11 / 99
T
reatment
of
brain
metastases
R
ev
A
ssoc
M
ed
B
ras
2016; 62(5):389-394
391
Survival time
The study by Patchel
(1B)
showed 40 weeks of survival in
the surgical group and 15 weeks in the group undergoing
radiotherapy (RT) (p<0.01), favoring surgical treatment.
Vecht
(1B)
found a longer survival (10 months) in the
surgical group compared with the RT group (6 months)
(p=0.04).
In the study by Mintz
(1B)
, there was no difference
regarding survival: 5.62 months in the surgical group,
6.28 months in the RT group (p=0.24).
The analysis of randomized trials based on survival
curves has several limitations.
4,5
The survival analysis did
not show a statistically significant difference between the
two treatments (HR=0.72, 95CI 0.34-1.53, p=0.40).
6
The
studies by Patchell and Vecht reported longer survival in
patients undergoing surgery plus radiotherapy, while the
study by Mintz revealed longer survival in patients treat-
ed with radiotherapy alone.
Outcome: Lesion recurrence
The study by Patchel
(1B)
was the only one to properly
describe the results in this outcome. Recurrence in the
surgical group totaled 20% and in the RT group, 52%. The
difference was statistically significant (p<0.02).
Methodological quality analysis
This trial was classified as Jadad = 3. The study’s strength
reached 64.77%.
Evidence summary
Surgery decreases the recurrence of the lesion as single
metastases, compared to radiotherapy.
Outcome: Functional independence
The three studies examined functional independence.
Patchel and Mitch used the Karnofsky scale. Vecht
used the performance status level of the World Health
Organization (between 0 and 4).
In the study by Patchel, the surgical group maintained
Karnofsky score > 70 in up to 38 weeks of follow-up (on
average), and the radiotherapy group maintained this
score only up to 8 weeks (p<0.0005).
In the study by Vecht, there was no difference in func-
tional independence between the groups.
The study by Mitch also revealed no difference in
functional independence (Karnofsky) (p=0.98).
Evidence summary
There is no evidence that surgical treatment preserves the
functional independence of patients, compared with ra-
diotherapy.
2) C
linical
question
Is radiosurgery combined with holocranial radiotherapy
more effective than radiosurgery or radiotherapy alone
(1 to 3 metastases)?
Description of the evidence collection method
The search strategy was conducted in the MedLine
(PubMed) database to identify articles published from
1964 to 2013. The objective was to identify studies com-
paring radiotherapy (combined with radiosurgery) and
radiosurgery or radiotherapy alone.
The following terms were searched as “Mesh” and
words in the text: “Brain Neoplasms”, “Radiosurgery”,
“Radiotherapy”, “Brain Neoplasms/radiotherapy”, “Ra-
diotherapy, Adjuvant”, “Radiosurgery/methods”, “Treat-
ment Outcome”, “Radiosurgery/adverse effects”.
Related articles were searched from the citations in
the primary texts.
•
•
Inclusion criteria: Randomized clinical trials, includ-
ing those published in English, Spanish and Portu-
guese.
•
•
Clinical outcomes included were: Functional indepen-
dence, survival, tumor control, cost-effectiveness, qual-
ity of life, cognitive decline and other adverse effects.
Results
In all, 2,638 articles were identified in the initial search
strategy and 29 articles were retrieved based on inclusion
criteria. Of these, 19 articles were excluded because they
were narrative reviews, evaluation of radiosurgery alone,
or treatment of high-grade gliomas.
Another article was manually selected. In the end, nine
randomized trials were analyzed to answer this question.
Methodological quality analysis
Andrews et al.
7
(1B)
(2004) studied, between January 1996
and June 2001, 333 patients in 55 participating centers –
167 underwent whole brain radiotherapy and stereotac-
tic radiosurgery, while 164 were allocated for whole brain
radiotherapy alone. All patients were aged 18 years or old-
er, and had not been treated with cranial radiotherapy.
Entry criteria included contrast-enhanced MRI showing
1-3 brain metastases, with maximum diameter of 4 cm
for the largest lesion and additional lesions not greater
than 3 cm in diameter. Patients with Karnofsky (KPS)
score less than 70, hemoglobin concentration below 80
g/L, absolute neutrophil count below 1,000 or 50,000 cells
were excluded. Patients were stratified by number of brain
metastases (single metastasis
vs.
2-3) and extent of extra-
cranial disease. Randomization was done by blocks us-
ing computerized techniques. Sample size was previous-