Rationale
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Surgery versus WBRT ± surgery
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Surgery ± WBRT or partial brain radiotherapy (RT) versus SRS ± WBRT or partial brain RT
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Surgery ± WBRT versus surgery + SRS
Methods
Search strategy
Eligibility criteria
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Published in English.
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Patients with newly diagnosed brain metastases.
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Fully-published (i.e., not in abstract form) peer-reviewed primary comparative studies (These included the following comparative study designs for primary data collection: RCTs, non-randomized trials, cohort studies and case–control studies).
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Study comparisons include one or more of the following:
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Surgery versus WBRT
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Surgery versus surgery + WBRT
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Surgery ± WBRT or partial brain RT versus SRS ± WBRT or partial brain RT
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Surgery versus surgery + SRS
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Surgery + WBRT versus surgery + SRS
(Where SRS could be single session and fractionated stereotactic radiotherapy) -
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Number of study participants with a newly diagnosed brain metastasis ≥5 per study arm for at least two of the study arms.
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Baseline information on study participants is provided by treatment group in studies evaluating interventions exclusively in patients with a newly diagnosed brain metastasis. For studies with mixed populations (i.e., includes participants with conditions other than newly diagnosed brain metastases), baseline information is provided for the intervention sub-groups of participants with a newly diagnosed brain metastasis.
Study selection and quality assessment
Evidence classification and recommendation levels
Guideline development process
Scientific foundation
Surgical resection versus surgical resection + WBRT
First author (Year) | Interventions | Median survival | # pts with recurrence/progressiona
| Median time to recurrence/progression |
---|---|---|---|---|
Randomized trials | ||||
Patchell [10] (1998) | G1: Surgery (n = 46) G2: Surgery + WBRT (n = 49) | G1: 43 wks G2: 48 wks (Log-rank; P = NS) | At original site: G1: 21/46 (46%) G2: 5/49 (10%) (P < 0.001) Overall in brain: G1: 32/46 (70%) G2: 9/49 (18%) (P < 0.001) | At original site: G1: 27 wks G2: > 50 wks (Log-rank; P < 0.001) Overall in brain: G1: 26 wks G2: 220 wks (Log-rank; P < 0.001) |
Retrospective cohort studies | ||||
Armstrong[11] (1994) | G1: Surgery (n = 32) G2: Surgery + WBRT (n = 32) [matched to G1] G3: Surgery + WBRT (n = 79) [not matched] | G1: 14 months G2: 10 months G3: 15 months (G1 vs. G2: Log-rank; P = NS) | At original site: G1: 11/32 (34%) G2 + G3: 25/111 (23%) (G1 vs. G2 + G3: P = NS) Overall in brain: G1: 38% G2: 47% G3: 42% (G1 vs. G2: P = NS) | NR |
Hagen [12] (1990) | G1: Surgery (n = 16) G2: Surgery + WBRT (n = 19) | G1: 8.3 months G2: 6.4 months (Test not specified; P = NS) | At original site: G1: 6/16 (38%) G2: 4/19 (21%) (P = NR) Overall in brain: G1: 11/16 (69%) G2: 7/19 (37%) (P = NR) | At original site: NR Overall in brain: G1: 5.7 months G2: 26.6 months (Test not specified; P < 0.05) |
Skibber [13] (1996) | G1: Surgery (n = 12) G2: Surgery + WBRT (n = 22) | G1: 6 months G2: 18 months (Generalized Wilcoxon; P = 0.002) | At original site: NR Overall in brain: G1: 9/12 (75%) G2: 5/22 (23%) (P = NR) | NR |
