Brain Metastases · Surgery vs SRS vs Whole-Brain Radiotherapy

Step-by-step decision

Choose step by step as prompted; reaching an endpoint gives the management recommendation. You can go back a step or restart anytime.

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Full pathway

1. [Decision] Number/size + mass effect/performance + primary control
   Number/size of lesions? Mass effect/performance status? Primary controllable?
   • Single or oligometastatic (1-4), large/symptomatic mass effect, good performance status → Single mass → surgery + postoperative SRS
   • Few in number, small, no significant mass effect → Small few → SRS
   • Multiple diffuse (beyond SRS scope) → Multiple diffuse → whole-brain radiotherapy
   • Large posterior fossa metastasis with hydrocephalus/brainstem compression → Posterior fossa mass → emergency decompression
2. [End] Single mass → surgery + postoperative SRS
   Single/oligometastatic, large or symptomatic mass effect, good performance status, controllable primary → surgical resection + postoperative cavity SRS; rapidly relieves mass effect and obtains pathology.
3. [End] Small few → SRS
   Few in number, small, no significant mass effect → stereotactic radiosurgery (SRS, better than WBRT, protects cognition); can treat multiple lesions in one session.
4. [End] Multiple diffuse → whole-brain radiotherapy
   Multiple diffuse (beyond SRS scope) → whole-brain radiotherapy (± hippocampal sparing/memantine); or SRS + systemic therapy individualized; leptomeningeal disease managed separately.
5. [End] Posterior fossa mass → emergency decompression
   Large posterior fossa metastasis with hydrocephalus/brainstem compression → emergency surgical decompression (± external ventricular drain).

Source guidelines & references

• Brain metastases management (ASTRO/NCCN; surgery/SRS/WBRT)

This pathway is our own synthesis of the decision logic in the guidelines above (not the guideline verbatim); thresholds and workflows change as guidelines update — in practice follow the latest guideline, your institution's protocol and the individual patient.

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