Overview of New Guidelines

The Congress of Neurological Surgeons (CNS) has released updated guidelines addressing the use of innovative therapies in the treatment of adults with metastatic brain tumors. These updates reflect advancements in pharmaceuticals, radiation technologies, and surgical instruments. The new guidelines have been published in the journal Neurosurgery.

Significance of the Update

The rapid advancement of both surgical and nonsurgical treatments for metastatic brain tumors has led to the formulation of specific recommendations aimed at guiding healthcare professionals in this complex field. The Joint Guidelines Review Committee, comprising members from both the CNS and AANS, has endorsed these updated guidelines.

Research Foundation

The updated guidelines are derived from a systematic review of 162 primary studies published in English, sourced from databases including PubMed and Embase, covering the period from January 1, 2016, to May 3, 2022. The recommendations primarily emphasize the application of targeted therapies in various cancer types.

Targeted Therapy Recommendations

• Non-small-cell lung cancer (NSCLC) with brain metastases:
  • For patients with three or more untreated metastases, icotinib combined with whole-brain radiation therapy (WBRT) is advised (evidence level I).
  • For any number of metastases, the addition of EGFR tyrosine kinase inhibitors (TKIs) to WBRT or stereotactic radiosurgery (SRS) is recommended (level III).
  • In cases of ALK mutation-positive NSCLC with untreated metastases, alectinib is recommended (level I), along with lorlatinib (level III).
  • For newly diagnosed metastases where EGFR and ALK status have not been evaluated, if WBRT is applicable, gefitinib should be included in the treatment plan (level I).
  • In the absence of contraindications, adding bevacizumab to regimens involving gefitinib or the combination of pemetrexed and platinum compounds is suggested (level III).
  • For EGFR-negative and ALK-negative NSCLC, incorporating a TKI into the treatment plan, alongside radiation therapy if suitable, is advised (level III).
• Melanoma with brain metastases:
  • For newly diagnosed BRAFV600E-positive melanoma metastases, adding dabrafenib and trametinib is recommended (level I).
  • If BRAF inhibitors are indicated, the addition of immunotherapy is suggested, provided there are no other contraindications (level III).
• Breast adenocarcinoma with brain metastases:
  • In cases of HER-2-positive breast adenocarcinoma where radiation therapy is indicated, trastuzumab should be included (level III).
  • In the context of SRS, lapatinib is recommended (level III).
• Leptomeningeal brain metastases:
  • For NSCLC, osimertinib is to be used for EGFR-mutant cases, while alectinib is recommended for ALK-positive cases (level III).
  • For HER-2-positive breast cancer, intrathecal trastuzumab is advised (level III).

Additional Treatment Options

Laser interstitial thermal therapy (LITT) is suggested for adults who have undergone SRS for brain metastases but show signs of progression on imaging (level III). If the progression is due to tumor development, LITT is regarded as comparable to craniotomy; if due to radiation necrosis, it is viewed as equivalent to medical management. Treatment decisions should be tailored based on tumor location and the clinical status of the patient.

Immune Modulators and Radiosensitizers

The guidelines also address the role of immune modulators and radiosensitizers in treatment. However, the reviewers found inadequate evidence to support recommendations for interstitial modalities or high-intensity focused ultrasound.

For more detailed information, refer to the publication in Neurosurgery.