Optimal Management of Brainstem Metastases

A Narrative Review

Joan Y. Lee; Danielle A. Cunningham; Erin S. Murphy; Samuel T. Chao; John H. Suh


Chin Clin Oncol. 2022;11(2):15 

In This Article

Abstract and Introduction


Background and Objective: Brainstem metastases comprise fewer than 7% of all brain metastases. Nonetheless, they present clinicians with unique clinical challenges in symptom management and treatment. No comprehensive review summarizing the management of brainstem metastases exists. This review aims to summarize epidemiology, anatomy, clinical correlation, prognosis, options for management of symptoms, treatment, treatment toxicity, and dose and fractionation for brainstem stereotactic radiosurgery (SRS) as reported in the literature.

Methods: In July 2021, we searched PubMed and Embase for retrospective studies of brainstem metastasis treatment, as well as case series and case reports describing diagnosis and clinical management of brainstem metastasis. Keywords and MeSH terms searched included "brainstem metastasis", "symptomatic brainstem metastasis", "brain metastasis", "stereotactic radiosurgery brainstem", "whole brain radiation brainstem", "brainstem metastasis resection", "brainstem radiation toxicity", "brainstem radiosurgery toxicity", "brainstem radiosurgery dose", and "radiosurgery dose tolerance". Titles and abstracts were screened for relevant articles and studies. References from full-text articles were screened for additional studies.

Key Content and Findings: Single-institution studies and multicenter retrospective analyses from 1993 to 2021 reflect a shift from reliance on whole-brain radiation therapy (WBRT) to SRS for primary treatment of brainstem metastases. Recent multicenter retrospective analyses and single-institution case series support the safety and efficacy of SRS of brainstem metastases in symptom management and preservation of quality of life. Incidence of radiation-induced toxicity following SRS of brainstem metastases is comparable to that of SRS for other brain metastases. Complications following brainstem SRS are most strongly associated with prior WBRT.

Conclusions: Radiation oncologists play a central role in the treatment of brainstem metastases due to reliance on SRS. Dose and fractionation of brainstem SRS remain largely institution-dependent. The field would benefit from inclusion of brainstem metastases in prospective trials of SRS and studies of adverse effects of salvage WBRT after prior SRS of brainstem metastases.


Brain metastases represent the most common neurologic complication of cancer patients with fewer than 7% of all brain metastases found in the brainstem. Historically, brainstem metastases were treated with whole-brain radiation therapy (WBRT) alone, as the density of nuclei and white matter tracts in the region rendered surgical resection and early targeted radiation prohibitively high risk for serious adverse effects. Prospective clinical trials of stereotactic radiosurgery (SRS) for brain metastases also excluded brainstem metastases due to caution with SRS radiation doses and the perceived radiosensitivity of brainstem. Nonetheless, single-institution case series of brainstem metastasis SRS emerged with encouraging findings of safety and efficacy. Recent analyses of multicenter retrospective data support the safety and efficacy of SRS for brainstem metastases and shed light on trends in adverse events after brainstem SRS. This review will outline the pathophysiology of brainstem metastases and their clinical manifestations, historical treatment paradigms, and contemporary trends in management. We present the following article in accordance with the Narrative Review reporting checklist (available at https://cco.amegroups.com/article/view/10.21037/cco-21-146/rc).