title: Comparing pre-operative stereotactic radiosurgery (SRS) to post-operative whole brain radiation therapy (WBRT) for resectable brain metastases: a multi-institutional analysis.
abstract: Pre-operative stereotactic radiosurgery (pre-SRS) has been shown as a viable treatment option for resectable brain metastases (BM). The aim of this study is to compare oncologic outcomes and toxicities for pre-SRS and post-operative WBRT (post-WBRT) for resectable BM. We reviewed records of consecutive patients who underwent resection of BM and either pre-SRS or post-WBRT between 2005 and 2013 at two institutions. Overall survival (OS) was calculated using the Kaplan-Meier method. Cumulative incidence was used for intracranial outcomes. Multivariate analysis (MVA) was performed using the Cox and Fine and Gray models, respectively. Overall, 102 patients underwent surgical resection of BM; 66 patients with 71 lesions received pre-SRS while 36 patients with 42 cavities received post-WBRT. Baseline characteristics were similar except for the pre-SRS cohort having more single lesions (65.2% vs. 38.9%, p = 0.001) and smaller median lesion volume (8.3 cc vs. 15.3 cc, p = 0.006). 1-year OS was similar between cohorts (58% vs. 56%, respectively) (p = 0.43). Intracranial outcomes were also similar (2-year outcomes, pre-SRS vs. post-WBRT): local recurrence: 24.5% vs. 25% (p = 0.81), distant brain failure (DBF): 53.2% vs. 45% (p = 0.66), and leptomeningeal disease (LMD) recurrence: 3.5% vs. 9.0% (p = 0.66). On MVA, radiation cohort was not independently associated with OS or any intracranial outcome. Crude rates of symptomatic radiation necrosis were 5.6 and 0%, respectively. OS and intracranial outcomes were similar for patients treated with pre-SRS or post-WBRT for resected BM. Pre-SRS is a viable alternative to post-WBRT for resected BM. Further confirmatory studies with neuro-cognitive outcomes comparing these two treatment paradigms are needed.
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA. krpate8@emory.edu.
authors.forename: Kirtesh R
authors.initials: KR
authors.lastname: Patel
authors.affiliation: Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA.
authors.forename: Stuart H
authors.initials: SH
authors.lastname: Burri
authors.affiliation: Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA.
authors.forename: Danielle
authors.initials: D
authors.lastname: Boselli
authors.affiliation: Department of Cancer Biostatistics, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA.
authors.forename: James T
authors.initials: JT
authors.lastname: Symanowski
authors.affiliation: Carolina Neurosurgery and Spine Associates, Levine Cancer Institute, Charlotte, NC, USA.
authors.forename: Anthony L
authors.initials: AL
authors.lastname: Asher
authors.affiliation: Department of Oncology, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA.
authors.forename: Ashley
authors.initials: A
authors.lastname: Sumrall
authors.affiliation: Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA.
authors.forename: Robert W
authors.initials: RW
authors.lastname: Fraser
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
authors.forename: Robert H
authors.initials: RH
authors.lastname: Press
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
authors.forename: Jim
authors.initials: J
authors.lastname: Zhong
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
authors.forename: Richard J
authors.initials: RJ
authors.lastname: Cassidy
authors.affiliation: Department of Neurosurgery and Winship Cancer Institute, Emory University, Atlanta, GA, USA.
authors.forename: Jeffrey J
authors.initials: JJ
authors.lastname: Olson
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
authors.forename: Walter J
authors.initials: WJ
authors.lastname: Curran
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
authors.forename: Hui-Kuo G
authors.initials: HG
authors.lastname: Shu
authors.affiliation: Department of Radiation Oncology, Winship Cancer Institute, Emory University, 1365 Clifton Rd NE, Room AT225, Atlanta, GA, 30322, USA.
authors.forename: Ian R
authors.initials: IR
authors.lastname: Crocker
authors.affiliation: Southeast Radiation Oncology Group, Levine Cancer Institute, Carolinas Healthcare System, Charlotte, NC, USA.
authors.forename: Roshan S
authors.initials: RS
authors.lastname: Prabhu
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001932:Brain Neoplasms / Q000532:radiotherapy* / Q000556:secondary / Q000601:surgery*; D016371:Cranial Irradiation / Q000009:adverse effects; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D011182:Postoperative Care; D011300:Preoperative Care; D016634:Radiosurgery / Q000009:adverse effects; D016019:Survival Analysis; D016896:Treatment Outcome
keywords: Brain metastases; Post-operative; Pre-operative; Resection; Stereotactic radiosurgery; Whole brain radiation therapy