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G
uidelines
for
the
treatment
of
central
nervous
system
metastases
using
radiosurgery
R
ev
A
ssoc
M
ed
B
ras
2017; 63(7):559-563
559
GUIDELINES IN FOCUS
Guidelines for the treatment of central nervous system metastases
using radiosurgery
D
iretrizes
para
tratamento
de
tumores metastáticos
de
sistema
nervoso
central
com
radiocirurgia
Authorship:
Brazilian Society of Radiotherapy (SBRT)
Participants:
Gustavo Nader Marta
1
, Helena Espindola Baraldi
1
, Fabio Ynoe de Moraes
1
Final draft:
June 20, 2017
1
Sociedade Brasileira de Radioterapia (SBR)
http://dx.doi.org/10.1590/1806-9282.63.07.559The Guidelines Project, an initiative of the Brazilian Medical Association, aims to combine information from the medical field in order to standardize
procedures to assist the reasoning and decision-making of doctors.
The information provided through this project must be assessed and criticized by the physician responsible for the conduct that will be adopted, depending
on the conditions and the clinical status of each patient.
G
rades
of
recommendation
and
levels
of
evidence
•
•
A:
Experimental or observational studies of higher
consistency.
•
•
B:
Experimental or observational studies of lower
consistency.
•
•
C:
Cases reports (non-controlled studies).
•
•
D:
Opinion without critical evaluation, based on con-
sensus, physiological studies or animal models.
O
bjective
The purpose of this guideline is to evaluate the radiosur-
gery technique for the treatment of patients with central
nervous system (CNS) metastatic tumors.
D
escription
of
evidence
collection method
Through the elaboration of six relevant clinical questions
related to the proposed theme, we sought to present the
main evidence regarding safety, toxicity and effectiveness
of radiosurgery in the treatment of CNS metastases. The
study population consisted of male and female patients
of all ages, with metastatic CNS cancer independent of
histological type and presence or absence of comor-
bidities. For this, a systematic review of the literature
was carried out in primary scientific databases (Medline
– PubMed; Embase – Elsevier; Lilacs – Bireme; Cochrane
Library – Record of Controlled Trials). All articles avail-
able through Thursday, April 2, 2015 were considered.
The search strategy used in Medline searches is described
in Appendix 1. The articles were selected based on criti-
cal evaluation, seeking the best evidence available. The
recommendations were elaborated after discussion with
the elaboration group composed by three members of
the Brazilian Society of Radiotherapy. The guideline
was reviewed by an independent group, which special-
izes in evidence-based clinical guidelines. After comple-
tion, the guideline was released for public consultation
for 15 days, the suggestions obtained being forwarded
to the authors for evaluation and possible insertion in
the final text.
I
ntroduction
Brain metastases are the most frequent intracranial
tumors in the adult population. It is estimated that 6 to
30% of patients diagnosed with malignant systemic dis-
ease will have cerebral metastases at some point in their
natural progression.
1-3
In recent years, the incidence of brain metastasis has
been increasing mainly due to the implementation in
clinical practice of cranial magnetic resonance imaging
(MRI), which has good accuracy in detecting early neo-
plastic lesions in the CNS. In addition, there was a sig-
nificant improvement in the control of extracranial disease,
something associated with the use of new systemic ther-
apies available for the treatment of several cancers.
4-6
In the adult population, the primary tumors most
frequently related to the development of CNS metastases
are lung, melanoma, kidney, breast and colorectal cancer.
7
Regarding pathogenesis, CNS metastases are most
commonly due to hematogenous spread. Metastases are
usually located directly at the junction of the gray matter
and white matter where the diameter of the blood vessels