THE CHOICE OF TREATMENT OF SINGLE BRAIN METASTASIS SHOULD BE BASED ONEXTRACRANIAL TUMOR-ACTIVITY AND AGE

Purpose: To determine if in patients with single brain metastasis the addition of neurosurgery to radiotherapy leads to lengthening of survi val or to better quality of life. Methods and Materials: From 1985 to 1990, 66 patients with single brain metastasis from a solid tumor were entered in a randomized trial of neurosurgery plus radiotherapy vs. r adiotherapy alone. Patients were stratified for lung cancer vs. other sites of cancer and for progressive vs. stable systemic cancer. Radiot herapy was given to the whole brain by a novel scheme of two fractions of 2 Gy per day for a total dose of 40 Gy in 2 weeks, to obtain a rel atively high total dose and short overall time, with minimal risk of l ate damage to normal tissue in long-term survivors. Results: In the wh ole group of 63 evaluable patients, both with lung cancer as with othe r tumors, the combined treatment led to a better duration of survival (median 10 vs. 6 months; p = 0.04). The largest difference between bot h treatment arms was observed in patients with inactive extracranial d isease (median 12 vs. 7 months; p = 0.02). Patients with active extrac ranial disease had an equal median survival of only 5 months, irrespec tive of given treatment. Age proved to be a strong and independent pro gnostic factor: patients older than 60 years had a hazard ratio of dyi ng of 2.74 (p = 0.003) compared with younger patients. Following treat ment, most patients remained functionally independent until a few week s before death. In the majority of patients the cause of death was sys temic tumor progression. Conclusion: Patients with single brain metast asis and with controlled or absent extracranial tumor activity should be treated with surgery and radiotherapy, especially when they are you nger than 60 years. For patients with progressive extracranial disease , radiotherapy alone seems to be sufficient. The accelerated radiother apy scheme of 40 Gy in 2 weeks to the whole brain is tolerated well an d should also be considered for patients in a good performance status with surgically unaccessible single metastasis or even with multiple b rain metastases.