Brain Metastases Treatment

If you are diagnosed with a brain metastases, your doctor will discuss the best options to treat it. This depends on several factors, including the type of cancer that has spread to the brain, the tumor’s location and your overall health.

Your treatment for a brain tumor will be customized to your particular needs. One or more of the following therapies may be recommended to treat your brain metastases or help relieve symptoms.

Surgery

Depending on the number, size, location and symptoms caused by the brain metastasis, surgery may be a treatment option. Surgery is used most often for single, large brain metastases. 

Even when complete removal of a brain metastasis is not possible, surgery may be able to:

• Help reduce the tumor’s size.
• Relieve brain metastases symptoms.
• Help doctors determine what other treatments are needed.

Craniotomy

Craniotomy is the most common surgery for brain tumors, including brain metastases. The procedure involves opening the skull to reach the tumor. Some brain tumors can be removed with little or no damage to the brain.

Craniotomies can take anywhere from 4 hours to 12 hours depending on the size and location of the tumor. Most require a three-to-four-night hospital stay.

Surgeons can perform different types of craniotomies surgeons to remove as much of the tumor as possible without harming healthy brain tissue.

Awake craniotomy

Most craniotomies are performed under general anesthesia, but some patients undergo awake craniotomies. During these procedures, patients are woken up during the surgery to interact with the surgical team. This helps doctors avoid damaging key structures in the brain. Learn more about awake craniotomies.

Craniotomy with intraoperative MRI 

If a patient has a large or complex tumor, doctors may use an intraoperative MRI during the procedure. This gives the surgeon a real-time image of the entire tumor throughout the operation. Surgeons use these images to help them remove as much of the tumor as possible while protecting normal, healthy brain tissue.

Recovering from surgery

Recovery from brain tumor surgery depends on the size and location of the tumor. Most side effects are temporary, but in rare cases they are permanent. These side effects include impacts on speech and movement.

Patients should begin therapy to help improve their speech and/or movement the day after surgery. These can include speech therapy, physical therapy and occupational therapy. Most patients start therapy the day after surgery. They usually begin walking with physical therapy and performing basic tasks like brushing teeth with occupational therapy. In some cases, the therapists may recommend a short stay in rehabilitation facility after they are discharged from the hospital.

Laser interstitial thermal therapy

Laser interstitial thermal therapy (LITT) is a treatment for primary and metastatic brain tumors that are hard to reach with conventional surgery or do not respond to stereotactic radiosurgery. 

During the procedure, doctors implant a laser catheter into the tumor and heat it to temperatures high enough to kill cancer cells.

Learn more about LITT.

Getting LITT

LITT is a minimally invasive treatment. In most cases it can be performed with just a two- to three-millimeter incision in the scalp. Only a very small area of hair needs to be shaved and  the procedure itself takes just a few minutes to perform. Patients are put under general anesthesia and usually spend just one night in the hospital.

Recovering from LITT

Most patients who get LITT can go home the day after treatment and can quickly return to normal activities like cooking, working and grocery shopping.

Side effects of LITT include a mild headache caused by swelling in the area of LITT treatment. This is typically managed with a small dose of steroids over a short period of time.

Radiation therapy

Radiation therapy uses powerful, focused beams of energy to kill cancer cells. 

Radiation therapy may be able to kill tumors. It can also stop or slow the growth of brain tumors that cannot be removed with surgery. It is often given after surgery to treat any remaining cancer cells and prevent the tumor from growing back. It can also be used alone or in combination with other treatments.

Learn more about radiation therapy.

Radiation simulation

There are many different types of radiation treatment. Brain metastases patients usually get stereotactic radiosurgery (SRS) or whole brain radiation therapy.

These treatments start with a simulation. Simulations are scheduled a few days before the first radiation therapy session. They help doctors develop the patient's exact treatment plan. 

Simulations begin with an imaging exam such as a CT scan and/or an MRI. The patient’s head is then positioned so radiation can be delivered to the tumor while limiting the impact to healthy tissue.

