At the 2026 SNO ASCO CNS Metastases Conference in Boston, MA, Ayal Aizer, MD, MHS, presented to his colleagues how stereotactic treatments for brain metastases have shifted in recent years. Aizer, senior physician and director of central nervous system (CNS) radiation oncology at Dana-Farber Cancer Institute, and associate professor of Radiation Oncology at Harvard Medical School, spoke with CancerNetwork® at the conference about this presentation.
Stereotactic radiosurgery (SRS) has become an increasingly central tool in the management of brain metastases, offering patients a high therapeutic ratio with substantial benefit and comparatively limited harm. As indications for SRS have expanded and patients are living longer with well-controlled disease, clinicians are confronting a longer-term consequence of the treatment itself: radiation necrosis. Unlike tumor progression, necrosis is a treatment-related complication that can develop well after a metastasis has been successfully controlled, and it is becoming more relevant as systemic therapies extend survival and, in some cases, interact with radiation to influence necrosis rates.
In this video, Aizer identifies what he sees as the most significant unresolved challenge in the stereotactic management of brain metastases today. He describes 2 distinct populations that require different strategies: patients whose tumors are difficult to control with stereotactic radiation in the first place, and patients whose tumors respond well to treatment but who go on to develop necrosis as a complication. For the latter group, controlling the disease is only part of the picture; minimizing the downstream burden of the treatment itself is, in his view, the next major area clinicians and researchers need to address.
Transcript:
Aizer: Stereotactic radiation is very helpful. It has a high therapeutic ratio; it provides a lot of benefit and not a ton of harm, but there are ways we can make it better. We have some patients with tumors that are hard to control with stereotactic radiation, and how we can make the radiation even better is a key question. The flip side is that we have one significant [adverse] effect from stereotactic radiation: necrosis.
Necrosis is becoming an increasingly relevant issue as patients live longer and as systemic therapies get better but also contribute, both indirectly and directly, to radiation necrosis rates. What we need to be doing is, first of all, developing strategies for these refractory tumors to make radiation more effective, but also, for the run-of-the-mill typical radiosurgery case, figuring out how to minimize those necrosis rates so that patients don’t have a situation where their tumor is addressed and controlled, but they’re now dealing with the complications of radiation. That’s the next frontier for SRS.
Reference
Aizer A. Advances in the stereotactic management of brain metastases. Presented at the 2026 SNO ASCO CNS Metastases Conference; August 13-15; Boston, MA.
