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Treatment of Brain Metastases
If there are multiple brain metastases the most common treatment is external beam irradiation to the whole brain, for an overview of radiation for brain metastases go here, and some of the early radiation studies here and here, then read these review articles:  #1, #2 , #3 , #4. and #5 and here.

For a another review of the benefits and risks from whole brain radiation go here. Different radiation dose schemes can be used (here).

If there is a single brain metastasis and particularly if the cancer is not active elsewhere in the body, then it may be useful to be even more aggressive in treating the brain (either surgical removal or highly focused radiation, called radiosurgery). For more information on metastasis surgery or radiosurgery read review and see sections on radiosurgery, surgery and gamma knife.

There is controversy about combing whole brain radiation with radiosurgery (go here). In lung cancer patients with a single brain metastasis, it may make sense to treat both lung and brain aggressively (see here).

Go here next and for pictures of treated brain metastases go here and here

                   
                      Selected Randomized Trials Examining Various Fractionation Schedules for Brain Metastasis
Author/Study Group Dose (Gy)/Fractions N Median Survival P Value
Borgelt /RTOG
   First study
      (1971–1973) 30/10 233 21 wk NS
30/15 217 18 wk
40/15 233 18 wk
40/20 227 16 wk
   Second study
      (1973–1976) 20/5 447 15 wk NS
30/10 228 15 wk
40/15 227 18 wk
Haie-Meder /French 25/10 110 4.2 mo NS
      (1986–1989) 36/6a 106 5.3 mo
Priestman /Royal College of Radiology (1990–1993) 30/10 263 84 d 0.04
12/2 270 77 d
Murray /RTOG 91-04 (1991–1995) 30/10 213 4.5 mo NS
54.4/34b 216 4.5 mo
NS, not significant; RTOG, Radiation Therapy Oncology Group.
a18 Gy/three split course with another 18 Gy/three within 1 month.
b54.4 Gy in 1.6 Gy twice daily hyperfractionation for the entire course of therapy.
 
                                                   Randomized Trials of Surgical Resection of Single Brain Metastasis
Author/Study Group Surgery + RT RT Alone P Value
Patchell et al./University of Kentucky (n = 48)
   Primary end point (36 Gy/12 fx)
      Overall survival 40 wk 15 wk <0.01
   Secondary end points
      Local control
         Local failure 20% 52% <0.02
         Time to local failure >59 wk 21 wk <0.0001
      Time to neurologic death 62 wk 26 wk <0.0009
      KPS ≥70 maintenance 38 wk 8 wk <0.005
Noordijk /Dutch (n = 63)
   Primary end points (40 Gy/20 fx)a
      Overall survival 10 mo 6 mo 0.04
      FISb 7.5 mo 3.5 mo 0.06
Mintz et /Canadian (n = 84)
   Primary end point (30 Gy/10 fx)
      Overall survival 5.6 mo 6.3 mo NS
   Secondary end points
      FIS (proportion of days, mean)c 32% 32% NS
      Quality of life (Spitzer score)
            1–3 months (mean) 6.38 5.36 NS
            4–6 months (mean) 6.32 6.15 NS
RT, whole-brain radiotherapy; fx, fraction number; KPS, Karnofsky performance score; FIS, functionally independent survival; NS, not significant.
a40 Gy total in 2-Gy twice daily hyperfractionation for the entire course of therapy.
bFIS defined by World Health Organization performance status ≤1 and neurologic condition ≤1.
cFIS defined by KPS ≥70.

 
                                      Randomized Trials of Stereotactic Radiosurgery Boost in Brain Metastases
Author/Study Group RT + SRS RT Alone SRS Alone P Value
Andrews /RTOG 95-08 (n = 333; 1 to 3 lesions)
   Primary end point (overall survival) (37.5 Gy/10 fx)
      1 to 3 lesions 5.7 mo 6.5 mo NS
      Single brain metastasis (planned subgroup analysis) 6.5 mo 4.9 mo 0.04
   Secondary end points
      Local control (1 year) 82% 71% 0.01
      Neurologic death rate 28% 31% NS
      Performance outcome
         KPS stable/improve
            at 3 mo 50% 33% 0.02
            at 6 mo 43% 27% 0.03
         Mental status NS
      Unplanned subgroup analysis (overall survival)
      Largest tumor >2 cm 6.5 mo 5.3 mo 0.04
      RPA class I 11.6 mo 9.6 mo 0.05
      Squamous/NSCLC 5.9 mo 3.9 mo 0.05
   Other outcomes
      Response rate (3 mo)
         Tumor 73% 62% 0.04
         Edema 70% 47% 0.002
Kondziolka /University of Pittsburgh (n = 27; 2 to 4 lesions)
   Primary end point (30 Gy/12 fx)
      Local control (1 yr) 92% 0% 0.0016
         Time to local failure 36 mo 6 mo 0.005
         Time to any brain failure 34 mo 5 mo 0.002
   Secondary end points
      Overall survival 11 mo 7.5 mo NS
      Treatment morbidity 0 0
      Progression-free survival Not reported
      Need for retreatment Not reported
Chougule /Brown University (n = 109; 1 to 3 lesions)
   End points (abstract only) (30 Gy + 20 Gy SRS) (30 Gy/10 fx) (30 Gy SRS)
      Overall survival 5 mo 9 mo 7 mo Not reported
      Local control 91% 62% 87% Not reported
      New brain lesions 19% 23% 43% Not reported
RT, whole-brain radiotherapy; SRS, stereotactic radiosurgery; RTOG, Radiation Therapy Oncology Group; fx, fraction number; KPS, Karnofsky performance score; RPA, recursive partitioning analysis; NSCLC, non-small cell lung cancer.