Clinical investigation: brain
A comparison of surgical resection and stereotactic radiosurgery in the treatment of solitary brain metastases

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Abstract

Purpose

To determine whether neurosurgery (NS) or stereotactic radiosurgery (RS) provided better local tumor control and enhanced patient survival.

Methods and materials

Retrospective review of all solitary brain metastases (SBM) patients newly diagnosed at Mayo Clinic Rochester between 1991 and 1999. Eligible patients satisfied tumor size and SBM site criteria to qualify for both NS and RS.

Results

There were no significant differences between 74 NS and 23 RS patients in terms of baseline characteristics (age, gender, systemic disease type, systemic disease status, signs/symptoms at SBM presentation) or percent of patients who received whole brain radiotherapy. Median follow-up for alive patients was 20 months (range 0–106 months). There was no significant difference in patient survival (p = 0.15); the 1-year survival rate was 56% for the RS patients and 62% for the NS patients. Multivariate Cox regression analysis found that a significant prognostic factor for survival was a performance score of 0 or 1. There was a significant (p = 0.020) difference in local tumor control between NS and RS for solitary brain metastasis; none of the RS group had local recurrence compared to 19 (58%) of the NS group.

Conclusion

The need for a Phase III study comparing these two techniques appears to be supported by the data from this study.

Introduction

Brain metastases are an important clinical problem for cancer patients, with approximately 25% of patients with brain metastases dying from neurologic causes (1). In addition, because of their disabling impact on cognition, memory, language, mobility, and adaptive skills, brain metastases are responsible for disproportionate morbidity and mortality for this patient population.

Approximately 200,000 cancer patients in the United States will develop brain metastases this year, and roughly half of these will be solitary (2). As the treatments for systemic disease improve, it is reasonable to assume that the number of cancer patients who develop brain metastases will increase, as well as the fraction of brain metastases that are solitary (3). Because solitary brain metastases (SBM) are being detected earlier in the cancer patient’s illness, the potential to improve the duration and quality of life is greatest in these patients. Unlike the patient with multiple brain metastases, local therapies should be applicable. However, it is not clear which local therapy produces superior results.

It is thought that patients with SBM benefit from more aggressive care than whole brain radiation therapy (WBRT) alone. Compared with WBRT, both neurosurgery (NS) and stereotactic radiosurgery (RS) appear to provide to the patient improved local tumor control, longer survival, and better quality of life 4, 5, 6, 7. However there is no class 1 evidence to support the use of one technique over the other for patients with SBM not suffering from symptomatic mass effect. The purpose of this study was to compare local tumor control and survival for patients with SBM having NS or RS.

Section snippets

Methods and materials

All aspects of this study were reviewed and approved by the Mayo Foundation Institutional Review Board. Patients who denied access to their medical records for research purposes were excluded from this study.

Patients who were potentially eligible for this study included all those with a diagnosis coded as “brain metastasis” or “brain metastases.” These patients were identified from three different databases: the Mayo Clinic Rochester (MCR) Medical Index, the department of neurosurgery’s

Results

A total of 97 SBM patients (42 women, 55 men) met the eligibility criteria for this study. Baseline standard-dose postgadolinium magnetic resonance imaging was performed on all patients to confirm that there was only one brain tumor. Of the 97 study patients, 23 (24%) underwent RS and 74 (76%) underwent NS. The use of WBRT was similar between the two groups (82% of NS patients and 96% of RS patients, p = 0.172). Time to death or last follow-up was measured from the date of the procedure. The

Discussion

Typically, SBM patients have been treated with WBRT after or instead of craniotomy and removal. In a 1990 report, Patchell et al. concluded that surgical resection combined with postoperative radiotherapy was more effective than treatment with radiotherapy alone (11). In a follow-up study, the same authors concluded that patients with cancer and single metastases to the brain who receive treatment with surgical resection and postoperative radiotherapy have fewer recurrences of cancer in the

Acknowledgements

We greatly acknowledge the help of Dr. Shekhar Dagam for data retrieval; Xiomara Carrero Martinez and Angela Fought for expert data analysis support and graph design; and Deborah A. Gorman, R.N., for the Mayo Clinic Department of Neurosurgery Gamma Knife Database management. We also acknowledge the support from the Linse Bock Program in Neuro-Oncology, Mayo Clinic Cancer Center (MCCC), and support from the Cancer Centers Support Grant P30 CA15083 to MCCC, an NCI-designated Comprehensive Cancer

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Supported in part by the Linse Bock Program in Neuro-Oncology, Mayo Clinic Cancer Center (MCCC) and the Cancer Centers Support Grant P30 CA15083 to MCCC, an NCI-designated Comprehensive Cancer Center.

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