EFNS TASK FORCE/CME ARTICLE EFNS Guidelines on diagnosis and treatment of brain metastases: report of an EFNS Task Force R. Soffietti a , P. Cornu b , J. Y. Delattre c , R. Grant d , F. Graus e , W. Grisold f , J. Heimans g , J. Hildebrand h , P. Hoskin i , M. Kalljo j , P. Krauseneck k , C. Marosi l , T. Siegal m and C. Vecht n a Department of Neurology and Oncology, San Giovanni Battista Hospital and University, Torino, Italy; b Department of Neurosurgery, Pitie `- Salpe ´trie `re and University, Paris; c Department of Neurology, Pitie ´-Salpe ´trie `re, Paris, France; d Department of Neurology, Western General Hospital and University, Edinburgh, UK; e Service of Neurology, Hospital Clinic, Villaroel, Barcelona Spain; f Department of Neurology, Kaiser-Franz-Josef Spital, Vienna, Austria; g Department of Neurology, Academisch Ziekenhuis V.U., Amsterdam, The Netherlands; h Consultant Neurologist, Brussels, Belgium; i Department of Radiotherapy, Mount Vernon Hospital and University, Northwood, Middlesex, UK; j Department of Neurology, University Hospital, Helsinki, Finland; k Neurologische Clinic, Bamberg, Germany; l Division Oncology, Vienna General Hospital and University, Vienna, Austria; m Neuro-Oncology Clinic, Hadassah Hebrew University, Jerusalem, Israel; and n Department of Neurology, Med Center Haaglanden, The Hague, The Netherlands Keywords: brain metastases, diagnosis, evidence-based guidelines, treatment Received 7 December 2005 Accepted 30 December 2005 The objectives have been to establish evidence-based guidelines and identify contro- versies regarding the management of patients with brain metastases. The collection of scientific data was obtained by consulting the Cochrane Library, bibliographic dat- abases, overview papers and previous guidelines from scientific societies and organi- zations. A tissue diagnosis is necessary when the primary tumor is unknown or the aspect on computed tomography/magnetic resonance imaging is atypical. Dexa- methasone is the corticosteroid of choice for cerebral edema. Anticonvulsants should not be prescribed prophylactically. Surgery should be considered in patients with up to three brain metastases, being effective in prolonging survival when the systemic disease is absent/controlled and the performance status is high. Stereotactic radiosurgery should be considered in patients with metastases of 3–3.5 cm of maximum diameter. Whole-brain radiotherapy (WBRT) after surgery or radiosurgery is debated: in case of absent/controlled systemic cancer and Karnofsky Performance score of 70 or more, one can either withhold initial WBRT or deliver early WBRT with conventional fractionation to avoid late neurotoxicity. WBRT alone is the treatment of choice for patients with single or multiple brain metastases not amenable to surgery or radio- surgery. Chemotherapy may be the initial treatment for patients with brain metastases from chemosensitive tumors. Background Brain metastases represent an important cause of morbidity and mortality for cancer patients. Brain metastases are more common than primary brain tumors. The incidence of brain metastases has increased over time as a consequence of the increase in overall survival for many types of cancer and the improved detection by magnetic resonance imaging (MRI). Brain metastases may occur in 20–40% of patients with can- cer, being symptomatic during life in 60–75%. In adults the primary tumors most likely to metastatize to the brain are located, in decreasing order, in the lung (minimum 50%), breast (15–25%), skin (melanoma) (5–20%), colon–rectum and kidney, but in general any malignant tumor is able to metastatize to the brain. The primary site is unknown in up to 15% of patients. Brain metastases are more often diagnosed in patients with known malignancy (metachronous presentation). Less frequently (up to 30%) brain metastases are diagnosed either at the time of primary tumor diagnosis (syn- chronous presentation) or before the discovery of the primary tumor (precocious presentation). High per- formance status (Fig. 1), solitary brain metastasis, ab- sence of systemic metastases, controlled primary tumor and younger age (<60–65 years) are the most im- portant favorable prognostic factors [1,2]. Based on these factors the Radiation Therapy Oncology Group (US) has identified subgroups of patients with different prognosis [Recursive Partitioning Analysis (RPA) Correspondence: Dr Riccardo Soffietti, MD, Chairperson of the Task Force, Neuro-Oncology Service, Department of Neuroscience and Oncology, University and San Giovanni Battista Hospital, V. Cherasco 15, 10126, Torino, Italy (tel.: ++39 011 6334904; fax: ++39 011 6963487; e-mail: riccardo.soffietti@unito.it). This is a Continuing Medical Education paper and can be found with corresponding questions on the Internet at: http://www. blackwellpublishing.com/products/journals/ene/mcqs. Certificates for correctly answering the questions will be issued by the EFNS. 674 Ó 2006 EFNS European Journal of Neurology 2006, 13: 674–681 doi:10.1111/j.1468-1331.2006.01506.x