Management of brain metastasis. Surgical resection versus stereotactic radiotherapy: a meta-analysis

Abstract

Background Treatment of metastatic brain tumors often involves radiotherapy with or without surgical resection as the first step. However, the indications for when to use surgery are not clearly defined for certain tumor sizes and multiplicity. This study seeks to determine whether resection of brain metastases versus exclusive radiotherapy provided improved survival and local control in cases where metastases are limited in number and diameter. Methods According to PRISMA guidelines, this meta-analysis compares outcomes from treatment of a median number of brain metastases ≤4 with a median diameter ≤4 cm with exclusive radiotherapy versus surgery followed by radiotherapy. Four randomized control trials and 11 observational studies (1693 patients) met inclusion criteria. For analysis, studies were grouped based on whether radiation involved stereotactic radiosurgery (SRS) or whole-brain radiotherapy (WBRT). Results In both analyses, there was no difference in survival between surgery ±SRS versus SRS alone two years after treatment (OR 1.89 (95% CI: 0.47 - 7.55, p = 0.23) or surgery + WBRT versus radiotherapy alone (either WBRT and/or SRS) (OR 1.18 (95% CI: 0.76 – 1.84, p = 0.46). However, surgical patients demonstrated greater risk for local tumor recurrence compared to SRS alone (OR 2.20 (95% CI: 1.49 - 3.25, p < 0.0001)) and compared to WBRT/SRS (OR 2.93; 95% CI: 1.68 - 5.13, p = 0.0002). Conclusion The higher incidence of local tumor recurrence for surgical patients suggests that more prospective studies are needed to clarify outcomes for treatment of 1-4 metastasis less than 4 cm diameter.

Treatment Outcome of the Brain Metastases in Peri-Rolandic Area: Comparison Between Surgery and Stereotactic Radiosurgery

“…In previous studies analyzing patients with BMs, no significant differences in median OS and PFS were observed based on treatment methods, but systemic progression was identified as a contributing factor [ 9 10 17 ]. Similarly, for metastasis in the peri-Rolandic area, there were no significant differences in OS and PFS among different treatment methods.…”

Intracranial Metastatic Melanoma

“…Patient factors such as surgical and anaesthetic risk and comorbidities need to be taken into account too [43]. Outcomes after neurosurgery and SRS are similar; a metaanalysis reported non-significant difference in local control between SRS and neurosurgery at 1 year, and non-significant difference in overall survival at 1 and 2 years [44].…”

Safety and efficacy of immune checkpoint blockade in patients with advanced nonsmall cell lung cancer and brain metastasis

“…However, an individual patient data meta‐analysis from three phase III randomised controlled trials has shown a statistically significant survival benefit for patients younger than 50 years who received SRS 36 . Another recent meta‐analysis reported that patients with four or fewer BM ≤4 cm in maximal diameter reaped a greater benefit in terms of local tumour control, when they were solely treated with SRS in comparison with surgery and subsequent radiation therapy (RT) 37 . The preferred systemic treatment for nononcogene‐driven NSCLC with BM is platinum‐doublet‐based chemotherapy leading to IC response rates that range from 20% to 45% 38‐40 .…”

“…36 Another recent meta-analysis reported that patients with four or fewer BM ≤4 cm in maximal diameter reaped a greater benefit in terms of local tumour control, when they were solely treated with SRS in comparison with surgery and subsequent radiation therapy (RT). 37 The preferred systemic treatment for nononcogene-driven NSCLC with BM is platinum-doublet-based chemotherapy leading to IC response rates that range from 20% to 45%. [38][39][40] After local CNS treatment, salvage chemotherapy only offers a very small therapeutic benefit.…”