Outcome Improvement in RPA I or II Patients With 1 or 2 Brain Metastases by Combined Surgery and Radiotherapy

BACKGROUND: To evaluate the role of surgery and postoperative radiotherapy in the management of brain metastases (BM): a retrospective analysis for overall survival (OS), local and brain control (LC and BC) of a series of 329 patients with recursive partitioning analysis (RPA) I or II with 1 or 2 BM in a single institution. METHODS: Patients were treated either with combined surgical resection and whole brain radiation therapy (WBRT) in 104 cases (31.6%) or with WBRT alone in 225 cases (68.4%). Ninety-five patients (91.4%) who underwent surgery and WBRT and 147 (65.3%) who underwent WBRT alone benefited from a radiation boost to the metastatic site. RESULTS: The median OS was higher for patients RPA I compared to RPA II: 21.3 and 5.9 months (P < 0.0001), as well as for the surgical group compared to the radiation group: 20.2 vs 5.3 months (P < 0.0001), respectively. After the multivariate analysis, the improved OS was significantly associated with control of primary tumor (P = 0.0002) after surgical resection and with type of primary tumor (P = 0.002), absence of extracranial metastases (ECM) (P = 0.006), and high Karnofsky performance status (90 - 100 vs 70 - 80) (P = 0.003) after radiotherapy alone. The 12-, 24- and 36-months LC rates were 91.1%, 91.1% and 83.9%, respectively, after surgical resection and 81.2%, 63.1% and 57.3%, respectively, after radiotherapy alone (P = 0.005). In a univariate analysis, improved LC for the surgical group was also associated with the absence of ECM (P = 0.01) and for the radiation group, with a radiation boost (P = 0.01). The BC rates at 12, 24 and 36 months were 73.2%, 66.9% and 56%, respectively, in the surgical group and 75.7%, 49.6% and 42.4%, respectively, in the radiation group (P = 0.2). In our univariate analysis, improved BC after surgical resection was associated with control of primary tumor (P = 0.02). For patients in the radiation group, gender (P = 0.03) and a radiation boost (P = 0.0003) were significant prognostic factors in a univariate analysis. In our multivariate analysis, only the radiation boost was significant (P = 0.001). CONCLUSIONS: Surgical resection followed by WBRT leads to a better outcome compared to WBRT alone for RPA I or II patients with 1 or 2 BM.