At our institution, if resection is performed and a GTR is achieved we generally do not recommend XRT. In cases of particularly large and complex resections and/or residual disease we would add RS.
Patchell compared WBRT vs WBRT + surgery w/o a surgery alone arm; it has been argued by some smarter than me that surgery = RS for most intents and purposes.
Well, patchell did publish on WBRT vs. WBRT + surgery (PMID 3008025). However, I referenced his trial of surgery vs. surgery + WBRT (PMID 9809728). The text is below. While there is no survival advantage, the addition of WBRT confers an advantage in local control, elsewhere in brain failure, and in death from neurological causes.
I do agree that WBRT + RS is essentially equivalent to surgery + WBRT in many cases. In fact, WBRT + RS is more common than resection + WBRT at my institution.
JAMA. 1998 Nov 4;280(17):1485-9.
Postoperative radiotherapy in the treatment of single metastases to the brain: a randomized trial.
Patchell RA, Tibbs PA, Regine WF, Dempsey RJ, Mohiuddin M, Kryscio RJ, Markesbery WR, Foon KA, Young B.
Department of Neurosurgery, University of Kentucky Medical Center, Lexington 40536-0084, USA.
[email protected]
CONTEXT: For the treatment of a single metastasis to the brain, surgical resection combined with postoperative radiotherapy is more effective than
treatment with radiotherapy alone. However, the efficacy of postoperative radiotherapy after complete surgical resection has not been established.
OBJECTIVE: To determine if postoperative radiotherapy resulted in improved neurologic control of disease and increased survival.
DESIGN: Multicenter, randomized, parallel group trial. SETTING: University-affiliated cancer treatment facilities.
PATIENTS: Ninety-five patients who had single metastases to the brain that were treated with complete surgical resections (as verified by postoperative magnetic resonance imaging) between September 1989 and November 1997 were entered into the study.
INTERVENTIONS: Patients were randomly assigned to treatment with postoperative whole-brain radiotherapy (radiotherapy group, 49 patients) or no further treatment (observation group, 46 patients) for the brain metastasis, with median follow-up of 48 weeks and 43 weeks, respectively.
MAIN OUTCOME MEASURES: The primary end point was recurrence of tumor in the brain; secondary end points
were length of survival, cause of death, and preservation of ability to function independently.
RESULTS: Recurrence of tumor anywhere in the brain was less frequent in the radiotherapy group than in the observation group (9 [18%] of 49 vs 32 [70%] of 46; P<.001). Postoperative radiotherapy prevented brain recurrence at the site of the original metastasis (5 [10%] of 49 vs 21 [46%] of 46; P<.001) and at other sites in the brain (7 [14%] of 49 vs 17 [37%] of 46; P<.01). Patients in the radiotherapy group were less likely to die of neurologic causes than patients in the observation group (6 [14%] of 43 who died vs 17 [44%] of 39; P=.003). There was no significant difference between the 2 groups in overall length of survival or the length of time that patients remained functionally
independent.
CONCLUSIONS: Patients with cancer and single metastases to the brain who receive treatment with surgical resection and postoperative radiotherapy have
fewer recurrences of cancer in the brain and are less likely to die of neurologic causes than similar patients treated with surgical resection alone.
