MedicalResearch.com Interview with:
Dr. Stephanie E. Weiss MD FASTRO
Chief, Division of Neurologic Oncology
Associate Professor, Department of Radiation Oncology
Director, Radiation Oncology Residency and Fellowship Training Program
Fox Chase Cancer Center
MedicalResearch.com: What is the background for this study?
Response: Brain metastasis are the most common form of brain tumor.
Historically all patients received whole brain radiation as the primary therapy. Patients required neurosurgery to remove lesions if there was a question of diagnosis, what the diagnosis is and if there was a mass effect not relieved with steroids. Surgery was also indicated for patients with a single brain lesion because this offers a survival benefit over just receiving whole brain radiotherapy.
In 2003 a randomized trial proved that radiosurgery offers a similar benefit. So the question taxing patients and doctors at tumor boards since has been: which is better? If neurosurgery is superior, we are under-treating a lot of patients with radiosurgery. If radiosurgery is superior, we are subjecting a lot of patients to unnecessary brain surgery. Attempts to study this in a head-to-head randomized trial have failed. Patient and physician preference for one treatment or the other has proven to be a barrier to randomization and accrual. The EORTC 22952-2600 trial was originally designed to compare outcomes with and without whole brain radiation for patients receiving surgery or radiosurgery for brain metastasis.
We used this as the highest-quality source data available to compare local control of brain metastasis after surgery or radiosurgery, adjusted for by receipt or not of whole brain radiation.
MedicalResearch.com: What are the main findings?
Response: We found that overall, local control was superior for radiosurgery. This was mitigated if the patients received whole brain radiation. Further, the superiority of radiosurgery diminished over time. When local recurrence was evaluated by time interval, we found that early local recurrence was dominated by patients undergoing neurosurgery, while later relapse was associated with patients receiving radiosurgery.
In other words, the rate of relapse is high after neurosurgery, but slows down over time. Relapse after radiosurgery is initially low early on, but doesn’t drop off as much over time.
At two years, local control still favored radiosurgery, but the difference was not statistically significant.
MedicalResearch.com: What should readers take away from your report?
Response: For most lesions that are conventionally amenable to radiosurgery, invasive neurosurgery can routinely be avoided with compromise of local control over two years time. If there is threatening mass effect, symptoms refractory to steroids or a need for pathologic tissue to guide therapy, surgery remains a vital intervention.
MedicalResearch.com: What recommendations do you have for future research as a result of this work?
Response: The advantage, if any, to combined modality therapy: surgery in addition to radiosurgery, is an interesting question, and may very likely be dependent upon sequencing: pre-operative versus post-operative radiosurgery. This will be most meaningful for patients who require surgery as part of sufficient therapy.
Churilla TM, Chowdhury IH, Handorf E, et al. Comparison of Local Control of Brain Metastases With Stereotactic Radiosurgery vs Surgical Resection
A Secondary Analysis of a Randomized Clinical Trial. JAMA Oncol.Published online November 08, 2018. doi:10.1001/jamaoncol.2018.4610
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