JCO: SRS or Surgery +/- WBRT for 1-3 brain mets

JCO this week:

The EORTC publishes a randomized trial looking at the effect of WBRT after surgical or SRS treatment of 1-3 brain mets. Their primary endpoint was time of functional independence, and found no differences in this outcome with the addition of WBRT. Additionally OS was no different, though recurrences were reduced both at the initial site and elsewhere within the brain. The late toxicity was not significantly different between the arms as evaluated by the trial, but the investigators admit that extensive neurocognitive testing was not performed.

The findings were not significantly different than what has been seen in other trials looking at both surgery and SRS. One thing I can't help but observe is that the failures were at least numerically higher in the surgery arm at the primary site. There are certainly reasons why this may be so (and indeed the size of lesions in the surgery cohort were larger), there certainly is no signal that SRS is worse than surgery in appropriately selected patients.

Link and Abstract:

Adjuvant Whole-Brain Radiotherapy Versus Observation After Radiosurgery or Surgical Resection of One to Three Cerebral Metastases: Results of the EORTC 22952-26001 Study [Neurooncology]: "Purpose

This European Organisation for Research and Treatment of Cancer phase III trial assesses whether adjuvant whole-brain radiotherapy (WBRT) increases the duration of functional independence after surgery or radiosurgery of brain metastases.

Patients and Methods

Patients with one to three brain metastases of solid tumors (small-cell lung cancer excluded) with stable systemic disease or asymptomatic primary tumors and WHO performance status (PS) of 0 to 2 were treated with complete surgery or radiosurgery and randomly assigned to adjuvant WBRT (30 Gy in 10 fractions) or observation (OBS). The primary end point was time to WHO PS deterioration to more than 2.

Results

Of 359 patients, 199 underwent radiosurgery, and 160 underwent surgery. In the radiosurgery group, 100 patients were allocated to OBS, and 99 were allocated to WBRT. After surgery, 79 patients were allocated to OBS, and 81 were allocated to adjuvant WBRT. The median time to WHO PS more than 2 was 10.0 months (95% CI, 8.1 to 11.7 months) after OBS and 9.5 months (95% CI, 7.8 to 11.9 months) after WBRT (P = .71). Overall survival was similar in the WBRT and OBS arms (median, 10.9 v 10.7 months, respectively; P = .89). WBRT reduced the 2-year relapse rate both at initial sites (surgery: 59% to 27%, P < .001; radiosurgery: 31% to 19%, P = .040) and at new sites (surgery: 42% to 23%, P = .008; radiosurgery: 48% to 33%, P = .023). Salvage therapies were used more frequently after OBS than after WBRT. Intracranial progression caused death in 78 (44%) of 179 patients in the OBS arm and in 50 (28%) of 180 patients in the WBRT arm.

Conclusion

After radiosurgery or surgery of a limited number of brain metastases, adjuvant WBRT reduces intracranial relapses and neurologic deaths but fails to improve the duration of functional independence and overall survival.

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