When is surgery needed for brain metastases?

Surgery is typically recommended when there is a single large metastasis, when a lesion is causing significant mass effect or symptoms that can’t be controlled another way, when tissue is needed to confirm the diagnosis, or when complete removal offers a meaningful benefit. Many brain metastases, especially smaller ones, are treated effectively with radiosurgery alone without surgery.

Brain Metastases

Q: How are brain metastases treated?

Treatment usually combines local therapy directed at the brain tumors (most often stereotactic radiosurgery, sometimes surgery or LITT) with systemic therapy directed at the primary cancer. The specific combination depends on the number and size of lesions, their location, the type of primary cancer, and the patient’s overall health.

Coordinated neurosurgical and oncologic care for cancer that has spread to the brain.

Overview

What Are Brain Metastases?

Brain metastases are tumors in the brain that started as cancer somewhere else in the body, most often the lungs, breast, skin, kidneys, or colon. They are the most common type of brain tumor in adults and occur more often than all primary brain tumors combined. A patient can have a single brain metastasis or several at once.

Common symptoms include new headaches, seizures, weakness or numbness on one side of the body, changes in speech, vision, or memory, balance problems, and personality or behavior changes. Some brain metastases cause no symptoms at all and are found on scans done as part of regular cancer follow-up.

Treatment usually combines focused radiation called stereotactic radiosurgery with treatment for the original cancer, and sometimes includes surgery for larger or symptomatic tumors. Dr. Sherman has experience treating brain metastases at Rutgers Cancer Institute in New Brunswick, NJ.

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The information on this page is general educational information and is not medical advice. It does not create a doctor-patient relationship or reflect a treatment recommendation for any individual. Treatment decisions require an individual evaluation by a qualified physician.

Patients with a known cancer diagnosis are generally monitored for symptoms that could suggest the disease has spread to the brain. New or changing neurologic symptoms in someone with an active or recent cancer should always be taken seriously, even if they seem minor.

Here’s what makes symptoms worth investigating.

New headaches that aren’t like your usual headaches. New-onset headaches, particularly those that are worse in the morning, worsen over days to weeks, or come with nausea or vomiting, warrant imaging. Patients with cancer who develop a new headache pattern should not assume it’s stress or chemotherapy side effects without being evaluated.

New seizures. A first seizure in an adult with cancer is never normal. It should prompt immediate brain imaging, regardless of what the patient’s primary cancer is doing otherwise.

Weakness, numbness, or coordination changes on one side of the body. Focal neurologic symptoms, those that affect one specific side or one specific function, point to a specific location in the brain. Any new focal symptom in a patient with cancer deserves urgent evaluation.

Changes in speech, vision, or memory. New difficulty finding words, new blurred or lost vision in part of the visual field, or new short-term memory problems are all worth reporting to an oncologist right away.

Personality or behavior changes. Subtle changes in mood, judgment, or behavior, especially if they’re noticed by family rather than the patient, can be an early sign of a frontal lobe metastasis and should be evaluated.

New balance problems or unsteady walking. Metastases in the cerebellum, which controls balance and coordination, can cause sudden changes in walking or gait that feel different from general fatigue or deconditioning.

When to treat it as an emergency. Sudden severe headache, loss of consciousness, sudden inability to speak or move one side of the body, or a seizure that doesn’t stop should be treated as an emergency. Go to the nearest emergency room rather than waiting for an oncology appointment.

For everything else, new neurologic symptoms in a cancer patient should prompt a call to the treating oncologist the same day or the next day, and imaging is usually ordered quickly. The pace of evaluation is typically faster than for a patient without a known cancer history because the clinical suspicion is higher.

Imaging

MRI of the brain with and without contrast is the standard test for diagnosing brain metastases. It is far more sensitive than a CT scan and can detect metastases that are too small to see on other imaging. The contrast agent used during the MRI helps highlight areas where the blood-brain barrier has been disrupted, which is typical of metastatic tumors. On imaging, brain metastases often appear as one or more enhancing lesions with surrounding swelling, and they are frequently found at the junction between the gray and white matter of the brain where blood vessels narrow and tumor cells tend to lodge.

In many patients, the diagnosis of brain metastases can be made from imaging alone when there is a known primary cancer, the lesions have a typical appearance, and the clinical context fits. A biopsy is not always necessary. However, there are situations where tissue is needed, including when the primary cancer site is unknown, when imaging findings are unclear or atypical, when there is a concerning mismatch between the brain lesions and the known behavior of the primary cancer, or when the pathology of the brain tumor would meaningfully change treatment.

When Tissue Is Needed

When a biopsy is required, it can be done as a stereotactic needle biopsy through a small opening in the skull, or as part of a surgical procedure to remove the metastasis. If surgery is already planned for treatment, the pathology comes from the removed tumor as part of the same operation.

Staging the Rest of the Body

When brain metastases are diagnosed in someone without a previously known cancer, the workup expands to find the primary site. This usually includes a CT scan of the chest, abdomen, and pelvis, sometimes a PET scan, and targeted evaluation of any organ where the primary might originate. Identifying the primary cancer is important because different primary cancers are treated with different systemic therapies, and those therapies are often a critical part of the brain metastasis treatment plan as well.

Brain metastases are almost always treated with more than one approach. The right combination depends on the number, size, and location of the lesions, the type and status of the primary cancer, the patient’s symptoms and overall health, and their goals and priorities. Treatment usually involves some combination of local therapy directed at the brain tumors themselves and systemic therapy directed at the primary cancer.

