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

  • Review
  • Intervention

Authors


Abstract

Background

The treatment of brain metastasis is generally palliative since most patients have uncontrollable systemic cancer. Historically, whole brain radiation therapy (WBRT) has been the treatment of choice, although more recently focused radiation therapy e.g. stereotactic radiosurgery (SRS) has developed a role in selected patients. 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 patients with single brain metastasis.

Search methods

The following databases were part of a systematic literature search: Cochrane Central Register of Controlled Trials (CENTRAL Issue 2, 2010), MEDLINE, EMBASE, CancerLit, Biosis and the Science Citation Index. References of identified studies were hand searched, as were the Journal of Neuro-Oncology and Neuro-Oncology, including all conference abstracts. Specialists in neuro-oncology were contacted for further information. The searches for MEDLINE and EMBASE were updated in October 2007 and December 2010.

Selection criteria

Randomised controlled trials (RCTs) comparing surgery and WBRT with WBRT alone in patients of all ages with proven or suspected single brain metastasis.

Data collection and analysis

Two review authors independently assessed the search results for relevance, undertook critical appraisal according to known guidelines and extracted data using a pre-specified pro-forma.

Main results

Three RCTs were identified enrolling 195 patients in total. No significant difference in survival was found (hazard ratio (HR) 0.72, 95% CI 0.34 to 1.55, P = 0.40) although there was heterogeneity between trials (I2 = 83%). One trial found surgery and WBRT increased the duration of Functionally 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 (relative risk (RR) 0.68, 95% CI 0.43 to 1.09, P = 0.11). The risk of adverse events was not statistically proven to be different between arms although actual event numbers were higher in the surgery arm.

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 were not reported to have any higher risk of adverse events than patients who only had WBRT.

Plain language summary

Surgery and whole brain radiation therapy versus whole brain radiation therapy alone for single brain metastases

For patients with single brain metastasis there is good evidence from randomised controlled trials (RCTs) that surgery in addition to whole brain radiation therapy (WBRT) does not improve overall survival.Treatment of brain metastasis is usually palliative although in selected patients - particularly those with only a single metastasis to the brain - surgery could be considered. This review analysed the evidence from three RCTs, enrolling a select group of patients, and found that the combination of surgery and WBRT did not improve overall survival compared with WBRT alone. The addition of surgery may improve the length of time patients remained independent from others for support and there is a suggestion it may also reduce the risk of death due to neurological causes. Patients undergoing surgery were not reported have a higher risk of adverse events than patients who only had WBRT. Decisions on the treatment for an individual patient are best made as part of a multidisciplinary team.

Резюме на простом языке

Хирургическое вмешательство и лучевая терапия всего головного мозга против только лучевой терапии всего головного мозга при одиночных метастазах в головной мозг

Для пациентов с одиночными метастазами в головной мозг есть хорошие доказательства из рандомизированных контролируемых испытаний (РКИ), что хирургическое вмешательство (операция) в дополнении к лучевой терапии всего головного мозга (WBRT) не улучшает общую выживаемость. Лечение метастазов в головном мозге обычно паллиативное, хотя у отдельных больных - особенно при единственном метастазе в головной мозг - можно рассмотреть возможность проведения хирургического вмешательства (операции). В этом обзоре проанализированы доказательства из трех РКИ, включающих отдельную группу пациентов, и было обнаружено, что комбинация хирургического вмешательства и лучевой терапии всего головного мозга не улучшает общую выживаемость, по сравнению с только лучевой терапией всего головного мозга. Добавление хирургического вмешательства [операции] может увеличить время, в течение которого пациенты остаются независимыми от помощи других, и есть предположение, что это также может снизить риск смерти из-за неврологических причин. Не было сообщений о том, что пациенты, подвергающиеся хирургическому вмешательству, имели более высокий риск неблагоприятных событий, по сравнению с пациентами, которые получали только лучевую терапию всего головного мозга. Решения о лечении конкретного пациента лучше принимать в составе многопрофильной команды.

Заметки по переводу

Перевод: Мухаметзянова Алсу Сириновна. Редактирование: Юдина Екатерина Викторовна. Координация проекта по переводу на русский язык: Казанский федеральный университет - аффилированный центр в Татарстане Северного Кокрейновского Центра. По вопросам, связанным с этим переводом, пожалуйста, обращайтесь к нам по адресу: lezign@gmail.com