Central Nervous System Metastases

Magnetic resonance imaging (MRI) is the first-line diagnostic examination for the evaluation of suspected central nervous system metastases.

MRI is performed with and without contrast enhancement and is targeted according to the suspected site of disease:

• Brain MRI in patients with suspected brain metastases
• Spinal MRI in patients with suspected vertebral or spinal metastases

When leptomeningeal metastasis is suspected based on cranial nerve deficits or spinal radicular symptoms, MRI should include evaluation of both the brain and spinal cord, allowing assessment of the meninges throughout the entire central nervous system.

Contrast-enhanced computed tomography (CT) has limitations in the evaluation of central nervous system metastases and is not sufficiently sensitive for detecting small lesions or metastases located in the brainstem.

CT is also less effective in identifying nodular or linear leptomeningeal lesions, particularly those involving the cerebellum and spinal cord.

For these reasons, magnetic resonance imaging (MRI) remains the preferred imaging modality when central nervous system metastases are suspected.

Brain PET imaging is particularly useful for distinguishing radiation necrosis from tumor recurrence following stereotactic radiosurgery or other radiation treatments.

Whole-body PET imaging is used for systemic disease staging and plays an important role in assessing the extent of cancer beyond the central nervous system.

This examination is particularly valuable before considering local treatments, such as radiation therapy or neurosurgery, as it helps guide treatment planning and patient selection.

Surgical resection of central nervous system metastases is indicated in selected clinical situations as part of a multidisciplinary treatment strategy.

In cases of a single brain metastasis larger than 3 cm, or lesions located in the posterior fossa with mass effect, surgery aims to reduce intracranial pressure, relieve neurological symptoms, and potentially allow reduction or discontinuation of corticosteroid therapy. In selected cases, resection may also be considered for lesions measuring 2 to 3 cm, following multidisciplinary evaluation.

Surgical removal may also have prognostic relevance when the metastasis is solitary, in the absence of active systemic disease, or when systemic disease is fully controlled.

In patients with multiple brain metastases, resection of the largest, edematous, or symptomatic lesion may be performed for palliative purposes prior to nonsurgical treatments. A postoperative MRI scan is essential to assess the presence of any residual tumor.

In patients with brain metastases, systemic therapy is planned according to the molecular and histological characteristics of the primary tumor, as well as any previous treatments received.

A key aspect of management is close collaboration with the radiation oncologist, which is essential to determine if and how systemic therapy should be combined with radiotherapy.

When a brain metastasis is surgically resected, reassessment of the molecular profile of the tumor may be useful to better tailor postoperative targeted therapies.

In cases of leptomeningeal metastases, treatment options may include systemic therapies or intrathecal administration directly into the cerebrospinal fluid (CSF). These approaches are always considered within a multidisciplinary evaluation.

Radiotherapy for brain metastases may have different objectives, including adjuvant treatment after surgery, radical treatment, or palliation of symptoms in more advanced disease.

Adjuvant Radiotherapy: Adjuvant radiotherapy is administered after surgical removal of the metastasis to treat the surgical bed and reduce the risk of local recurrence.

Modern techniques such as stereotactic radiotherapy and intensity-modulated radiotherapy (VMAT) allow precise targeting of the treated area while sparing healthy brain tissue as much as possible.

Radical Radiotherapy: Radical radiotherapy aims to achieve complete local control of the metastasis. It can be delivered as a single session (radiosurgery) or in a few fractions, usually up to five, depending on the size and location of the lesion.

Palliative (Whole-Brain) Radiotherapy: In cases where metastases are diffuse throughout the brain, radiotherapy may be delivered to the entire brain to alleviate symptoms and preserve quality of life.

In selected patients with good performance status and limited disease burden, techniques such as hippocampal sparing may be used to protect the hippocampus, a structure involved in long-term memory.

This approach allows effective disease control while minimizing damage to healthy brain tissue.

In patients with brain metastases, corticosteroids, particularly dexamethasone (4 to 16 mg/day depending on neurological symptom severity), are indicated to control cerebral edema.

The possible prophylactic use of steroids in asymptomatic patients undergoing radiosurgery is left to the discretion of the radiotherapist.

In cases of leptomeningeal metastases, corticosteroids are generally of limited benefit, whereas nonsteroidal anti-inflammatory drugs (NSAIDs), even at high doses, may provide better palliative symptom control.

Antiepileptic therapy is indicated in patients who present with seizures.

Treatment for brain metastases may be associated with side effects that can variably affect quality of life. However, these effects can often be mitigated or, in some cases, prevented through appropriate medical interventions and lifestyle measures.

At the Candiolo Cancer Institute, physicians and nurses within the multidisciplinary team (GIC) provide continuous support to ensure that each patient receives the necessary care to manage the different side effects that may arise during the course of treatment.

The impact of cancer also extends to the psychological sphere. A cancer diagnosis is often a traumatic event that affects all aspects of a person’s life and may generate anxiety, fear, anger, and depression.

At the Canciolo Cancer Institute, alongside advanced medical therapies, the care pathway always includes specialized psycho-oncological support, helping patients cope not only with treatment but also with the delicate phases of physical and psychological recovery.

Patients may also participate in psychological support groups, where they can share experiences with others who are facing or have faced a similar condition.

To ensure timely support and provide prompt answers to questions or concerns, the Candiolo Cancer Institute offers a dedicated assistance service for all patients.

From Monday through Friday, between 8:00 a.m. and 5:00 p.m., patients can contact the Oncology Day Hospital Secretariat at +39 011 993 3775 to request an urgent consultation.

Patients are promptly connected with their specialist physician, ensuring rapid access to expert advice, clear information, and immediate support when needed.

Cancer patients often have complex needs that extend beyond the treatment of the disease itself and require comprehensive, multidisciplinary care.

At the Candiolo Cancer Institute, patients who need additional support have access to specialists from a range of disciplines, ensuring personalized management of cancer-related symptoms and associated conditions. Services may include nutritional counseling, physical rehabilitation, pain management, and support for other medical needs that may arise during the course of treatment and recovery.

The goal is to improve quality of life, promote overall well-being, and provide comprehensive care tailored to each patient’s individual needs.

The Social Work Service at the Candiolo Cancer Institute provides information, guidance, and support to patients and their families regarding access to community services and the welfare and social security benefits available under current legislation.

During dedicated consultations, social workers assist with matters such as disability recognition, access to aids and prosthetic devices, employment-related benefits and leave, and other social support services.

The service is available on Wednesdays and Fridays from 9:00 a.m. to 1:00 p.m. and can be contacted at +39 011 993 3059.

Follow-up after treatment is mainly based on periodic magnetic resonance imaging (MRI), usually every 3 to 4 months, to monitor disease status and detect any early signs of recurrence.

In cases of leptomeningeal metastases, in addition to MRI, a lumbar puncture (spinal tap) may be required to collect and analyze cerebrospinal fluid (CSF).

The frequency of this procedure is not fixed and is determined by the specialist team based on the patient’s clinical condition and the evolution of the disease.