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Radiotherapy for the Management of Brain Metastases

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Dear Colleagues,

Advancements in imaging and systemic options have recently led to groundbreaking changes in the treatment of brain metastases. In this issue, “Radiotherapy for the Management of Brain Metastases”, we present modern approaches to patients with brain metastases, the significance of their molecular profiles, systemic treatment options, and radiotherapeutic techniques. We will discuss sequencing or systemic options and radiotherapeutic options, such as primary irradiation and re-irradiation. Senior scholars will discuss state-of-the-art treatment approaches and cutting-edge clinical research.

Dr. Alla Gabriella Wernicke
Guest Editor

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23 pages, 2004 KB

Open AccessReview

Radiation Necrosis in Neuro-Oncology: Diagnostic Complexity and Precision Radiotherapy Strategies

by Laura Mittelman, James Duehr, Jacob S. Kazmi, Luis O. Vargas, Nora Donahue, John Chen, Sandra Leskinen, Shoaib A. Syed, A. Gabriella Wernicke and Randy S. D’Amico

Cancers 2025, 17(21), 3542; https://doi.org/10.3390/cancers17213542 - 1 Nov 2025

Cited by 1 | Viewed by 4198

Abstract

Background: Radiation necrosis (RN) is a delayed and potentially debilitating complication of radiotherapy for central nervous system (CNS) tumors. It presents significant diagnostic and therapeutic challenges due to the variable clinical manifestations and overlap with tumor recurrence. Although advances in radiotherapy have improved tumor control, RN remains incompletely understood and inadequately addressed. This narrative review synthesizes current evidence on RN pathophysiology, risk factors, diagnostic strategies, and management approaches. Methods: A literature search was conducted for English-language literature published between January 1990 and December 2024. Studies were included if they addressed RN incidence, diagnosis, treatment, or novel preventive strategies in CNS tumor populations. Relevant findings were synthesized to produce a narrative review summarizing pathophysiology, diagnostic challenges, and treatment strategies. Results: RN results from radiation-induced neurovascular injury, inflammation, and vessel permeability, with incidence ranging from 3 to 26% depending on tumor type, location, and treatment parameters. Risk is influenced by dose, fractionation, cumulative exposure, re-irradiation, and adjuvant therapies. Advanced modalities such as SRS, HFSRT, brachytherapy, proton therapy, and IORT reduce but do not eliminate RN risk. Diagnosis remains challenging despite advanced MRI and PET techniques, with histopathology as the gold standard. Management includes corticosteroids, bevacizumab, surgery, LITT, and experimental therapies. Connectomics-based planning shows promise in minimizing RN by sparing critical brain networks. Conclusions: RN is a clinically significant and multifactorial complication of CNS radiotherapy. Precision treatment modalities and advanced imaging have improved prevention and detection, but diagnostic uncertainty and recurrence risk persist. Integration of connectomics into treatment planning may offer future promise of a reduction in RN-related morbidity by preserving structural and functional network integrity. Full article

(This article belongs to the Special Issue Radiotherapy for the Management of Brain Metastases)

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18 pages, 1024 KB

Open AccessSystematic Review

The Use of Radiotherapy in Leptomeningeal Carcinomatosis: A Systematic Review and Random-Effects Proportions Meta-Analysis

by Pamela Ochoa-Lantigua, Mauricio Moreno-Bejarano, Cayetana Guarderas-Arias, José Bueno-Miño and Jose E. Leon-Rojas

Cancers 2026, 18(4), 547; https://doi.org/10.3390/cancers18040547 - 7 Feb 2026

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Abstract

Objective: Leptomeningeal carcinomatosis (LMC) is a rare but devastating complication of advanced cancer, particularly in patients with breast and lung malignancies. This systematic review provides a descriptive synthesis of radiotherapy approaches used in patients with leptomeningeal metastases, with a quantitative proportions meta-analysis focused on treatment-related toxicity. Materials and methods: A systematic search was conducted in PubMed, Scopus, and the virtual health library (BVS) databases following PRISMA 2020 guidelines. Studies including patients diagnosed with LMC and treated with RT were selected. Outcomes included overall survival (OS), adverse events (toxicities), and functional response. Results: A total of 39 studies comprising 2822 patients were included; the most frequent primary tumors were lung (n = 1337) and breast (n = 990) cancers. The mean time from cancer diagnosis to LMC was 22.4 months. Radiotherapy regimens included whole-brain radiotherapy (WBRT, n = 1054), craniospinal irradiation (CSI, n = 148), and focal RT (n = 27); RT was administered alone or in combination with systemic treatments. Toxicity was reported in 462 patients, primarily fatigue (n = 115), nausea/vomiting (n = 72), and hematological events (notably in CSI). The pooled toxicity prevalence was 50.8% (95% CI, 26.1–75.4; I² = 96.1; p < 0.0001) for all RT modalities, and 31.6% (95%CI, 15.0–50.8; I² = 90.7; p < 0.0001) for WBRT. CSI toxicity estimates were based on a limited number of studies and did not reach statistical significance, and should therefore be interpreted as exploratory. Mean OS from LMC diagnosis was 18.2 weeks; OS by treatment was 21.5 weeks and 20.3 weeks, for RT by itself and combined, respectively. Conclusions: LMC predominantly affects patients with advanced-stage lung and breast cancers and presents with variable clinical timelines and functional impairment. Radiotherapy represents a frequently utilized and clinically important component of the palliative management of leptomeningeal disease, particularly for symptom control and neurological stabilization, rather than a treatment associated with superior survival outcomes. Prognosis is more closely linked to patient-specific factors than to treatment type. Radiotherapy toxicity is prevalent; however, most are categorized as type 1 toxicities with insignificant to little damaging effects on patients. Full article

(This article belongs to the Special Issue Radiotherapy for the Management of Brain Metastases)

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