Brain Metastasis Clinical Practice Guidelines (EANO/ESMO, 2021)

European Association of Neuro-Oncology, European Society for Medical Oncology

These are some of the highlights of the guidelines without analysis or commentary. For more information, go directly to the guidelines by clicking the link in the reference.

December 01, 2021

Clinical practice guidelines on the diagnosis and treatment of brain metastasis by the European Association of Neuro-Oncology (EANO) and the European Society for Medical Oncology (ESMO) were published in November 2021 in Annals of Oncology.[1]


Consider screening for brain metastasis in patients with lung cancer, except possibly in those with stage I non-small-cell lung cancer; in patients with stage IV melanoma; and in patients with metastatic human epidermal growth factor receptor 2-positive and triple-negative breast cancer.

A neurologic workup, including neuroimaging, is recommended for all patients with cancer who have raised intracranial pressure, seizures, and/or new neurologic deficits.

The workup for suspected brain metastasis should include cranial magnetic resonance imaging, with pre- and post-contrast T1-weighted, T2-weighted, and/or T2-fluid-attenuated inversion recovery and diffusion-weighted sequences.


Consider surgical resection for patients with a single brain metastasis. For those with multiple resectable brain metastases, surgical resection may be considered.

Consider surgery for patients who have acute symptoms of raised intracranial pressure. Surgery may be considered for those who require steroids and those who are candidates for immune checkpoint inhibition.

For patients who have 1-4 brain metastases, stereotactic radiosurgery is recommended. For those who have 5-10 brain metastases, with a cumulative tumor volume of less than 15 mL, stereotactic radiosurgery may be considered.

Consider whole-brain radiotherapy for patients with multiple brain metastases that are not amenable to stereotactic radiosurgery.

For most patients with brain metastases, systemic pharmacotherapy should be considered. The regimen should be based on the histologic and molecular characteristics of the primary tumor and previous treatment.

In selecting targeted therapy and immunotherapy, the molecular genetic workup of the brain metastasis rather than the primary tumor should be considered, if possible.

For more information, please go to Brain Metastasis.


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