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


Brainstem metastases pose challenging clinical problems in the setting of various primary malignancies. The radiation oncologist occupies a central role in the treatment of brainstem metastases, perhaps even more than in the treatment of metastatic disease in other regions of the brain, due to the inoperability of the brainstem. Despite the exclusion of brainstem metastases from prospective trials of SRS, single-institution reports on brainstem SRS consistently demonstrated improvement or prevention of symptoms secondary to brainstem lesions, preservation of quality of life, and toxicity rates that are comparable to those of SRS for other brain metastases. A compelling rationale therefore exists for inclusion of brainstem metastases in future prospective trials of SRS to develop optimal dose and fractionation schemes. Dose and fractionation for brainstem SRS remain institution-dependent with some guidelines. The extant literature demonstrates that complications following brainstem SRS are most strongly associated with prior WBRT. As WBRT is used less frequently as the initial mode of treatment for brain metastases, toxicity following brainstem SRS may be of lesser concern. However, future studies may examine adverse effects of WBRT for salvage therapy after prior SRS of brainstem metastases.