1.
• Cerebral (75%)
• Cerebellar (21%)
• Brainstem – (3%)
Intratumoral Haemorrhage :
Melanoma, Choriocarcinoma, RCC, Thyroid malignancies..

2.
“New-onset neurologic symptoms in a known cancer patient should
always be presumed to be from brain metastasis until proven otherwise.”

3.
MRI is more sensitive than CT detects a
lesion as small as a dot (2mm).

4.
MR Spectroscopy
Intratumoural choline peak with no choline elevation in the peritumoural
oedema any tumour necrosis results in a lipid peak, NAA depleted

5.
DEXAMETHASONE – Preferred
➢ No mineralocorticoid activity ( no fluid retention)
➢ Lower risk of infection and cognitive impairment than other GC.
➢ Effects seen within 24hrs – 48 hrs
➢ Load at 16mg – severe // 8mg moderate….4mg/day…over a period of 4
weeks.*
Vecht CJ et al. Neurology 1994;44(4):675–680.

6.
Therapeutic strategies:
Surgery Radiation
Therapy
SRS
Preop/Post op SRS
SRS alone ≤ 4
SRS alone ≥5
WBRT
HA-WBRT
WBRT
BSC Systemic
Therapy

7.
*Lancet Oncol. 2017;18:1040-1048.
**Lancet Oncol. 2017;18:1049-1060.

8.
Pre-Op T1PC 1wk Postop T1 2wk Postop T1PC 3wk postop T1PC
– cavity
constriction
60%

9.
N107C/CEC.3

10.
Int J Radiat Oncol Biol Phys. 2017;99:1179-1189., Neurosurgery. 2016;79:279-285

11.
EORTC 22952-26001, MDACC, JSROG, JLGK0901, Alliance N0574.
As WBRT offers no survival benefit over SRS and worse neurocognitive outcomes, in
patients with reasonably good PS and with up to 4 intact brain metastases SRS is
recommended.

12.
J Neurosurg. 2006;104:907-912.

13.
Int J Radiat Oncol Biol Phys. 2016;95:1142-1148.
MDACC/Mount Sinai, NY

14.
Based on this prospective Study,, the task force conditionally recommends SRS to
patients with 5 to 10 intact brain metastases who have a ECOG-PS ≤ 2.

15.
A total of 30 Gy in 10 fractions or 37.5 Gy in 15 fractions continue
to remain the standards for a vast majority of patients.
(24% CR and 35% PR).

16.
• SIB/Sequential/Delayed
• Mostly Retrospective
• Dose/Fr:
• 30Gy/10 fr with sequential 20/10 fr
• 33Gy/15fr with SIB 43.5 Gy/15 fr
• 40Gy/20 fr with SIB 56 Gy/20 fr

17.
➢ Leukoencephalopathy and brain atrophy, leading to
neurocognitive deterioration and dementia
➢ Normal pressure hydrocephalus, causing cognitive, gait and
bladder dysfunction
➢ Neuroendocrine dysfunction, most commonly hypothyroidism
➢ Cerebrovascular disease etc
Concerns of WBRT

18.
Lynch M. Journal of Oncology Pharmacy Practice. 2019;25(3):657-662.

19.
TRIAL DESIGN Outcome
RTOG 0933 PH II- HA-WBRT 7% Cognitive Decline in
Avoidance Arm vs 30% in
historical arm
RTOG 0614 Phase III
Memantine
22% relative decline
reduction in Cognitive
Decline
NRG-CC001 Phase III
HA-WBRT+Memantine
26% relative decline
reduction in Cognitive
Decline
How to reduce Neurocognitive Decline

20.
Dmax and D100% < 16 Gy and 9Gy
HA-WBRT is not Suitable for:
• Within 5 mm
• KPS<70
• Life expectancy < 4 mo
• Leptomeningeal disease

21.
Mulvenna et al, Lancet, 2016.
Best Supportive Care (QUARTZ-A non inferiority Trial)

22.
For such patients multidisciplinary and patient-centered decision making with
close MRI surveillance is recommended to determine whether local therapy
may be safely deferred.

23.
Response Eval - RANO Criteria

24.
Solitary/Single Metastasis
Mass Effect, PS
Resection
No ME
PS 1/2/3
T
.B SRS
ME ++
PS 0/1
SRS
Recurrence
Limited (2–10) Metastases
Assess systemic disease
control & functional status
Poor
Good
SRS alone Hippo WBRT
Recurrence
SRS alone
>10 Metastases
Lesion located around
hippocampus
> 5mm
Hippo WBRT
< 5 mm
WBRT
Progression
SRS Boost

25.
Suggested Readings

26.
Thanks!