This protocol addresses central nervous system metastases in patients who have a high intracranial burden and concurrent active systemic disease — a situation in which focal approaches are insufficient.
The protocol applies when all three features are present: more than 10 brain metastases, uncontrolled extra-central nervous system disease, and multiple brain metastases not amenable to stereotactic radiosurgery (SRS). Clinical decision-making in this setting weighs the presence of neurological symptoms, the number, size, and location of brain lesions, and the availability of CNS-active systemic therapy.
When SRS is not feasible across the full burden of disease, the approach centres on whole-brain radiotherapy (WBRT), which may be delivered with an optional boost directed at macroscopic lesions. The complete fractionation schedule, selection criteria, and sequencing are detailed in the full structured protocol.
DOI: 10.1016/j.annonc.2021.07.016
WBRT should be considered for treatment of multiple BMs not amenable to SRS, depending on the presence of neurological symptoms, size, number and location of BMs and the choice and availability of CNS-active systemic therapy.
WBRT, typically 20-30 Gy in 5-10 fractions, has been used either as a consolidating treatment after local therapy or as the primary treatment modality primarily for patients with multiple BMs.
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