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CNS: Brain metastases SRS vs WBRT

Free question published 06 September 2026

Central nervous systemBrain metastases SRS vs WBRT

A 60-year-old woman with controlled HER2-positive breast cancer is found to have two small (each under 2 cm) asymptomatic brain metastases on surveillance MRI. Her extracranial disease is stable on systemic therapy and her Karnofsky performance status is 90. She is anxious about memory loss. Which intracranial treatment best balances disease control and cognitive preservation?

  1. AWhole-brain radiotherapy alone
  2. BStereotactic radiosurgery to both lesions, without whole-brain radiotherapy
  3. CSurgical resection of both metastases followed by whole-brain radiotherapy
  4. DStereotactic radiosurgery to both lesions plus adjuvant whole-brain radiotherapy
  5. EOptimal supportive care with no local intracranial treatment

Why B is correct

The N0574 (Alliance) trial showed that adding whole-brain radiotherapy to stereotactic radiosurgery for 1 to 3 brain metastases significantly increased cognitive deterioration at 3 months without improving overall survival. NICE NG99 supports maximal local therapy for limited brain metastases and advises against routine adjuvant whole-brain radiotherapy after radical local treatment. SRS alone, with close MRI monitoring, is therefore the optimal choice for this fit patient with two metastases and controlled systemic disease.

And why the others are not

  • AIncorrect: whole-brain radiotherapy alone gives inferior local control and greater cognitive toxicity than SRS for limited metastases.
  • CIncorrect: surgery is not required for small asymptomatic lesions amenable to radiosurgery, and adjuvant WBRT is not indicated.
  • DIncorrect: adding whole-brain radiotherapy worsens cognition without a survival benefit and is specifically advised against by NICE.
  • EIncorrect: this fit patient with controlled systemic disease and limited brain metastases should receive maximal local therapy, not supportive care alone.

Source N0574 (Alliance) — stereotactic radiosurgery with or without whole-brain radiotherapy for limited brain metastases — Brown PD, Jaeckle K, Ballman KV, et al. Effect of radiosurgery alone vs radiosurgery with whole brain radiation therapy on cognitive function in patients with 1 to 3 brain metastases: a randomized clinical trial (NCCTG N0574/Alliance). JAMA. 2016;316(4):401-409.

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