Brain Metastases&nbsp;&nbsp;&nbsp;

How would you treat a patient with HER2 positive CNS only progression on fam-trastuzumab which had previously progressed on tucatinib/capecitabine/trastuzumab, and has failed both SRS and WBRT?

Do you routinely prescribe memantine for patients who will be receiving hippocampal sparing whole brain RT if they are already on donepezil, or is donepezil alone sufficient?

Aside from radiation, what is your approach to patients with EGFR-mutated or ALK-translocated metastatic NSCLC who have systemic disease control but fail in the CNS?

Do you increase the dosage of the TKI or switch to a different generation TKI? How does your answer differ for EGFR vs. ALK, and for discrete brain me...

How would you manage new symptomatic brain metastases (10-15) in a young woman with HER2+ metastatic breast cancer?

Controlled extracranial disease on trastuzumab+pertuzumab for 2 years. Treatment options include Enhertu or WBRT. Not a candidate for SRS or neurosurg...

What would be your approach in a patient who presented with a solitary brain metastasis that resolved after chemo without local therapy?

Would you offer consolidative brain SRS, SRS + consolidative RT to the primary (e.g. lung), consolidative RT to the primary alone?

Do you hold osimertinib when delivering partial or whole brain 3D radiation?

If so, how many days before and after? Does this change if delivering SRS?

What criteria do you use to decide whether to start anticonvulsants in patients with brain metastases?

Do all patients with brain metastases get started on anticonvulsants? Do you decide based on extent of edema, tumor size, or something else?&nb...

Is it acceptable to treat newly diagnosed small cell lung cancer with limited brain metastasis with upfront SRS?

This has become standard practice at our institution for patients with a good performance status, with whole brain radiotherapy given after the comple...

12 Answers available

How do you contour a resected brain metastases for fractionated partial brain radiation?

What is your GTV, CTV and PTV? If giving 30 Gy in 10 fx, does the contour need to extend all the way to the cut in the skull on both sides (is there a...

Would you offer post-operative SRS/SBRT in the case of a resected brain metastasis from metastatic NSCLC with an EGFR mutation?

With targeted therapies available, is there a utility for post-op SRS to the resection cavity?

Will you treat brain mets with SRS in patients who cannot undergo MRI?

In patients with contraindications to receiving an MRI scan, are other imaging modalities sufficient to treat patients with SRS?

Who is a good candidate for pre-operative SRS for resectable brain metastases?

Based on recent ASTRO data, what is your selection criteria and size cutoffs?

What is your surveillance strategy in patients with brain metastases who are getting systemic therapy?

How often are you scanning the brain and what is your trigger to treat?

What is an acceptable maximum "bridging" dose between SRS/SRT targeted brain metastases in close proximity to one another?

What maximum dose do you allow to “connect” adjacent metastatic lesions receiving SRS/SRT? What is this value for one-, three-, and five-...

Do you recommend holding a TKI when treating brain metastases with SRS/WBRT?

Is there evidence that supports/refutes the safety of concurrent use?

Is it reasonable to offer observation with MRI rather than immediate PCI for patients with limited stage SCLC?

7 Answers available

For a young patient who had a prior pCR to neoadjuvant therapy, would you consider systemic therapy after local resection and radiation of an isolated brain metastatic recurrence of triple negative breast cancer?

CNS recurrence occurred within two years of prior neoadjuvant therapy

How do you treat leptomeningeal disease in metastatic HR+ HER2- breast cancer?

The patient is treatment naïve and asymptomatic. She also has disease in the body (bone and liver metastases).

What is your preferred fSRS dose/fractionation for large brain metastases?

How does the presence of prior WBRT alter your treatment plan?

What systemic therapy would you consider, if any, for an isolated but multifocal CNS recurrence of HER2+ HR negative breast cancer treated with local therapy (>4 lesions treated with resection and SRS)?

Patient completed neoadjuvant therapy with TCH 2 years prior, and has no evidence of disease outside the CNS on PET/CT.

Do you constrain the dose to the oropharynx, parotids, or oral cavity when planning HA-WBRT?

A HA-WBRT patient developed brisk mucositis on the soft palate at fraction 8/10

What is the best treatment dose and fractionation for WBRT in a patient who has numerous brain mets and previously received PCI with 25Gy/10fx for small cell lung cancer?

