Surgery Versus Radiosurgery to Treat Metastatic Brain Tumors

Introduction: Metastatic brain tumors occur more frequently than primary brain tumors and occur in approximately 25% of patients who die of cancer each year. The main treatment goals for patients with brain metastases are the relief of neurological symptoms and long-term control of the tumors. Glucocorticoids and external beam whole brain radiation therapy (WBRT) comprise the current standard of care and increase median survival from one month to three to six months. Patients with three or less tumors (greater than 70% of patients) also commonly undergo surgery or stereotactic radiosurgery (SRS) with the goal of lengthening survival. Two prospective randomized trials have shown a significant survival benefit for patients undergoing surgical resection of single tumors in combination with WBRT compared to patients receiving WBRT alone. Although there have been no prospective randomized studies comparing SRS and WBRT to WBRT alone, there have been numerous large retrospective series reporting a significant survival benefit from SRS. To date, a prospective randomized trial comparing surgery to SRS has not been reported. Despite the lack of rigorous data, there are proponents for each of these treatment modalities. Those in favor of surgery cite the ability to achieve a complete resection in most cases, the almost immediate relief of symptoms, and the low rate of local recurrence. Those in favor of SRS cite an equivalent degree of local tumor control compared to surgery, the relative ease of the one day outpatient procedure, and the ability to treat lesions in deeper brain structures. Objectives: We plan to determine in a prospective randomized manner if surgery is superior to SRS for prolonging survival in patients with one to three surgically accessible brain tumors. Study Population: Patients aged twenty one years and older with one to three brain metastases will be assessed for enrollment in this study. Design: Patients who meet eligibility criteria will be randomly assigned to undergo either surgery or SRS for their tumors. Patients will then be followed at regularly scheduled intervals for the duration of their disease. Outcome measures: The primary outcome measure will be time of survival following treatment. Among the secondary outcomes that will be measured over time are tumor recurrence or progression, neurologic sign or symptom development, functional independence, steroid and anticonvulsant use, and overall quality of life.