Most patients are then fitted with a mesh mask. This will be attached to the treatment table during treatment to and hold their head in that same position. 

Certain SRS patients do not get a mesh mask. Instead, they are fitted with a metal frame, similar to a halo, on the day of treatment. This also holds the patient’s head in place.

Stereotactic radiosurgery

Despite its name, SRS is not a surgery. It is a non-invasive treatment that uses multiple radiation beams to accurately target tumors with high doses of radiation. 

SRS is effective for treating small- to medium-sized tumors in the brain. For brain metastases, it can be used:

• Instead of surgery
• After surgery to reduce the risk of the cancer returning
• For patients who have had previous radiation to the brain

Doctors are also studying the use of SRS prior to surgery to improve overall disease control.

Patients usually get between one and five steretotactic treatments. 

Learn more about stereotactic radiosurgery. 

Getting SRS

SRS can be delivered with several different methods. These include a dedicated device called the Gamma Knife. Another method uses standard radiation therapy machine called a linear accelerator, or linac, that is outfitted with special modifications to deliver SRS. Patients are treated with the technique that is best for them.

SRS starts with a simulation to make the SRS treatment plan. 

To hold the patient’s head in position, some patients are fitted with a mesh mask during simulation. This mask is attached to the treatment table during radiation therapy sessions.

Other patients are fitted with a metal frame, similar to a halo, around the head on the day of the procedure. The frame is attached with four pins that are inserted through the skin. The pins rest on the skull. Patients only need local anesthesia to be fit with the frame.

The SRS treatment itself can take as little as 30 minutes or as long as several hours.

Patients who use the mesh mask generally don’t need any recovery time.

If a patient was fitted with a frame, doctors remove the device after the procedure and seal the skin. The patient then waits in a recovery area until they are ready to be discharged later that day.

After SRS treatment, patients are monitored with an MRI scan every few months. If new brain metastases develop, the patient can often undergo another SRS treatment.

SRS Side effects

The short-term side effects of SRS are usually mild and often depend on the location and size of the tumors that were treated. They include: 

• Fatigue.
• Headaches.
• Brain swelling, which may cause the tumor symptoms to worsen or recur. This is usually mild and temporary and can be treated with medications.
• Patients fitted with the frame may have soreness around the incision sites and swelling of the forehead and around the eyes.

SRS can cause side effects that appear several months to years after treatment. Although uncommon, patients can develop radiation necrosis, which is inflammation of the area of the brain that received radiation. 

Overall, though, side effects are uncommon, and the benefits of radiation therapy far outweigh the risks.

Whole brain radiation therapy 

Whole brain radiation therapy (WBRT) is an option for patients with numerous brain metastases or patients who are developing new metastases at a high rate.  

While WBRT does have side effects, it is recommended only when the care team thinks it is the best possible treatment for the patient. In addition, some patients may be candidates for WBRT with hippocampal avoidance. This is an advanced treatment with fewer side effects than standard WBRT.

Getting WBRT

Patients get WBRT once a day, Monday-Friday, usually for ten days. Each session lasts around 30 minutes. Patients may be prescribed a drug to reduce side effects. They typically take this drug for six months.

WBRT Side Effects

Short term side effects of WBRT include:

• Fatigue
• Headaches
• Sense of fullness in the ears (like when on an airplane)
• Dry mouth
• Hair loss

Radiation therapy to the brain can cause side effects that appear several months to years after treatment is complete. Possible side effects include an increased risk of stroke, changes in memory and processing speed, and changes in hormone function.

Overall, though, the benefits of radiation therapy far outweigh the risks. If a doctors recommends WBRT, they believe it is the best treatment for the patient.

Targeted therapy

Targeted therapy drugs are designed to stop or slow the growth of cancer on a cellular level. They interfere with, or target, molecules or genes that support the spread of cancer.