Surgical resection ± WBRT or partial brain RT versus stereotactic radiosurgery (SRS) ± whole or partial brain RT
First author (Year) | Interventions | Median survival | # pts with recurrence/progressiona
| Median time to recurrence/progression |
---|---|---|---|---|
Randomized controlled trials | ||||
Muacevic [23] (2008) | G1: SRS (n = 31) G2: Surgery + WBRT (n = 33) | G1: 10.3 months G2: 9.5 months (Log-rank; P = NS) | 1 yr local control rate: G1: 97% G2: 82% 1 yr distant recurrence rate: G1: 26% G2: 3% | At original site: Median: NR (LR curves: log-rank; P = 0.06, NS) At distant brain sites: Median: NR (DR curves: log-rank; P = 0.04) |
Retrospective cohort studies | ||||
Muacevic [14] (1999) | G1: SRS (n = 56) G2: Surgery + WBRT (n = 52) | G1: 35 weeks G2: 68 weeks (Log-rank; P = NS) | 1 yr freedom from LR rate: G1: 83% G2: 75% 1 yr freedom from DR rate: G1: 68% G2: 90% (P = 0.0025) | At original site: G1: Median not reached G2: Median not reached (Log-rank; P = NS) At distant brain sites: NR |
Rades [15] (2007) | G1: SRS (n = 94) | Median survival: NR | 1 yr freedom from LR rate: | At original site: |
G2: Surgery + WBRT (n = 112) | 1 yr survival rate: G1: 54% G2: 38% (Log-rank; P = NS) | G1: 64% G2: 56% 1 yr freedom from BR rate: G1: 49% G2: 44% | Median: NR (LR curves: log-rank; P = NS) Overall in brain: Median: NR (BR curves: log-rank; P = NS) |
First author (Year) | Interventions | Median survival | # pts with recurrence/progressiona
| Median time to recurrence/progression |
---|---|---|---|---|
Retrospective cohort studies | ||||
Bindal [16] (1996) | G1: Surgery ± WBRTb (n = 62) [matched to G2] G2: SRS ± WBRTb (n = 31) | G1: 16.4 months G2: 7.5 months (Log-rank; P = 0.0018) | 1 yr freedom from LR rate: G2 poorer than G1 [Data: NR] 1 yr freedom from DR rate: G1: 75% G2: 69% | At original site: G1: Median not reached G2: 6 months (Log-rank; P = 0.0001) At distant brain sites: G1: Median not reached G2: Median not reached (Log-rank; P = NS) |
Garell [17] (1999) | G1: Surgery + WBRT (n = 37) G2: SRS + WBRT (n = 8) | G1: 8 months G2: 12.5 months (Log-rank P = NS) | NR | NR |
Schoggl [18] (2000) | G1: Surgery + WBRT (n = 66) G2: SRS + WBRT (n = 67) | G1: 9 months G2: 12 months (Test unclear;
P = NS) | At original site: G1: 11/66 (17%) G2: 3/67 (5%) (P = NR) At distant brain sites: G1: 10/66 (15%) G2: 7/67 (10%) (P = NR) | At original site: G1: 3.9 months G2: 4.9 months (Test unclear; P < 0.05) At distant brain sites: G1: 3.7 months G2: 4.4 months (Test unclear; P = NS) |
O’Neill [19] (2003) | G1: Surgery ± WBRTb (n = 74) G2: SRS ± WBRTb (n = 23) | Median survival: NR 1 yr survival rate: G1: 62% G2: 56% (Log-rank; P = NS) | At original site: G1: 11/64 (17%) G2: 0/21 (0%) (P = NR) Overall in brain: G1: 19/64 (30%) G2: 6/21 (29%) (P = NR) | NR |
First author (year) | Interventions | Median survival | # pts with recurrence/progressiona
| Median time to recurrence/progression |
---|---|---|---|---|
Retrospective cohorts | ||||
Ikushima [20] (2000) | G1: Fractionated SRS (n = 10) G2: Surgery + RT (n = 11) G3: RT (n = 14) [RT = WBRT or local] | G1: 25.6 months G2: 18.7 months G3: 4.3 months (Univariate analysis: G1 vs. G2 + G3: P = 0.05) | 1 yr local control rate: G1: 90% G2: 88% G3: NR | At original site: Median: NR (LR curves: log-rank; P = NS) |
Shinoura [21] (2002) | G1: SRS (n = 28) G2: Surgery + RT (n = 35) [RT = WBRT or local] | G1: 8.2 months G2: 34.4 months (Log-rank; P < 0.0001) | # lesions that recurred at original site: G1: 16/52 (31%) G2: 14/46 (30%) (P-value: NR) | Mean time at original site: G1: 7.2 months G2: 25 months (Log-rank; P = 0.0199) |
Wang [22] (2002) | G1: Surgery G2: WBRT G3: SRS G4: SRS + WBRT | G1: 43 wks G2: 37 wks G3: 67 wks G4: 91 wks (Log-rank P < 0.00001) | 1 month local tumor control: G1: 89% G2: 88% G3: 93% G4: 96% | NR . |