Congress of Neurological Surgeons Systematic Review and Evidence-Based Guidelines Update for the Role of Emerging Therapies in the Management of Patients With Metastatic Brain Tumors

Neurosurgery 96:1172–1177, 2025

This 2025 CNS guideline update reviews evidence for emerging therapies in adult brain metastases, providing new recommendations on targeted therapies, immunotherapy, radiosensitizers, and laser interstitial thermal therapy, while noting insufficient evidence for some modalities. Recommendations aim to guide multidisciplinary management beyond standard surgical and radiation treatments.

• This guideline is an updated systematic review on emerging therapies for adult patients with metastatic brain tumors (MBTs), focusing on evidence-based recommendations.

• Targeted therapies and immunotherapies have the strongest new evidence, especially for NSCLC, melanoma, and breast cancer brain metastases.

• Level I recommendations include the use of specific agents such as icotinib with WBRT for EGFR-mutant NSCLC, alectinib for ALK-positive NSCLC, and dabrafenib plus trametinib for BRAFV600E-positive melanoma.

• Immune checkpoint inhibitors (e.g., ipilimumab plus nivolumab for melanoma, ICIs for NSCLC) are recommended to improve survival and intracranial control in selected patients.

• Laser interstitial thermal therapy (LITT) may be considered equivalent to craniotomy or medical management in certain cases of tumor progression or radiation necrosis after SRS.

• There is insufficient evidence to recommend interstitial modalities or high-intensity focused ultrasound (HIFU) for brain metastases.

• Future research should prioritize prospective, comparative studies for modalities like LITT and HIFU, and the guideline will be updated as new evidence emerges.

• Clinical decisions should be individualized, and participation in clinical trials is encouraged to refine treatment strategies for MBTs.