Central Nervous System
PV QA 2 - Poster Viewing Q&A 2
Purpose/Objective(s):Brain metastases (BM) commonly manifest in patients with cancer and account for the majority of intracranial neoplasms. Among patients with BM, 33-50% present with one intracranial lesion. The value of surgery in brain metastases has been established in two randomized controlled trials showing the effectiveness of surgery in combination with whole brain radiotherapy (WBRT) for a single BM. Due to the morbidity associated with neurosurgical interventions, surgery is generally reserved for patients with good prognosis and larger symptomatic brain metastases. In general, patients with small (<2 cm), asymptomatic brain metastases undergo stereotactic radiation (SRS/SRT) as treatment of choice. We sought to evaluate the impact of surgery in addition to SRS/SRT compared to SRS/SRT alone in patients with good prognosis, controlled or absent extra cranial disease, with one brain metastasis less than 2 cm in size.
Materials/Methods:We retrospectively identified patients with a single (n=86) or solitary (n=49) brain metastasis less than or equal to 2 cm in maximal unidimensional size treated between 2000-2015. Patients with a solitary brain metastasis had no evidence of extracranial disease, while patients with a single brain metastasis were defined, in our cohort, as having controlled extracranial disease at the time of BM diagnosis. Treatment related outcomes assessed included the use of SRS/SRT or craniotomy with adjuvant SRS/SRT as an initial management strategy. Oncologic outcomes assessed included time to local recurrence (LR), time to all-cause mortality (ACM), and percentage of patients who experienced death due to progressive neurological disease.
Results:Baseline characteristics were similar between the two cohorts. Median follow-up in surviving patients was 27.4 months. For patients with a single or solitary brain metastasis less than 2 cm in size, there was a weak trend towards longer time to LR in patients receiving surgery plus SRS/SRT versus SRS/SRT alone (HR: 0.518, 95% Confidence Interval (CI) 0.158 to 1.706; P= 0.280 for single metastasis, and HR: 0.424, CI 0.102 to 1.758; P= 0.237 for solitary metastasis). For patients with a single brain metastasis, there was a significantly lower rate of ACM in patients managed with surgery plus SRS/SRT versus SRS/SRT alone (HR 0.439, CI 0.193 to 0.999; P= 0.0497). While non-significant, a similar trend for ACM was noted for patients with solitary brain metastasis (HR 0.307, CI 0.087 to 1.087; P= 0.067). Patients receiving surgery plus SRS/SRT also trended toward a lower rate of neurological death as compared to those receiving SRS/SRT alone (HR 0.289, CI 0.063 to 1.333; P= 0.112 for single metastasis; HR 0.329, CI 0.060 to 1.817; P= 0.202 for solitary metastasis).
Conclusion:In patients with controlled or absent extracranial disease who present with one brain metastasis less than 2 cm in size, surgery plus SRS/SRT may result in improved rates of local control, all-cause mortality, and neurological death as compared to SRS/SRT alone.
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