgery for symptomatic or progressing lesions.
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Where whole-brain radiotherapy is still chosen, for many metastases or leptomeningeal disease, hippocampal avoidance with memantine is the recommended technique.
Surgical cavity radiosurgery, rather than whole-brain radiotherapy, follows resection of a brain metastasis in fit patients, part of the broader move away from whole-brain treatment.
Patients with a limited number of brain metastases are treated with radiosurgery alone and surveillance, accepting more new brain lesions in return for preserved cognition.
Whole-brain radiotherapy is not a default for poor-prognosis brain metastases; supportive care alone is an acceptable choice, with radiotherapy reserved for selected younger, fitter patients.
Query for this cancer: (TITLE:"Brain metastases" OR ABSTRACT:"Brain metastases" OR TITLE:"secondary brain tumours" OR ABSTRACT:"secondary brain tumours" OR TITLE:"Secondary brain cancer" OR ABSTRACT:"Secondary brain cancer" OR TITLE:"Intracranial metastases" OR ABSTRACT:"Intracranial metastases" OR TITLE:"Cerebral metastases" OR ABSTRACT:"Cerebral metastases" OR TITLE:"Brain mets" OR ABSTRACT:"Brain mets") AND (treatment OR therapy OR trial OR survival OR diagnosis). Results are unfiltered search hits about Brain metastases (secondary brain tumours), not a curated reading list.
Chao and colleagues describe palliative irradiation of cerebral metastases.
Brown and colleagues (JAMA): cognitive deterioration at three months in 63.5 percent with radiosurgery alone against 91.7 percent with added whole-brain radiotherapy; no survival difference.
The targets of this cancer's medicines and the ones linked to it directly.
Cases by country, the UK and NHS pathway and other country lenses, the expert centres with trials on record, and the centres named on this cancer's subtypes.
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Fainting, near-fainting, or an irregular or racing heartbeat; several kinase inhibitors prolong the QT interval and the labels require ECG and electrolyte monitoring.
Persistent headache with extreme tiredness, nausea, dizziness on standing or low blood pressure. Vomiting, severe weakness or collapse is adrenal crisis.
Any new or worsening cough, breathlessness or fever. The label says to interrupt treatment for any suspected ILD and to permanently discontinue for grade 2 or higher.
Temperature of 38 C or higher, or feeling shivery and unwell even without a fever. Antibody-drug conjugates suppress the bone marrow, and several carry a boxed warning for severe neutropenia.
CYP3A4: Tucatinib (strong inhibitor) raises Lorlatinib exposure (sensitive substrate).. Avoid; if unavoidable, reduce from 100 mg to 75 mg daily.
Take with food; exposure roughly triples with a high-fat meal, and the trials dosed with food.
See all on the product pages:AlectinibDabrafenib + trametinibIpilimumabLorlatinibNivolumabOsimertinibTrastuzumab deruxtecanTucatinib·Printable cards in the navigator
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