The role of surgical resection in the management of newly diagnosed brain metastases: a systematic review and evidence-based clinical practice guideline

Abstract

QuestionShould patients with newly-diagnosed metastatic brain tumors undergo open surgical resection versus whole brain radiation therapy (WBRT) and/or other treatment modalities such as radiosurgery, and in what clinical settings?Target populationThese recommendations apply to adults with a newly diagnosed single brain metastasis amenable to surgical resection.RecommendationsSurgical resection plus WBRT versus surgical resection aloneLevel 1 Surgical resection followed by WBRT represents a superior treatment modality, in terms of improving tumor control at the original site of the metastasis and in the brain overall, when compared to surgical resection alone.Surgical resection plus WBRT versus SRS ± WBRTLevel 2 Surgical resection plus WBRT, versus stereotactic radiosurgery (SRS) plus WBRT, both represent effective treatment strategies, resulting in relatively equal survival rates. SRS has not been assessed from an evidence-based standpoint for larger lesions (>3 cm) or for those causing significant mass effect (>1 cm midline shift).Level 3 Underpowered class I evidence along with the preponderance of conflicting class II evidence suggests that SRS alone may provide equivalent functional and survival outcomes compared with resection + WBRT for patients with single brain metastases, so long as ready detection of distant site failure and salvage SRS are possible.Note The following question is fully addressed in the WBRT guideline paper within this series by Gaspar et al. Given that the recommendation resulting from the systematic review of the literature on this topic is also highly relevant to the discussion of the role of surgical resection in the management of brain metastases, this recommendation has been included below.QuestionDoes surgical resection in addition to WBRT improve outcomes when compared with WBRT alone?Target populationThis recommendation applies to adults with a newly diagnosed single brain metastasis amenable to surgical resection; however, the recommendation does not apply to relatively radiosensitive tumors histologies (i.e., small cell lung cancer, leukemia, lymphoma, germ cell tumors and multiple myeloma).RecommendationSurgical resection plus WBRT versus WBRT aloneLevel 1 Class I evidence supports the use of surgical resection plus post-operative WBRT, as compared to WBRT alone, in patients with good performance status (functionally independent and spending less than 50% of time in bed) and limited extra-cranial disease. There is insufficient evidence to make a recommendation for patients with poor performance scores, advanced systemic disease, or multiple brain metastases.

Intraoperative radiotherapy to treat newly diagnosed solitary brain metastasis: initial experience and long-term outcomes

“…2,4,32,41 Whole-brain radiation therapy (WBRT), alone or in combination with excision, has been used for traditional and palliative therapy for nearly all patients with BrM. 4,15,19,20,22,23,[30][31][32]41,43,44 Most recently, stereotactic radiosurgery (SRS) has been added to the palliative armamentarium. 20,37,40 Most chemotherapeutic agents are impotent in the treatment of BrMs because of the relative impenetrability of the blood-brain and blood-tumor barriers.…”

Overview of Survival and Related Parameters in Malignancies with Brain Metastasis

“…[11][12][13] Overall, local control of the primary disease, and the number, site, and size of the metastasis in the brain must be taken into consideration in the prognostic and therapeutic approaches.…”

Interdisciplinary management of central nervous system metastasis and neoplastic meningitis: recent developments and future perspectives

“…To date, the strongest evidence for a survival benefit from surgery is for single CNS metastases. [53] In 1996, Mintz et al [54] did not confirm a positive impact of surgery on overall survival in these patients. However, only 21.4% of patients in this study had a controlled extracerebral disease, and none of the patients had brain MRI assessment; therefore, comparability with other studies is rather limited.…”