How do you manage brain mets involving the cavernous sinus?

I don’t recall seeing this and, sadly, that covers a lot of ground. SRS if you can avoid the chasm. Otherwise, fractionated.

I recently treated a patient with two simultaneous mets from carcinoid tumor to the meninges of the optic nerve sheath and the cavernous sinus. Both were treated in a single plan to 50.4 Gy fractionated, like I usually would for an optic nerve sheath meningioma.

By treatment end, the patient had a gratifying improvement in vision and visible shrinkage of the optic nerve tumor on her daily CBCTs.

Metastatic disease to cavernous sinus region is rare, but has been described in the literature.

Assuming the patient is a candidate for SRS, can consider delivering, in 5 fractions, 30 Gy as feasible to GTV, while underdosing PTV margin to a dose of 25 Gy while keeping optics structures within appropriate 5Fx dose tolerances. Depends on the location of the tumor(s) within the sinus and proximity to the optic structures.

If not a candidate for SRS due to other reasons, then consider WBRT.