Key points
- One to four metastases (not needing surgery): radiosurgery (SRS) instead of whole-brain radiotherapy [1].
- After surgery: radiosurgery to the cavity [1].
- If whole-brain radiotherapy is needed: memantine and hippocampal avoidance [1].
- EGFR or ALK lung cancer and BRAF melanoma with asymptomatic metastases: treatment can start with a brain-penetrant systemic drug and radiotherapy can be deferred [1].
Guideline summary
| Situation | Suggested treatment |
|---|---|
| A large lesion with mass effect or a need for diagnosis | Surgery, then radiosurgery to the cavity |
| 1 to 4 untreated lesions | Radiosurgery |
| 5 to 10 lesions | Radiosurgery or whole-brain radiotherapy (individual decision) |
| Extensive or leptomeningeal disease | Hippocampal-avoidance whole-brain radiotherapy with memantine, or supportive care |
| EGFR or ALK lung cancer, asymptomatic | Osimertinib, alectinib, brigatinib or lorlatinib with MRI monitoring |
| Melanoma, asymptomatic | Ipilimumab and nivolumab, or dabrafenib and trametinib in BRAF |
Supportive points
Dexamethasone only for symptoms, at the lowest dose for the shortest time; prophylactic antiseizure medicine is not recommended in patients without seizures [1].
Related cancer types
Treatment regimens (physicians)
AC followed by paclitaxel (dose-dense and weekly)TC regimen (docetaxel and cyclophosphamide): dose and scheduleTCHP regimen: dose and schedule in HER2-positive breast cancerWeekly paclitaxel with trastuzumab (APT regimen)KEYNOTE-522 regimen: pembrolizumab and chemotherapy in triple-negative breast cancerTrastuzumab emtansine (T-DM1, Kadcyla): dose and scheduleTrastuzumab deruxtecan (T-DXd, Enhertu): dose and monitoringAdjuvant capecitabine after neoadjuvant treatment (CREATE-X)Sacituzumab govitecan (Trodelvy)Pembrolizumab with chemotherapy in metastatic triple-negative breast cancer (KEYNOTE-355)Carboplatin, pemetrexed and pembrolizumab (KEYNOTE-189)Carboplatin, paclitaxel and pembrolizumab (KEYNOTE-407)
Physician tools and lessons
Cumulative Anthracycline Dose and Doxorubicin EquivalentsKhorana Score (Cancer-Associated Thrombosis Risk)Should I Be Screened for Lung Cancer? (Pack-Year Calculator)10 cheap steps that save patients' livesBone-modifying agents in cancer: bone metastases, adjuvant use and osteonecrosis of the jawGermline genetic testing in cancer: who, and which genes?Fertility preservation before cancer treatmentMalignant pleural effusion: drainage, pleurodesis or an indwelling catheterCancer during pregnancy: chemotherapy and decisions
References
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Numbers in the text, such as [1], refer to these sources. Sources with a “Study card” button are summarised in the site’s evidence library.
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This page is based on reputable scientific sources and was last updated on 28 October 2026. The content of this website is for educational and informational purposes only and does not replace consultation, diagnosis or treatment by a specialist physician. Consult your treating physician about any treatment decision.
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