Future perspectives on brain metastasis management

Brain metastases are the most common intracranial tumors encountered by physicians. Historically, the mainstays of therapy were limited to surgery and whole brain radiation. Surgery is typically reserved for safely accessible and symptomatic tumors in patients well enough to tolerate a procedure. Whole-brain radiation therapy has proven to have limited efficacy and concerns have arisen regarding its toxicity. Advances in the treatment of systemic cancers have yielded improved long-term survival and quality of life for patients. To parallel these efforts in systemic treatment, continual improvement of the treatment of brain metastases is a must. The last two decades have seen a paradigm shift in the thinking about metastatic brain tumor treatment as a result of the advent of stereotactic radiosurgery. Radiosurgery has proven to be an efficacious, minimally invasive, and highly selective treatment for metastatic brain tumors. In this review, we discuss the evolution of metastatic brain tumor management, the appropriately diminished role for reflexive whole brain radiation, and the growing importance of stereotactic radiosurgery as an upfront treatment modality in conjunction with surgery and subsequent salvage radiosurgery.