In agreement.

If you’re looking for drama, you won’t find it in ASTRO’s updated guidelines on radiation treatment for brain mets, which are concordant to those published by ASCO late last year. Again consensus is that surgery should be discussed when lesions are over 4 cm or causing mass effect, though here there is much more clarification on radiation as an adjunct to resection. Simply put, barring significant surgical complications, radiation should always be added—the patient was well enough for brain surgery, after all—with the most robust evidence for post-op delivery. Perioperative stereotactic radiosurgery (SRS) versus whole brain radiation (WBRT) should be determined by extent of unresected intracranial disease. Included are helpful post-op SRS dosing guidelines based on maximal cross-sectional measurements, Again hippocampal avoidance and memantine should always be considered when delivering WBRT to minimize neurocognitive decline. Finally, again it is reasonable to discuss deferring local therapy for small asymptomatic mets when initiating systemic therapy with known intracranial activity. | Gondi, Pract Radiat Oncol 2022