Targeted therapy drugs may be an option for patients with brain metastases from certain primary cancers. These include:

• HER2-positive breast cancer.
• non-small cell lung cancer with a mutation to either the ALK gene or EGFR gene.
• melanoma with a BRAF gene mutation.

Learn more about targeted therapy.

Getting targeted therapy

Most patients with brain metastases on targeted therapy get the medicine orally, as a pill. Patients typically take these pills every day for as long as they are effective.

For patients with leptomeningeal metastasis, targeted therapy may be taken orally or delivered directly to the fluid around the brain and spine through an Ommaya reservoir.

Targeted therapy side effects

Targeted therapy side effects for patients with brain metastases are often mild, though they can be more serious in some cases.

Some patients experience rash or gastrointestinal issues such as diarrhea, constipation, and nausea/vomiting. Patients should talk to their care team about ways to treat these and other side effects.

Learn more about the side effects of targeted therapy.

Immune checkpoint inhibitors

Immune checkpoint inhibitors are a type of immunotherapy. They "cut the breaks" on the immune system, helping it to fight cancer in some patients. Patient may receive a single immunotherapy drug or multiple drugs in combination.  

Immune checkpoint inhibitors are a standard treatment for some patients with melanoma brain metastases.  In select cases, they may also be used to treat other types of brain metastases.

Read more on our immune checkpoint inhibitors page.

Getting immune checkpoint inhibitors

Immune checkpoint inhibitors are delivered through an IV infusion. Patients typically get one infusion every few weeks, but this can change based on the patient’s medical needs. Patients may get these drugs in combination with other immunotherapies, targeted therapy and/or chemotherapy.

Immune checkpoint inhibitor side effects

In some cases, immune checkpoint inhibitors can cause inflammation in healthy organs, leading to many different symptoms. Patients experiencing this side effect will often pause the treatment, undergo further testing and start steroids.

If any new symptom arises, patients should tell their care team right away or go to an emergency room. Most of these symptoms are treatable, but they should be addressed as soon as possible.

Learn more about the side effects of immune checkpoint inhibitors.

Chemotherapy

Chemotherapy drugs kill cancer cells, control their growth or relieve cancer-related symptoms. Chemotherapy may involve a single drug or a combination of two or more drugs, depending on the type of cancer and how fast it is growing.

Chemotherapy is used to treat metastases in the brain only in limited situations.

For patients with leptomeningeal metastasis, chemotherapy is sometimes delivered directly to the central nervous system through an implanted device called an Ommaya reservoir.  

Read more on our chemotherapy page.

Chemotherapy side effects

The side effects of chemotherapy can include gastrointestinal symptoms, hair loss, fatigue and an increased risk of infection. Patients should talk to their doctors about ways to prevent or limit the side effects of chemotherapy.

Chemotherapy can also lead to drops in blood cell production. During treatment, the patient’s blood counts will be closely monitored to ensure they stay in a safe range.  

Learn more about the side effects of chemotherapy.

Clinical Trials

Clinical trials are a key part of MD Anderson's mission to end cancer. MD Anderson uses clinical trials to find better ways to prevent, diagnose and treat cancer. Trials could include new treatments or new combinations of existing treatments. 

Learn more about clinical trials.

Leptomeningeal metastasis treatment

Leptomeningeal metastasis (LM) is the spread of cancer to the leptomeninges, the inner lining of the brain and spinal cord, as well as cerebrospinal fluid.

LM can be treated with radiation therapy and/or cancer drugs.

Radiation options include whole brain radiation therapy WBRT. Some patients may be candidates for craniospinal irradiation, which is WBRT plus radiation to the entire spinal canal. 

LM can sometimes be treated with targeted therapy drugs. These can be taken orally or delivered directly to the leptomeninges through an Ommaya reservoir.

This device consists of a plastic dome inserted under the scalp. The dome is connected to a catheter inserted through a small hole in the skull and into the brain. It can then deliver cancer drugs directly to tumors.