Modern multidisciplinary management of brain metastasis

Brain metastases (BrM) are no longer considered to be a uniform end-stage complication of cancer, but as a biologically and clinically heterogeneous disease requiring coordinated management. This article synthesises the fundamentals of BrM diagnosis and treatment, relevant to primary and urgent care settings. Treatment sequencing should account for acuity of neurologic symptoms, anticipated intracranial response, extracranial disease tempo, steroid requirements, and risks of local therapy. Focal radiotherapy is now the dominant local modality for limited BrM. Surgery remains central for large, symptomatic, diagnostically uncertain, or mass-effect-producing lesions. Postoperative stereotactic radiosurgery is favoured over whole-brain radiotherapy. Novel CNS-active targeted agents and immune checkpoint inhibitors can permit deferral of radiotherapy in carefully selected asymptomatic patients with certain molecularly defined cancers. Follow-up, based on longitudinal MRI, requires multi-disciplinary surveillance and decision-making. Optimal care combines integrated multi-disciplinary management and risk-adapted sequencing to jointly achieve preservation of neurologic function while maintaining durable systemic control.