Stereotactic Radiosurgery

Stereotactic radiosurgery is one of the most important advances in brain metastasis treatment over the past two decades. Despite the name, it isn’t surgery in the traditional sense. It uses precisely targeted, high-dose radiation beams to destroy tumor tissue while minimizing radiation to the surrounding brain. It is delivered in a single session or a small number of sessions, without an incision, and most patients go home the same day.

Stereotactic radiosurgery is now the standard of care for patients with a limited number of brain metastases, and its indications have expanded in recent years to include patients with more lesions than were historically considered candidates. It can treat lesions that are difficult or unsafe to reach with surgery and can address multiple metastases in a single session.

Surgery

Surgery still plays a critical role in brain metastasis care, especially in specific situations: when there is a single large metastasis causing significant pressure on the brain, when a lesion is causing symptoms that can’t be controlled with radiation and medication alone, when the diagnosis is uncertain and tissue is needed, or when complete removal offers a meaningful survival and quality-of-life benefit. Surgery can also be combined with radiosurgery, with radiation directed at the surgical cavity after the tumor is removed to reduce the risk of local recurrence.

For metastases located in areas of the brain that control speech or movement, awake craniotomy allows the surgical team to map brain function in real time during the operation, protecting essential functions while removing as much tumor as possible.

LITT (Laser Interstitial Thermal Therapy)

LITT is a minimally invasive option for deep-seated metastases that are difficult to reach with traditional surgery, and for lesions that have recurred after previous radiation treatment. It uses a thin laser probe inserted through a small opening in the skull to heat and destroy tumor tissue from the inside.

Systemic Therapy

For many patients, the most important part of treatment is systemic therapy directed at the primary cancer. Several newer targeted therapies and immunotherapies cross the blood-brain barrier and can shrink brain metastases from certain cancers, including particular subtypes of lung cancer, breast cancer, and melanoma. This has fundamentally changed what’s possible for many patients and is one of the main reasons brain metastasis outcomes have improved.

Whole-Brain Radiation

Whole-brain radiation was historically the most common treatment for brain metastases but has become less central as stereotactic radiosurgery and systemic therapies have improved. It remains an important option in certain situations, including patients with many metastases that cannot be managed with radiosurgery alone, and patients whose disease has spread extensively within the brain.

Clinical Trials

Clinical trials are an active area in brain metastasis care, testing new drug combinations, novel radiation approaches, and treatments that target specific molecular features of the primary cancer. Whether a trial is appropriate depends on the primary cancer type, its molecular profile, and what’s currently enrolling.

How the Plan Gets Made

Brain metastasis treatment is built on coordination. Decisions typically involve neurosurgery, radiation oncology, medical oncology, and neuropathology, and the plan is usually made by weighing the brain tumors and the systemic cancer together, not separately. The timing and sequence matter. Local treatment of the brain tumors, systemic treatment of the primary cancer, and ongoing surveillance have to fit together. Rutgers Cancer Institute is the only NCI-designated comprehensive cancer center in New Jersey.

Treatments commonly used for this conditionStereotactic Radiosurgery, Brain Tumor Surgery, Awake Craniotomy, Laser Interstitial Thermal Therapy (LITT), and Clinical Trial Enrollment.

Technology

Using XR Technology To Advance Medical Care

Dr. Sherman integrates VR and AR visualization into surgical planning and patient education, giving patients a clearer picture of their diagnosis and the approach to treatment.

Common Questions About Brain Metastases

For most patients, the realistic goal of treatment is long-term control rather than cure. Published outcomes have improved in recent years, and durable disease control is increasingly achievable for some patients, particularly those with a small number of metastases and well-controlled primary cancer. For many patients today, the cause of death is the underlying systemic cancer rather than the brain metastases themselves, though this varies significantly by primary tumor type. The specific outlook depends on the primary cancer type, the number and location of metastases, overall health, and how the cancer responds to treatment, and can only be assessed by a treating physician.

Brain metastases are tumors that started as cancer somewhere else in the body and spread to the brain. Primary brain tumors, such as glioblastoma or meningioma, start in the brain itself. They are different diseases with different behaviors and different treatments, even though both involve tumors in the brain. A metastasis from lung cancer in the brain is still lung cancer, and many treatment decisions are driven by the primary cancer’s biology.

There’s no single cutoff. Historically, stereotactic radiosurgery was used for patients with one to three or four metastases, and patients with more lesions were given whole-brain radiation. That’s changed significantly. Radiosurgery is now used for patients with more metastases than were once considered candidates, and newer systemic therapies can shrink multiple brain metastases at once in certain cancers. Treatment decisions depend on the total volume of disease and the patient’s overall situation, not just the number of lesions.

Yes, and it’s encouraged. Brain metastasis treatment has changed significantly in recent years, and the range of available options can differ meaningfully between centers. A second opinion with a neurosurgical oncologist who treats brain metastases regularly can clarify the options, identify any clinical trials that might be appropriate, and confirm that the plan fits with the broader cancer treatment strategy.

Next Step

Newly Diagnosed or Seeking a Second Opinion?

Dr. Sherman is accepting new patients at Rutgers Cancer Institute in New Brunswick, New Jersey. Whether you’ve just learned that cancer has spread to your brain or you’re looking for another perspective on a treatment plan, a consultation is the first step toward understanding your options.

Schedule a Consultation 732-235-6333

Brain Metastases

What Are Brain Metastases?

Symptoms

Diagnosis

Treatment

Using XR Technology To Advance Medical Care

Common Questions About Brain Metastases

Newly Diagnosed or Seeking a Second Opinion?