Surgical resection and whole brain radiation therapy versus whole brain radiation therapy alone for single brain metastases

For patients with single brain metastasis there is no good evidence from randomised controlled trials (RCTs) that surgery in addition to whole brain radiation therapy (WBRT) improves overall survival

Treatment of brain metastasis is usually with WBRT although in selected patients - particularly those with only a single metastasis to the brain - surgical resection may be considered. This review found no evidence that the combination of surgery and WBRT improved overall survival compared with WBRT alone but it may improve the length of time patients remained independent from others for support. The risk of deaths due to neurological cause may also be reduced. Patients undergoing surgery did not appear to have any higher risk of adverse events that patients who only had WBRT. Decisions on the treatment for an individual patient are best made as part of a multidisciplinary team meeting in keeping with NICE guidance.

This is a Cochrane review abstract and plain language summary, prepared and maintained by The Cochrane Collaboration, currently published in The Cochrane Database of Systematic Reviews 2009 Issue 1, Copyright © 2009 The Cochrane Collaboration. Published by John Wiley and Sons, Ltd.. The full text of the review is available in (ISSN 1464-780X).
This record should be cited as: Hart MG, Grant R, Walker M, Dickinson HO. Surgical resection and whole brain radiation therapy versus whole brain radiation therapy alone for single brain metastases. Cochrane Database of Systematic Reviews 2004, Issue 4. Art. No.: CD003292. DOI: 10.1002/14651858.CD003292.pub2.

This version first published online: January 24. 2005
Last assessed as up-to-date: October 09. 2007

Abstract

Background

The treatment of brain metastasis is generally palliative, with whole brain radiation therapy (WBRT), since most patients have uncontrollable systemic cancer. In certain circumstances, such as single brain metastasis, death may be more likely from brain involvement than systemic disease. In this group surgical resection has been proposed to relieve symptoms and prolong survival.

Objectives

To assess the clinical effectiveness of surgical resection plus WBRT versus WBRT alone in the treatment of single brain metastasis.

Search strategy

The following databases were part of a systematic literature search: Cochrane Central Register of Controlled Trials (CENTRAL), Medline, Embase, Cancerlit, Biosis and the Science Citation Index. References of identified studies were hand searched, as was the Journal of Neuro-Oncology over the previous 10 years and Neuro-Oncology over the past two years, including all conference abstracts. Specialists in neuro-oncology were also contacted. The searches were updated in October 2007.

Selection criteria

Randomised controlled trials (RCTs) comparing surgery and WBRT with WBRT alone, in patients with single brain metastasis.

Data collection and analysis

Two review authors independently assessed trial quality and extracted data using pre-specified pro-formas.

Main results

Three RCTs were identified enrolling 195 patients in total. No significant difference in survival was found (HR 0.72, 95% CI 0.34 to 1.53, p = 0.40) although there was heterogeneity between trials (I² = 82%). One trial found surgery and WBRT increased the duration of Funcitonally Independent Survival (FIS) (HR 0.42, 95% CI 0.22 to 0.82, p = 0.01). There was some indication that surgery and WBRT might reduce the risk of deaths due to neurological cause: odds ratio (RR = 0.68 95% CI 0.43 to 1.09, p = 0.11). The risk of adverse events was similar in both arms.

Authors' conclusions

Surgery and WBRT may improve FIS but not overall survival. It may also reduce the proportion of deaths due to neurological cause. All these results were in a highly selected group of patients. Patients undergoing surgery did not appear to have any higher risk of adverse events than patients who only had WBRT.