Brain Metastasis with Poor Prognosis

Key components:

  1. Control of peritumoral edema and increased ICP with steroids
  2. Treatment of seizures
  3. Management of venous thromboembolic disease


  1. whole brain radiation therapy (WBRT)
  2. surgery
  3. stereotactic radiosurgery (SRS)

Supportive care + corticosteroids – median survival of 1-2 months

WBRT – average survival of 3-6 onths

3 factors determining survival:  performance status, extent of extracranial disease, age

Three prognostic classes:

  1. Class 1 Karnofsky performance score (KPS) 70/+, <65y, controlled primary tumor, no extracranial metastases à median survival 7.1 months
  2. Class 2 KPS 70/+ but with other unfavorable characteristics à2 months
  3. Class 3 KPS <70 à median survival 2.3 months

DS-GPA: (diagnosis-specific graded prognostic assessment) = separate criteria for patients with NSCLC, SCLC, melanoma, RCC, breast cancer, GI cancer

  1. NSCLC or SCLC – all factors were significant
  2. Melanoma or RCC – only KPS and # of brain mets significant factors
  3. Breast CA or GI Ca – KPS only


  • Aggressive treatment not warranted
  • If active treatment – prefer WBRT.
  • SRS and surgery for favorable prognosis
  • 2 exceptions: poor performance status due to mets, SRS associated with improved survival; also lesions <5, SRS instead of WBRT (SRS is 1 day, while WBRT is multiple days)


  • goal is to improve deficits, questionable if survival is improved
  • response rate 40-60% (breast and SCLC responsive, less with melanoma or RCC; small, solid tumors more likely than large, necrotic or cystic)
  • Overall survival determined by activity and extent of extracranial disease rather than control of brain mets; there is a trial that compares WBRT with best supportive care showing no difference I survival between optimal supportive care compared with adding WBRT
  • Most common regimen: total dose 30Gy in 10 daily fractions of 3 Gy
  • Acute toxicity: mild and self-limited; cerebral edema may worsen, so start steroids 48 hours prior
  • Late toxicity: leukoencephalopathy, brain atrophy à dementia, radiation necrosis, NPH, hypothyroidism, cerebrovascular disease

Recurrent brain mets:  surgery, SRS, reirradiation, systemic chemo?



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