Would you offer systemic therapy after rendered NED from SRS to isolated CNS metastases in a patient with prior curative intent treatment of lung adenocarcinoma and clear cell RCC?

0 Answers available

Which normal brain dosimetric constraints are most important when treating brain mets with SRS?

How should they be prioritized? V10, V12, mean brain dose, prior WB radiation? To what extent should tumor coverage, conformality and homogeneity be c...

How would you approach treatment of a posterior fossa metastasis with surrounding vasogenic edema causing mass effect on the 4th ventricle in an asymptomatic patient?

After completing SRS for brain mets, how long should the medical oncologist wait before starting chemotherapy?

Would this be any different for whole brain radiotherapy?

Is it acceptable to treat patients with limited, asymptomatic brain metastases and EGFR-mutant NSCLC with upfront TKI?

Can SRS or whole brain radiotherapy be reserved for progression in these young, healthy patients?

8 Answers available

What is your cutoff for the maximum number and size of brain metastases that you will treat with SRS?

What factors do you use to determine whether an enlarging lesion after SRS is radionecrosis versus progression?

How long after intrathecal chemotherapy do you typically wait before giving whole brain radiation?

Do you modify your dose/fractionation depending on the amount of prior intrathecal therapy?

In patients with good performance status, metastatic clear cell kidney cancer, and minimal metastatic disease, would you consider nephrectomy or partial nephrectomy if there are mets to brain?

Is it preferable to offer hypofractionated SRT over single fraction SRS for brain metastases?

There are solid data from Emory, Korea and others suggesting that is as effective as single fraction SRS but has less complications.

For linac based fractionated radiosurgery (5 fx) to a brainstem metastasis, is there a dose constraint for normal brainstem outside of the target volume?

Also, is there a maximum hotspot within the target volume?

Is ASTRO's recommendation to avoid whole brain radiotherapy following SRS for limited brain metastases practical for patients treated in the community setting?

The 2014 "Choosing Wisely" list, released this past September, includes the assertion that we should not "routinely add adjuvant whole brain radiation...

6 Answers available

How do you manage anticoagulation for patients with DVT/PE who have brain metastases?

Some medical oncologists tend to hold anticoagulation in patients who develop brain metastases for fear of causing intracranial hemorrhage. Is t...

Would you continue immune checkpoint inhibitor therapy in a metastatic NSCLC patient with CNS failure if the systemic disease is otherwise controlled?

Does the extent/duration of systemic disease control (complete response vs. stable disease, for example) influence your decision? What about whe...

In a patient with brain metastasis confined to the cerebellum, would it be reasonable to treat the posterior fossa only (vs WBRT)?

What are the best options to treat a patient with brain metastasis confined to the posterior fossa if the patient is young, has a favorable cancer, gr...

How frequently should you order brain imaging after whole brain RT in patients not undergoing a planned SRS boost?

Is it based on symptoms only? Every 3 months?

Would you treat the whole brain for brain metastases in a patient with active systemic scleroderma?

In a patient with multiple brain metastases from NSCLC, is this reasonable?

What is the maximum time you would allow between simulation/treatment planning MRI and delivered treatment for stereotactic radiosurgery for brain metastases?

How do the number of lesions treated and histology affect your decision making?

What is the rate of dementia following whole brain radiotherapy in patients with brain metastases who survive for over a year?

The most frequent argument against whole brain RT is debilitating toxicity. However, I am having a hard time finding the most evidence based data on h...

Do you add a margin when treating brain metastases with SRS?

While the Duke randomized study found similar rates of control with 1mm v. 3mm margins and higher radionecrosis with 3mm, it did not look at treating ...

What size cut-off do you suggest for the safe administration of SRS in the setting of brain metastases?

In RTOG 9508, 4 cm was the cut-off size for WBRT followed by SRS.

How do you stereotactically treat brain metastases greater than 3 cm +/- additional brain mets?

It is my impression that for brain metastases >3 cm it may be preferable to deliver fractionated SRT versus the RTOG dose of 15 Gy SRS, if WBRT is ...

Do you cover vasogenic edema surrounding the GTV when treating brain metastasis with SRS?