I briefly mentioned the potential value of surgery for a solitary brain metastasis, where it is commonly used, in another post. Today I’ll talk more specifically about where the role for surgery has been specifically tested for brain metastases in lung cancer. Aside from possibly removing the only lesion (in certain cases, where it can be associated with long-term survival, as I described in my post on solitary brain metastases), neurosurgery is used to offer rapid relief of symptoms resulting from the mass effect of a large tumor, to improve local control of brain metastases, and/or to clarify the tissue diagnosis when there is some question about the underlying diagnosis of a brain lesion. Improvements in anesthesia and neurosurgery have made this intervention safer and more feasible for patients over time.
One way to assess the value of surgery in the treatment of brain metastases is by comparing the results of WBRT vs. a combination of neurosurgery and SRS, and three randomized trials have done that (abstracts here and here and here). The first was an influential trial by Patchell and colleagues (abstract here), of 48 patients with a single brain metastasis who underwent surgery followed within two weeks by WBRT (36 Gy over 12 fractions) or WBRT alone. This study, although small, did show very clear and statistically significant improvements in likelihood of recurrence of brain metastases (20% vs. 52%) and median overal survival (40 vs. 15 wks). These results were corroborated by another trial (abstract here) of 63 patients with a single brain lesion who received WBRT alone or preceded by surgery, showing a significant improvement in survival (10 vs. 6 months). These trials both also showed that patients undergoing a combination of surgery and WBRT remained functionally independent for longer. The third and largest trial (abstract here), with 84 patients who also had a single brain lesion, actually did not demonstrate a significant improvement in survival or functional status, but this trial had patients with a greater burden of distant disease than the other trials. The results of these three studies are shown here:
(click to enlarge)
The differences among these trials reminds us that the value of surgery for brain metastases is still questionable, and it is a most compelling consideration for patients with a single metastasis, good performance status, and controlled disease outside of the brain. There is really remarkably little experience to guide us on the value of surgery for more than a solitary brain metastasis, but it is generally felt to be far less appealing than in the more commonly advocated setting of treating a single brain metastasis.
posted by Dr. West @ 2:06 pm link to this post
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April 22nd, 2007 at 6:55 pm
This posting is extremely relevant to me right now. My husband will have his single brain tumor removed surgically on Thursday, and will have WBR once recovered. Though the decision was his, I struggled with it from a quality of life standpoint. Acceptance of the decision was made easier by a rapid progression of related vision and overall functional problems - by rapid, I mean over 2 or so weeks…and the fact that Decadron and the associated relief of edema did nothing to improve his symptoms. I’ll let you know how he does. Thanks for the post - as I said, very pertinent for us right now, and very clear.
April 22nd, 2007 at 7:51 pm
Dr. West, I had another thought and went back and re-read your post on “precocious brain mets”.
My attention was drawn to the following words: “For patients in these situations, treated aggressively and with curative intent, survival far exceeds the general numbers for metastatic NSCLC. The five-year survival in many of these case series, which has involved a delay between lung tumor treatment and brain tumor treatment in about 2/3 of cases, hovers around 21%, with a range of around 16-30%.”
Since my husband was diagnosed in an “early” stage (2B) 7 months ago, and has a single occipital lobe brain met (2.86 cm at largest dimension), might he fall into the category of people who might be expected to have longer survival/better survival odds?
His basic timeline is diagnosis and bilobectomy October ‘06, chemo November - January, and diagnoses of brain tumor April ‘07. He had a clean brain MRI in October ‘06.
Thanks so much
April 22nd, 2007 at 9:04 pm
I’d be hopeful. Regardless, there is evidence to support the sugery and plenty of people would agree with it. In situations like these, I find it helps to think of whether you’d ever wonder “what if…” about not taking the alternate route. Many people would have a problem with not pursuing an option that leaves some realistic possibility of cure if the alternative doesn’t. I would say that surgery leaves open a possibility that doesn’t exist otherwise.
-Dr. West
April 23rd, 2007 at 11:11 am
Thank you. I guess the remaining open item is to find out tomorrow if his whole body PET/CT done on Friday is clean. If it is, then this is probably worth a shot. if it isn’t then I guess we have a different situation. Thanks wholeheartedly for your insight.
May 3rd, 2007 at 1:42 pm
Dr. West:
Following up on preceding posts; my husband had his brain tumor removed a week ago, and is recovering. We are still debating whether to do WBR or another form of radiation in a couple of weeks. The tumor was determined pathologically to be a met from the primary, which I guess was a forgone conclusion. Very fortunately, the whole body PET had no indication of any other mets.
My remaining question, after doing a lot of reading, is whether the short time frame between diagnosis/initial treatment and the appearance of the brain met is or is not a significantly negative prognostic factor?Some studies seem to state that it is, and others do not.
Any input you might have on this question would be (as always) appreciated.
Thanks